EIN: 020350051
UEI: HWXJS7BLUGN5
Data as of August 22, 2026
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on December 23, 2025. Under 2 CFR 200.521(d), a pass-through entity that provided federal funds to this organization for this audit period must issue a management decision on these findings by June 23, 2026 (60 days ago).
What is a management decision? →During testing of payroll charges, 3 of the 25 employees tested had salary charges which exceeded the Executive Level II cap. Upon further review of the full population, a total of 4 employees were identified whose salary charges to the grant exceeded the cap. Although the Organization calculated the capped allowable salaries for each employee, the allocations entered into the payroll system reflected full gross wages rather than the capped amounts, resulting in the excess salaries. Cause: The Organization did not have a system of internal controls that included verification of accurate entry of salary allocations into the payroll system. Effect: Unallowable salary amounts were initially charged to the grant. However, the Organization was able to identify other allowable expenditures sufficient to support the total amount of grant funds drawn. Questioned Costs: None Repeat Finding: No Recommendation: We recommend the Organization update its policies and procedures to include an independent review of payroll allocations entered into the payroll system to ensure they agree to the calculated capped amounts. Additionally, periodic reconciliation of salary charges to the Executive Level II limitation should be performed to prevent similar errors in the future. Views of a Responsible Official and Corrective Action Plan: Management agrees with the finding and will update payroll policies and procedures to include verification of salary allocations charged to federal awards. An independent review process and periodic reconciliations to the Executive Level II limitation will be implemented to prevent recurrence.
Show full finding ▾Hide full finding ▴Finding Number: 2025-001 Finding Type: Immaterial noncompliance and significant deficiency in internal controls over compliance related to allowable costs Information on the Federal Program: Program Name: Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) (ALN 93.224/93.527) Federal Awards Project Title: Health Center Program Award Period: June 1, 2024 – May 31, 2025 and June 1, 2025 – May 31, 2026 Award Number: H80CS00508 Agency: U.S. Department of Health and Human Services (HHS), Health Resources and Services Administration (HRSA) Criteria: Under 2 CFR §200.430(c)(2), compensation charged to federal awards must comply with the Executive Level II salary limitation established by the Office of Personnel Management (OPM). Salary costs allocated to the Health Center Program may not exceed this cap, and only the allowable portion up to the Executive Level II rate may be charged to the federal award. Condition: During testing of payroll charges, 3 of the 25 employees tested had salary charges which exceeded the Executive Level II cap. Upon further review of the full population, a total of 4 employees were identified whose salary charges to the grant exceeded the cap. Although the Organization calculated the capped allowable salaries for each employee, the allocations entered into the payroll system reflected full gross wages rather than the capped amounts, resulting in the excess salaries. Cause: The Organization did not have a system of internal controls that included verification of accurate entry of salary allocations into the payroll system. Effect: Unallowable salary amounts were initially charged to the grant. However, the Organization was able to identify other allowable expenditures sufficient to support the total amount of grant funds drawn. Questioned Costs: None Repeat Finding: No Recommendation: We recommend the Organization update its policies and procedures to include an independent review of payroll allocations entered into the payroll system to ensure they agree to the calculated capped amounts. Additionally, periodic reconciliation of salary charges to the Executive Level II limitation should be performed to prevent similar errors in the future. Views of a Responsible Official and Corrective Action Plan: Management agrees with the finding and will update payroll policies and procedures to include verification of salary allocations charged to federal awards. An independent review process and periodic reconciliations to the Executive Level II limitation will be implemented to prevent recurrence.
Finding: 2025-001 Condition Found: During testing of payroll charges, 3 of the 25 employees tested had salary charges which exceeded the Executive Level II cap. Upon further review of the full population, a total of 4 employees were identified whose salary charges to the grant exceeded the cap. Although the Organization calculated the capped allowable salaries for each employee, the allocations entered into the payroll system reflected full gross wages rather than the capped amounts, resulting in the excess salaries. Individual(s) Responsible for Corrective Action: Philip Kneer, CFO Brandon Gilbert, Corporate Compliance Officer / Co-Director of HR April Bledsoe, / Co-Director of HR Planned Corrective Action: Integrate automatic HRSA salary cap checks into payroll and HRIS systems. Create salary cap flags that prevent or warn when charges exceed allowable rates. Implement quarterly salary compliance audits comparing employee salaries to HRSA limits. Anticipated Completion Date: Update payroll system control within the HRIS/Payroll system by February 28, 2026 First quarterly salary compliance audit to be completed by February 26, 2026
FAC accepted this audit on November 11, 2022 — management decision was due May 11, 2023.
