EIN: 141880824
UEI: YVZNUTUA68Z9
Audited by: CliftonLarsonAllen LLP
Oversight agency: 93 [Department of Health and Human Services]
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Data as of August 28, 2026
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on July 2, 2026. 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 January 2, 2027 (124 days from today).
What is a management decision? →The amount reported for one of the key line items within the UDS report did not agree to the supporting documentation provided by the Organization. Questioned Costs: None Context: Within the UDS report, Table 4, which contains a breakout of patients by income as a percentage of the federal poverty guideline, contained an amount on Line 6, Column A for the total number of patients which did not agree to the supporting documentation provided by the Organization. Cause: Support was not saved in real time. The reports run after the fact do not agree to the final UDS report. Effect: Reporting of incorrect amounts within the UDS report. Repeat Finding: No. Recommendation: We recommend the Organization perform a final review of amounts entered within the UDS report, as compared to the supporting schedules, prior to submission. Views of Responsible Officials: There is no disagreement with the audit finding.
Show full finding ▾Hide full finding ▴Reporting Federal agency: U.S. Department of Health and Human Services Federal program title: Health Center Program Cluster Assistance Listing Number: 93.224/93.527 Award Period: 6/1/24-5/31/25; 6/1/25-5/31/26 Criteria: Code of federal regulation (CFR) § 200.303 requires that recipients of federal funds establish, document, and maintain effective internal control over the Federal award that provides reasonable assurance that the recipient is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. Recipients of grants from the Bureau of Primary Health Care Health Center Program are required to submit the Uniform Data System (UDS) report on an annual basis. The UDS report contains various information which has been identified as key line items with the compliance supplement for the Health Center Program Cluster. Condition: The amount reported for one of the key line items within the UDS report did not agree to the supporting documentation provided by the Organization. Questioned Costs: None Context: Within the UDS report, Table 4, which contains a breakout of patients by income as a percentage of the federal poverty guideline, contained an amount on Line 6, Column A for the total number of patients which did not agree to the supporting documentation provided by the Organization. Cause: Support was not saved in real time. The reports run after the fact do not agree to the final UDS report. Effect: Reporting of incorrect amounts within the UDS report. Repeat Finding: No. Recommendation: We recommend the Organization perform a final review of amounts entered within the UDS report, as compared to the supporting schedules, prior to submission. Views of Responsible Officials: There is no disagreement with the audit finding.
Reporting – Assistance Listing No. 93.224/93.527 Recommendation: We recommend the Organization perform a final review of amounts entered within the UDS report, as compared to the supporting schedules, prior to submission. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: • Update UDS procedure to pull detail reports on all numbers reported in the UDS. • Add to the UDS procedure a review of detail reports to tie them to UDS report • Add a sign off to UDS report as part of final review that detail reports were pulled and verified. Name of the contact person responsible for corrective action: Keith Flores, CFO Planned completion date for corrective action plan: July 2026
There was no documentation available to support that the Organization followed its procurement policies and procedures related to transactions selected for testing. Questioned Costs: $209,640 Context: Five of five transactions selected for procurement testing did not have documentation to support that policies and procedures were followed. Cause: Unknown. Effect: Potential use of federal funds in a manner that is not most efficient or economical. Repeat Finding: No. Recommendation: We recommend the Organization consistently follow its established policies and procedures related to the maintaining of necessary documentation to support the method of procurement utilized. The Organization may also consider qualifying multiple vendors for particular goods/services and then utilizing an approved vendors list. Views of Responsible Officials: There is no disagreement with the audit finding.
