Finding 554940 (2024-001)

Significant Deficiency
Requirement
L
Questioned Costs
-
Year
2024
Accepted
2025-04-14

AI Summary

  • Core Issue: There is a significant deficiency in internal controls over compliance, specifically related to the preparation of the UDS report.
  • Impacted Requirements: Health centers must maintain accurate records for the annual UDS report as mandated by the Health Center Program.
  • Recommended Follow-Up: Ensure that all data used for the UDS report is saved alongside the final report to verify completeness and accuracy.

Finding Text

Performance Reporting Federal agency: U.S. Department of Health and Human Services Federal program title: Health Center Program Cluster (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) Assistance Listing Number: 93.224/93.527 Federal Award Identification Number: H8026575-2023, H8026575-2024, H8G48725-2022 Award Period: December 2022 through February 2025 Type of Finding: Significant Deficiency in Internal Control over Compliance Criteria or specific requirement: Health centers must prepare an annual Uniform Data System (UDS) Report required under the Health Center Program authorized by section 330 of the Public Health Service Act. Condition: During our testing, we noted a breakdown in internal controls as the information compiled to prepare the UDS report was not retained internally. Questioned costs: None Context: During our testing of 7 Key Line-Items identified as containing critical information it was noted that the following key line items were not properly supported: 1. Total accrued cost before donations and after allocation of overhead (Table 8A Line 17 Column c) 2. Total accrued medical staff and other medical cost after allocation of overhead excluding medical lab and x-ray cost (Table 8A, Line 1, Column c and Table 8A, Line 3, Column c) 3. Total accrued BPHC COVID-19 Supplemental grant draw-down from January 1 to December 31, of the calendar measurement year (Table 9E, Line 1q, Column a) Cause: There was staff turnover in the financial department during 2023 and the process used by the prior CFO to gather data for UDS reporting was not communicated to the incoming CFO, and therefore tracking of the data was not consistently maintained to support the amounts reported. Effect: The key line-item amounts reported may not be complete and accurate or have documentation readily available to support amounts reported. Repeat Finding: No Recommendation: We recommend that data compiled to prepare the report is saved with a final copy of the report to support the information is complete and accurate. Views of responsible officials: There is no disagreement with the audit finding.

Corrective Action Plan

Health Center Program Cluster (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) -Assistance Listing No. 93.224 /93.527 Recommendation: Data compiled to prepare a report is saved with a final copy of the report to support the information is complete and accurate. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: CHWP has made enhancements to its financial reporting structure and used this in calculating the UOS data for CY 2024. We believe that we documented the numbers appropriately but will make sure that we continue to comply with this requirement in future UOS reporting, Name(s) of the contact person(s) responsible for corrective action: Jeff Forman, CFO. Planned completion date for corrective action plan: March 21, 2025.

Categories

Allowable Costs / Cost Principles HUD Housing Programs Reporting Significant Deficiency Internal Control / Segregation of Duties

Other Findings in this Audit

  • 554941 2024-002
    Significant Deficiency
  • 554942 2024-003
    Significant Deficiency
  • 554943 2024-001
    Significant Deficiency
  • 554944 2024-002
    Significant Deficiency
  • 554945 2024-003
    Significant Deficiency
  • 1131382 2024-001
    Significant Deficiency
  • 1131383 2024-002
    Significant Deficiency
  • 1131384 2024-003
    Significant Deficiency
  • 1131385 2024-001
    Significant Deficiency
  • 1131386 2024-002
    Significant Deficiency
  • 1131387 2024-003
    Significant Deficiency

Programs in Audit

ALN Program Name Expenditures
93.224 Community Health Centers $1.27M
93.354 Public Health Emergency Response: Cooperative Agreement for Emergency Response: Public Health Crisis Response $268,215
93.527 Affordable Care Act (aca) Grants for New and Expanded Services Under the Health Center Program $9,511