Finding Number: 2022 001 Finding Type: Significant deficiency in internal control over compliance and compliance Information on the Federal Program: Program Name: Health Center Program Cluster (AL numbers 93.224 and 93.527) Grant Award: 5 H80CS00508 20 from June 1, 2021 through May 31, 2022 and 2 H80CS00508 21 from June 1, 2022 through May 31, 2023 Agency: U.S. Department of Health and Human Services, Health Resources and Services Administration Pass Through Entity: N/A Criteria: In accordance with Section 330(k)(3)(G) of the Public Health Service Act (42 U.S. Code ? 254b), as an FQHC, the Organization must have a sliding fee discount program in which the Organization?s fee schedule is discounted based on a patient?s ability to pay. Condition and Context: The Organization has not applied sliding fee discounts to patient charges consistent with its sliding fee discount program. Through testing a statistically valid sample of transactions for the appropriate application of the Organization's sliding fee discount program to 25 individual patient balances, we noted the sliding fee discount applied was not consistent with the Organization's sliding fee discount policy for three patients. For one of the patients, an incorrect discount was applied to the patient account. For the other two patients, the sliding fee discount category awarded to each patient was not consistent with the category that each patient was eligible for based on the patient's family size and income. Cause and Effect: The Organization has limited internal monitoring procedures established for ensuring compliance with the sliding fee discount program. The errors resulted in the following deviations from the Organization's sliding fee discount program: ? One patient was responsible to pay $10 more than required ? One patient was responsible to pay $10 less than required ? One patient responsible to pay $19.60 less than required Questioned Costs: None Repeat Finding: Yes, 2021 002 Recommendation: We continue to recommend the Organization develop routine internal monitoring procedures to perform periodic testing of sliding fee discounts to help ensure the discounts are provided consistent with the Organization?s sliding fee discount program. Views of a Responsible Official and Corrective Action Plan: Management agrees with the finding. Routine and timely documented reviews of sliding fee discounts will be completed to ensure compliance with the Organization's sliding fee discount program.
Show full finding ▾Hide full finding ▴Finding Number: 2022 001 Finding Type: Significant deficiency in internal control over compliance and compliance Information on the Federal Program: Program Name: Health Center Program Cluster (AL numbers 93.224 and 93.527) Grant Award: 5 H80CS00508 20 from June 1, 2021 through May 31, 2022 and 2 H80CS00508 21 from June 1, 2022 through May 31, 2023 Agency: U.S. Department of Health and Human Services, Health Resources and Services Administration Pass Through Entity: N/A Criteria: In accordance with Section 330(k)(3)(G) of the Public Health Service Act (42 U.S. Code ? 254b), as an FQHC, the Organization must have a sliding fee discount program in which the Organization?s fee schedule is discounted based on a patient?s ability to pay. Condition and Context: The Organization has not applied sliding fee discounts to patient charges consistent with its sliding fee discount program. Through testing a statistically valid sample of transactions for the appropriate application of the Organization's sliding fee discount program to 25 individual patient balances, we noted the sliding fee discount applied was not consistent with the Organization's sliding fee discount policy for three patients. For one of the patients, an incorrect discount was applied to the patient account. For the other two patients, the sliding fee discount category awarded to each patient was not consistent with the category that each patient was eligible for based on the patient's family size and income. Cause and Effect: The Organization has limited internal monitoring procedures established for ensuring compliance with the sliding fee discount program. The errors resulted in the following deviations from the Organization's sliding fee discount program: ? One patient was responsible to pay $10 more than required ? One patient was responsible to pay $10 less than required ? One patient responsible to pay $19.60 less than required Questioned Costs: None Repeat Finding: Yes, 2021 002 Recommendation: We continue to recommend the Organization develop routine internal monitoring procedures to perform periodic testing of sliding fee discounts to help ensure the discounts are provided consistent with the Organization?s sliding fee discount program. Views of a Responsible Official and Corrective Action Plan: Management agrees with the finding. Routine and timely documented reviews of sliding fee discounts will be completed to ensure compliance with the Organization's sliding fee discount program.
Finding Number: 2022-001 Condition Found: The Organization has not applied sliding fee discounts to patient charges consistent with its sliding fee discount program. Individual(s) Responsible for Corrective Action: Brenda Ladd-Front Office Manager Brandon Gilbert-Compliance Officer Corrective Action Planned: 1. The Front Office Manager will provide additional training to the Front Desk/Reception Staff. 2. Assign the Compliance Officer the task of performing monthly audits on 25 random sliding fee charges to verify patient eligibility and discount. The results of the monthly audits will be reported to the Chief Executive Officer, Chief Financial Officer, and the Revenue Cycle Manager. Anticipated Completion Date: 1. Retraining of Front Desk/Reception will begin immediately. 2. Monthly audits of 25 random sliding fee charges will begin immediately.
2021-002
FAC accepted this audit on October 12, 2021 — management decision was due April 12, 2022.