Show full finding ▾Hide full finding ▴Procurement Federal agency: U.S. Department of Health and Human Services Federal program title: Health Center Program Cluster Assistance Listing Number: 93.224/93.527 Award Period: 6/1/24-5/31/25; 6/1/25-5/31/26 Criteria: CFR § 200.320 (methods of procurement to be followed) indicates that the non-Federal entity must have and use documented procurement procedures, consistent with the standards of this section and CFR § 200.317, 200.318, and 200.319 for any of the approved procurement methods used for the acquisition of property or services required under a Federal award or subaward. Condition: There was no documentation available to support that the Organization followed its procurement policies and procedures related to transactions selected for testing. Questioned Costs: $209,640 Context: Five of five transactions selected for procurement testing did not have documentation to support that policies and procedures were followed. Cause: Unknown. Effect: Potential use of federal funds in a manner that is not most efficient or economical. Repeat Finding: No. Recommendation: We recommend the Organization consistently follow its established policies and procedures related to the maintaining of necessary documentation to support the method of procurement utilized. The Organization may also consider qualifying multiple vendors for particular goods/services and then utilizing an approved vendors list. Views of Responsible Officials: There is no disagreement with the audit finding.
Procurement – Assistance Listing No. 93.224/93.527 Recommendation: We recommend the Organization consistently follow its established policies and procedures related to the maintaining of necessary documentation to support the method of procurement utilized. The Organization may also consider qualifying multiple vendors for particular goods/service and then utilizing an approved vendors list. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: • Review Contract and procurement policies and procedures. • Compare current procurement process and training to the policies and identify areas for correction and improvement. • Update Policies and procedures as needed. • Implement procedures to review vendors on a periodic basis. • Implement procedures and assign responsibility for checking off that procurement documentation exists and is in the vendor folder or designated area. • Retrain staff involved in procurement on updated procedures. • Monitor process and adjust as needed. Name of the contact person responsible for corrective action: Keith Flores, CFO Planned completion date for corrective action plan: January 2027
FAC accepted this audit on July 7, 2025 — management decision was due January 7, 2026.
Cost incurred prior to the start of the period of performance were charged to the grant. Questioned Costs: $2,979 Context: Two of thirteen transactions selected for testing. Cause: These costs related to a payroll period which crossed over two different grant budget periods, and the costs allocated to the grant were not prorated for the number of days within the period of performance. Effect: Unallowable costs may be allocated to the grant. Repeat Finding: No. Recommendation: We recommend that only costs incurred during the period of performance be charged to the grant. For payroll in which pay periods extend over multiple budget periods, we recommend prorating the amount charged to the grant by the days worked within the grant period. Views of Responsible Officials: There is no disagreement with the audit finding.
Show full finding ▾Hide full finding ▴Federal agency: U.S. Department of Health and Human Services Federal program title: Health Centers Cluster Assistance Listing Number: 93.224/93.527 Pass-Through Agency: N/A Pass-Through Number(s): N/A Award Period: 6/1/24-5/31/25 Type of Finding: Compliance and Significant Deficiency in Internal Control over Compliance Criteria or Specific Requirement: A nonfederal entity may only charge allowable costs incurred during the approved budget period of a federal award’s period of performance and any costs incurred before the federal awarding agency made the federal award that were authorized by the federal awarding agency (2 CFR sections 200.308, 200.309 and 200.403(h)). A period of performance may contain one or more budget periods. Condition: Cost incurred prior to the start of the period of performance were charged to the grant. Questioned Costs: $2,979 Context: Two of thirteen transactions selected for testing. Cause: These costs related to a payroll period which crossed over two different grant budget periods, and the costs allocated to the grant were not prorated for the number of days within the period of performance. Effect: Unallowable costs may be allocated to the grant. Repeat Finding: No. Recommendation: We recommend that only costs incurred during the period of performance be charged to the grant. For payroll in which pay periods extend over multiple budget periods, we recommend prorating the amount charged to the grant by the days worked within the grant period. Views of Responsible Officials: There is no disagreement with the audit finding.
