Finding 572057 (2023-003)

Significant Deficiency

Requirement

Questioned Costs

Year

2023

Accepted

2025-07-28

Audit: 363175

Organization: Waikiki Health (HI)

Auditor: Cohnreznick LLP

AI Summary

Core Issue: The Center lacks proper documentation and internal controls for calculating sliding fee discounts, leading to potential non-compliance with federal guidelines.
Impacted Requirements: Compliance with DHHS regulations regarding patient eligibility and sliding fee scale adjustments is not being met.
Recommended Follow-Up: Implement a robust system of internal controls to ensure accurate calculation and documentation of sliding fee discounts based on family size and income.

Finding Text

Finding 2023.003: Special Tests and Provisions - Sliding Fee Scale Documentation - Significant Deficiency Grantor: U.S. Department of Health and Human Services Federal Program Names: Health Center Program Cluster: Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care), COVID-19 - Health Center Program Cluster: Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care), Grants for New and Expanded Services under the Health Center Program Federal Assistance Listing Numbers: 93.224 and 93.527 Federal Award Identification Number and Year: H80CS00053 - 2022 and 2023, H8FCS41422 - 2023 Criteria Health centers are required to have a corresponding schedule of discounts applied and adjusted on the basis of patients' ability to pay and their eligibility. A patient's eligibility to pay is determined on the basis of the official poverty guideline, as revised by DHHS (42 CFR Sections 51c, 107(b)(5), 56.108(b)(5) and 56.303(f)). The Center should be implementing and monitoring procedures to properly determine, calculate and review sliding fee discounts issued to patients in accordance with the Center's sliding fee scale. Condition The Center did not always have the proper slide fee documentation readily available to ensure the proper slide fee discount was applied based on approved policies or the discount was calculated incorrectly. Cause The Center did not have adequate internal controls in place to effectively ensure that all sliding fee discounts were properly calculated based on approved documentation. Effect or Potential Effect The Center did not comply with the appropriate rules and regulations as per the Uniform Guidance. Questioned Costs None Context A test of 40 sliding fee discount transactions was performed and resulted in 15 instances where the Center was unable to provide approved documentation, or the sliding fee discount was calculated incorrectly. Our sample was a statistically valid sample. Identification of Repeat Finding This finding is not a repeat finding. Recommendation The Center should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated and supported based on family size and income. Views of Responsible Officials and Planned Corrective Actions Management agrees with the audit finding and will strengthen internal controls and accountability to correct the deficiency. Management has prepared a Corrective Action Plan that outlines the additional controls implemented.

Corrective Action Plan

Finding 2023.003 - Special Tests and Provisions - Sliding Fee Scale Documentation Recommendation The Center should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated and supported based on family size and income. Action Taken I will work directly with the Director of Clinical Operations, Kei Wee, to conduct a comprehensive review of the Center's existing sliding fee scale policy to ensure alignment with federal guidelines and best practices, clarifying documentation requirements, including acceptable forms of income verification and definition of family size. The Clinical Operations Director, Kei Wee, will develop and implement a step-by-step standard operating procedure (SOP) for staff to consistently assess and apply sliding fee discounts. The SOP will include clear instructions for verifying documentation, calculating discount eligibility, and recording determinations in the patient's record. The Clinical Operations Director, Kei Wee's management team, will conduct monthly spot audits of a sample of sliding fee files to verify correct application and documentation. The managers will report the findings to management for corrective follow-up and provide training for registration/front-desk staff and billing personnel on the updated policy and procedures as needed.

Other Findings in this Audit

572058 2023-004

Significant Deficiency
572059 2023-003

Significant Deficiency
572060 2023-004

Significant Deficiency
572061 2023-003

Significant Deficiency
572062 2023-004

Significant Deficiency
1148499 2023-003

Significant Deficiency
1148500 2023-004

Significant Deficiency
1148501 2023-003

Significant Deficiency
1148502 2023-004

Significant Deficiency
1148503 2023-003

Significant Deficiency
1148504 2023-004

Significant Deficiency

Programs in Audit

ALN	Program Name	Expenditures
93.527	Grants for New and Expanded Services Under the Health Center Program	$1.29M
93.918	Grants to Provide Outpatient Early Intervention Services with Respect to Hiv Disease	$525,441
93.224	Health Center Program (community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care)	$344,034