Finding Number: 2021-002 Finding Type: Significant deficiency in internal control over compliance Information on the Federal Program: Program Name: Health Center Program Cluster (AL numbers 93.224 and 93.527) Grant Award: 6 H80CS00508-19 from June 1, 2020 through May 31, 2021 and 5 H80CS00508-20 from June 1, 2021 through May 31, 2022 Agency: U.S. Department of Health and Human Services, Health Resources and Services Administration Pass-Through Entity: N/A Criteria: In accordance with Section 330(k)(3)(G) of the PHS Act (42 U.S. Code ?254b), as an FQHC, the Organization must have a sliding fee discount program in which the Organization?s fee schedule is discounted based on a patient?s ability to pay. Condition Found and Context: The Organization has not applied sliding fee discounts to patient charges consistent with its sliding fee discount program. Through testing a statistically valid sample of transactions for the appropriate application of the Organization's sliding fee discount program to 25 individual patient balances, we noted the sliding fee discount applied was not consistent with the Organization's sliding fee discount policy for two dental patients. One patient was provided a 40% discount rather than a 60% discount which resulted in the patient paying $27 more than required under the program. One patient was provided a discount of $81 after their sliding fee application expired without completing a new application. Cause and Effect: The Organization has limited internal monitoring procedures established for ensuring compliance with the sliding fee discount program. The errors resulted in patients paying both more and less than what was required under the Organization sliding fee discount program. Questioned Costs: None Repeat Finding: No Recommendation: We recommend the Organization develop routine internal monitoring procedures to perform periodic testing of sliding fee discounts to help ensure the discounts are provided consistent with the Organization?s sliding fee discount program. We further recommend management review the complexity of the Organization?s discount schedule and consider whether it would be beneficial to change the schedule from percentage discounts to flat dollar amounts and help improve compliance with the program. Views of a Responsible Official and Corrective Action Plan: Management agrees with the finding. Routine and timely documented reviews of sliding fee discounts will be completed to ensure compliance with the Organization's sliding fee discount program.
Show full finding ▾Hide full finding ▴Finding Number: 2021-002 Finding Type: Significant deficiency in internal control over compliance Information on the Federal Program: Program Name: Health Center Program Cluster (AL numbers 93.224 and 93.527) Grant Award: 6 H80CS00508-19 from June 1, 2020 through May 31, 2021 and 5 H80CS00508-20 from June 1, 2021 through May 31, 2022 Agency: U.S. Department of Health and Human Services, Health Resources and Services Administration Pass-Through Entity: N/A Criteria: In accordance with Section 330(k)(3)(G) of the PHS Act (42 U.S. Code ?254b), as an FQHC, the Organization must have a sliding fee discount program in which the Organization?s fee schedule is discounted based on a patient?s ability to pay. Condition Found and Context: The Organization has not applied sliding fee discounts to patient charges consistent with its sliding fee discount program. Through testing a statistically valid sample of transactions for the appropriate application of the Organization's sliding fee discount program to 25 individual patient balances, we noted the sliding fee discount applied was not consistent with the Organization's sliding fee discount policy for two dental patients. One patient was provided a 40% discount rather than a 60% discount which resulted in the patient paying $27 more than required under the program. One patient was provided a discount of $81 after their sliding fee application expired without completing a new application. Cause and Effect: The Organization has limited internal monitoring procedures established for ensuring compliance with the sliding fee discount program. The errors resulted in patients paying both more and less than what was required under the Organization sliding fee discount program. Questioned Costs: None Repeat Finding: No Recommendation: We recommend the Organization develop routine internal monitoring procedures to perform periodic testing of sliding fee discounts to help ensure the discounts are provided consistent with the Organization?s sliding fee discount program. We further recommend management review the complexity of the Organization?s discount schedule and consider whether it would be beneficial to change the schedule from percentage discounts to flat dollar amounts and help improve compliance with the program. Views of a Responsible Official and Corrective Action Plan: Management agrees with the finding. Routine and timely documented reviews of sliding fee discounts will be completed to ensure compliance with the Organization's sliding fee discount program.
Finding Number: 2021-002 Condition Found and Context: The Organization has not applied sliding fee discounts to patient charges consistent with its sliding fee discount program. Through testing a statistically valid sample of transactions for the appropriate application of the Organization's sliding fee discount program to 25 individual patient balances, we noted the sliding fee discount applied was not consistent with the Organization's sliding fee discount policy for two dental patients. One patient was provided a 40% discount rather than a 60% discount which resulted in the patient paying $27 more than required under the program. One patient was provided a discount of $81 after their sliding fee application expired without completing a new application. Cause and Effect: The Organization has limited internal monitoring procedures established for ensuring compliance with the sliding fee discount program. The errors resulted in patients paying both more and less than what was required under the Organization sliding fee discount program. lndividual(s) Responsible for Corrective Action: - Team Coordinator/ Reception Clerk - Accounts Receivable Clerk - Billing Manager Corrective Action Planned: 1. Retraining the Front Desk/Reception Staff. 2. Assign the Accounts Receivable clerk the task of performing monthly audits on 25 random sliding fee charges to verify patient eligibility and discount. 3. Change the Sliding Fee discount from a percentage-based fee to a flat fee. Anticipated Completion Date: 1. Retraining of Front Desk/Reception wi ll begin immediately. 2. Monthly audits of 25 random sliding fee charges will begin January 2022. 3. The change from a percentage-based Sliding Fee discount to a Flat Fee discount will commence on 03/01/2022.
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