Recommendation: We recommend that only costs incurred during the period of performance be charged to the grant. For payroll in which pay periods extend over multiple budget periods, we recommend prorating the amount charged to the grant by the days worked within the grant period. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: 1. Create list of grants with pertinent contract terms for monitoring and reference. Highlight grants with term end dates within the fiscal year. 2. Update Grant Tracking workpapers to alert on grant year end and create allocation tab to separate payroll expenses that crossover grant end terms. Review non-payroll expenses to ensure they belong to proper grant term. 3. Monitor progress and review grants at fiscal year end to ensure process was followed. Name of the contact person responsible for corrective action: Keith Flores, CFO Planned completion date for corrective action plan: 8/31/2025
FAC accepted this audit on October 14, 2024 — management decision was due April 14, 2025.
The Organization could not provide documentation to support that the draw down request was prepared by someone independent of the person who reviewed the request. Questioned Costs: None. Context: For six of six drawdowns selected for testing, CLA was able to obtain documentation of approval prior to draw down, but there was no documentation to support segregation of duties in the draw down process. Cause: Management turnover. Effect: Lack of segregation of duties could result in inaccurate amounts being drawn down. Repeat Finding: No. Recommendation: CLA recommends that the Organization maintain documentation of the individual preparing the draw down request, along documentation of an independent review being performed prior to the drawdown. This can be in the form of sign off, email, checklist, etc. Views of Responsible Officials: There is no disagreement with the audit finding.
Show full finding ▾Hide full finding ▴2023-002 – Cash Management Federal agency: U.S. Department of Health and Human Services Federal program title: Health Centers Cluster Assistance Listing Number: 93.224/93.527 Pass-Through Agency: n/a Pass-Through Number(s): n/a Award Period: 9/1/23-8/31/25; 4/1/21-3/31/23; 6/1/19-5/31/23; 6/1/23-5/31/26; 12/1/22-5/31/23 Type of Finding: Material Weakness in Internal Control over Compliance Criteria or Specific Requirement: § 200.305(b)(3) indicates reimbursement of costs previously occurred is an acceptable method for requesting payment of Federal funds. However, the Organization is responsible for determining that the entity paid for the costs for which reimbursement is being requested, prior to the date of the reimbursement request. Condition: The Organization could not provide documentation to support that the draw down request was prepared by someone independent of the person who reviewed the request. Questioned Costs: None. Context: For six of six drawdowns selected for testing, CLA was able to obtain documentation of approval prior to draw down, but there was no documentation to support segregation of duties in the draw down process. Cause: Management turnover. Effect: Lack of segregation of duties could result in inaccurate amounts being drawn down. Repeat Finding: No. Recommendation: CLA recommends that the Organization maintain documentation of the individual preparing the draw down request, along documentation of an independent review being performed prior to the drawdown. This can be in the form of sign off, email, checklist, etc. Views of Responsible Officials: There is no disagreement with the audit finding.
Action taken in response to finding: 1. Develop documentation procedures: In Progress a. Establish a standardized procedure for documenting the preparation and review of drawdown requests. 2. Select appropriate party for independent review: Complete 3. Store and maintain documentation in a shared location for future audit and review: Complete Name of the contact person responsible for corrective action: Keith Flores, CFO Planned completion date for corrective action plan: End of 2024
Two employees' wages for the pay periods selected for testing were charged in excess of 100% to the various federal and non-federal grants. One employee was charged 115% and the other 120%. Questioned Costs: $588. Context: Of the 37 payroll transactions selected for testing, two employees' wages were charged in excess of 100% to the various federal and non-federal grants. Cause: Oversight. Effect: Employees' wages are charged in excess of actual expenses incurred. Repeat Finding: No. Recommendation: CLA recommends the Organization maintain a master file where employees' who are charged in excess to the grant can be easily identified, or the Organization implement grant tracking within its payroll system to ensure no employee's wages are charged greater than 100%. Views of Responsible Officials: There is no disagreement with the audit finding.
