Finding 561489 (2022-007)

Material Weakness
Requirement
N
Questioned Costs
$1
Year
2022
Accepted
2025-05-23
Audit: 357068
Organization: Sayre Health Center (PA)
Auditor: Cbiz CPAS PC

AI Summary

  • Core Issue: The Health Center lacks proper documentation for applying sliding fee discounts based on patient income.
  • Impacted Requirements: Compliance with sliding fee discount criteria is compromised due to inadequate internal controls and staff turnover.
  • Recommended Follow-Up: Management should establish procedures for verifying eligibility and ensure documentation of discount approvals is retained for future reference.

Finding Text

Special Provisions - Inadequate Documentation and Records for Application of Sliding Fee Discounts – Material Weakness in Internal Control Over Compliance Criteria The Health Center is required to apply a sliding fee discount for health services provided to eligible patients. This sliding fee discount is based on the patient’s ability to pay. Condition and Context The Health Center was unable to provide documentation to support the income requirements of patients and the proper application of the sliding fee discount to patients seen during the year. Cause Staff turnover in the Finance Department coupled with inadequate controls to ensure that the sliding fee discount was properly applied to patient’s based on their eligibility. Effect Discounts to patient service fees may have been improperly provided and inaccurate information may have been used in making management decisions during the year. Questioned Costs Amount, if any, could not be determined due to lack of supporting documentation. Repeat Finding No. Recommendation We recommend that management implement procedures to ensure that the sliding fee discount is properly applied to patients based on their eligibility. We also recommend that management implement a process of formal documenting the review and approval of sliding fee discount eligibility forms. Such forms should also be retained in case needed for future reference purposes. Views of Responsible Officials and Planned Corrective Action See corrective action plan.

Corrective Action Plan

Finding No. 2022-007: Inadequate Documentation and Records for Application of Sliding Fee Discounts We have incorporated a policy that establishes the basis for the sliding fee policy to assure affordable access to care for uninsured and underinsured patients of the organization. The policy will recognize a “full discount” for individuals and families with annual incomes at or below 100% Federal poverty level (FPL) with only nominal fees charged, three levels of discount between 100% and 200%, and no discounts for copays for individuals and families earning over 200% FPL. This policy will be in accordance with Section 330(k)(3)(G) of the PHS Act and 42 CFR Part 51c.303(f) and 42 CFR Part 51c.303(u) which are incorporated herewith. We will charge a nominal fee to individuals and families with annual incomes at or below 100% of the FPL. Patients whose incomes are above 100% or below 200% of the FPL will be charged according to our sliding fee scale based on income and family size. Discounts will be provided to patients with incomes up to 200% of the FPL for medical visits. Discounts will be provided to patients with incomes up to 250% of the FPL for family planning visits. Staff will assess patients’ incomes based upon a sliding fee scale and no patient will be denied care based upon their inability to pay. The organization also has a policy of nondiscrimination in the delivery of health care as stated in its Patient Bill of Rights. Also, the Board of Directors define the income and family size, and has defined the family size to be all parents, minors or guardians that are financially responsible for the household. The tracking and documentation of sliding fees is now maintained with the deposit record of each fee received in the shared file for immediate availability and reference.

Categories

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles Eligibility Material Weakness Internal Control / Segregation of Duties Special Tests & Provisions

Other Findings in this Audit

  • 561487 2022-005
    Material Weakness
  • 561488 2022-006
    Material Weakness
  • 561490 2022-008
    Material Weakness
  • 561491 2022-005
    Material Weakness
  • 561492 2022-006
    Material Weakness
  • 561493 2022-007
    Material Weakness
  • 561494 2022-008
    Material Weakness
  • 561495 2022-005
    Material Weakness
  • 561496 2022-006
    Material Weakness
  • 561497 2022-007
    Material Weakness
  • 561498 2022-008
    Material Weakness
  • 1137929 2022-005
    Material Weakness
  • 1137930 2022-006
    Material Weakness
  • 1137931 2022-007
    Material Weakness
  • 1137932 2022-008
    Material Weakness
  • 1137933 2022-005
    Material Weakness
  • 1137934 2022-006
    Material Weakness
  • 1137935 2022-007
    Material Weakness
  • 1137936 2022-008
    Material Weakness
  • 1137937 2022-005
    Material Weakness
  • 1137938 2022-006
    Material Weakness
  • 1137939 2022-007
    Material Weakness
  • 1137940 2022-008
    Material Weakness

Programs in Audit

ALN Program Name Expenditures
93.224 Health Center Program (community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) $512,128
93.461 Hrsa Covid-19 Claims Reimbursement for the Uninsured Program and the Covid-19 Coverage Assistance Fund $347,656
93.527 Grants for New and Expanded Services Under the Health Center Program $246,813