Finding Text
Department of Health and Human Services
Federal Financial Assistance Listing #93.224 and #93.527
Community Health Center Cluster
Reporting
Material Weakness in Internal Control Over Compliance
Criteria Health Center Program awardees and look-alies are required to report a core set of
information, including data on patient characteristics, services provided, clinical
processes and health outcomes, patients’ use of services, staffing, costs, and revenues
as a part of a standardized reporting system known as the Universal Data System (UDS).
There is very specific criteria on how the UDS is to be completed contained in the UDS
Manual published by the Health Resources and Services Administration. The information
needs to be reported annually on a calendar year basis regardless of a grantees’ fiscal
year-end.
Condition Certain tables within the UDS Report did not reconcile to the information contained in
the Organization’s records. The tables that did not reconcile to the supporting
information included Table 4, Selected Patient Characteristics, and Table 5, Staffing and
Utilization. Table 4 reports the total number of patients. The number of patients
reported in the UDS Report was 74,680 while the number of patients noted in the
supporting documentation was 73,021.
Table 5 reports the number of clinic visits by both physicians and by Nurse Practitioners
(NP), Physician Assistants (PA), and Certified Nurse Midwives (CNM). The number of
clinic visits by physicians reported in the UDS Report was 102,677 (clinic and virtual)
while the number of clinic visits by physicians noted in the supporting documentation
was 115,177 (clinic and virtual). The number of clinic visits by NPs, PAs, and CNMs
reported in the UDS Report was 62,915 (clinic and virtual) while the number of clinic
visits by NPs, PAs and CNMs noted in the supporting documentation was 82,621 (clinic
and virtual).
Cause The Organization acquired Borrego Health on July 31, 2023. Borrego Health used a
different medical record system than the Organization through late May 2024. This
resulted in the UDS Report for the period ended December 31, 2023 needing to be
prepared using two different databases for information. In addition, management did
not retain the supporting detail used to prepare the UDS Report. When the supporting
detail was recreated during the audit, differences were identified between the
supporting detail and the UDS Report that was filed. Also, the review process of the UDS
report does not appear to have been functioning properly.
Effect The lack of internal control policies to require retention of supporting documentation as
well as a lack of evidence of a review outside of the person preparing the report
increases the risk that employees may not be able to detect and correct errors and
issues in a timely manner. The Organization submitted a UDS Report that did not have
supporting information and the information that was recreated does not reconcile to
the amount shown in the UDS Report filed.
Questioned Costs None reported.
Context Seven key line items on the UDS Report are required to be reconciled to supporting
documentation:
1. The total number of patients
2. Total Physician Clinic and Virtual Visits
3. Total NP, PA, and CNM Clinic and Virtual Visits
4. Total accrued costs before donations and after allocation of overhead
5. Total accrued medical staff and other medical costs after allocation of overhead
excluding lab and x-ray costs
6. Total BPHC Health Center Program grants drawn down for the period from January
1 through December 31 of the calendar measurement year
7. Total accrued BPHC COVID-19 Supplemental grants drawn down for the period from
January 1 through December 31 of the calendar measurement year.
Two of the key line items (#1 and #2 above) did not agree to the supporting
documentation.
Repeat Finding
From Prior Year No
Recommendation We recommend that the Organization enhance internal control policies to ensure all
amounts reported and submitted to the federal agency are adequately documented and
supported. We also recommend that the Organization enhance internal control policies
to ensure that all required reports are properly reviewed prior to submission and that all
key line items are necessary, correct, meet the requirements of the federal program,
and are properly reported in the reports required to be submitted to the federal agency.
We also recommend that there is evidence retained of this review.
Views of Responsible
Officials Management agrees with the finding and has immediately implemented new
procedures to memorialize the data used to compile and report the UDS report. This
included adding all new acquired clinics to the Organization’s Electronic Health Record
System.