Show full finding ▾Hide full finding ▴2023-003 – Allowable Costs Federal agency: U.S. Department of Health and Human Services Federal program title: Health Centers Cluster Assistance Listing Number: 93.224/93.527 Pass-Through Agency: n/a Pass-Through Number(s): n/a Award Period: 9/1/23-8/31/25; 4/1/21-3/31/23; 6/1/19-5/31/23; 6/1/23-5/31/26; 12/1/22-5/31/23 Type of Finding: Material Weakness in Internal Control over Compliance Criteria or Specific Requirement: § 200.303(a) indicates non-federal entities must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States or the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). Condition: Two employees' wages for the pay periods selected for testing were charged in excess of 100% to the various federal and non-federal grants. One employee was charged 115% and the other 120%. Questioned Costs: $588. Context: Of the 37 payroll transactions selected for testing, two employees' wages were charged in excess of 100% to the various federal and non-federal grants. Cause: Oversight. Effect: Employees' wages are charged in excess of actual expenses incurred. Repeat Finding: No. Recommendation: CLA recommends the Organization maintain a master file where employees' who are charged in excess to the grant can be easily identified, or the Organization implement grant tracking within its payroll system to ensure no employee's wages are charged greater than 100%. Views of Responsible Officials: There is no disagreement with the audit finding.
Action taken in response to finding: 1. Create a grant matrix to track employee grant allocations in one file: Complete 2. Utilize the matrix to apply allocation to each employee on every payroll occurrence: In Progress 3. Review the matrix with grant project managers monthly to ensure accuracy and capture changes: In Progress 4. Maintain records of for each payroll of grant matrix application: In progress Name of the contact person responsible for corrective action: Keith Flores, CFO Planned completion date for corrective action plan: End of 2024
The Organization did not have a procurement policy in place which was consistent with the requirements of the Uniform Guidance. As a result, the organization could not provide supporting documentation showing that engaged vendors had gone through an appropriate procurement process. Questioned Costs: $50,649 . Context: Five of five vendors selected for procurement testing did not have documentation showing that the cost had been procured in accordance with the Uniform Guidance. Cause: Management turnover. Effect: Lack of appropriate procurement policies could result in the Organization engaging vendors who are not the most efficient or economical. Repeat Finding: Yes, 2022-004. Recommendation: We recommend the Organization revise its procurement policy to be consistent with the requirements of the Uniform Guidance and follow the stated procedures. Views of Responsible Officials: There is no disagreement with the audit finding.
Show full finding ▾Hide full finding ▴2023-004 – Procurement Federal agency: U.S. Department of Health and Human Services Federal program title: Health Centers Cluster Assistance Listing Number: 93.224/93.527 Pass-Through Agency: n/a Pass-Through Number(s): n/a Award Period: 9/1/23-8/31/25; 4/1/21-3/31/23; 6/1/19-5/31/23; 6/1/23-5/31/26; 12/1/22-5/31/23 Type of Finding: Material Noncompliance and Material Weakness in Internal Control over Compliance Criteria or Specific Requirement: § 200.320 Methods of procurement to be followed: The non-Federal entity must have and use documented procurement procedures, consistent with the standards of this section and §§ 200.317, 200.318, and 200.319 for any of the approved procurement methods used for the acquisition of property or services required under a Federal award or sub-award. Condition: The Organization did not have a procurement policy in place which was consistent with the requirements of the Uniform Guidance. As a result, the organization could not provide supporting documentation showing that engaged vendors had gone through an appropriate procurement process. Questioned Costs: $50,649 . Context: Five of five vendors selected for procurement testing did not have documentation showing that the cost had been procured in accordance with the Uniform Guidance. Cause: Management turnover. Effect: Lack of appropriate procurement policies could result in the Organization engaging vendors who are not the most efficient or economical. Repeat Finding: Yes, 2022-004. Recommendation: We recommend the Organization revise its procurement policy to be consistent with the requirements of the Uniform Guidance and follow the stated procedures. Views of Responsible Officials: There is no disagreement with the audit finding.
Action taken in response to finding: 1. Review Current Procurement Policy: in progress a. Conduct a comprehensive review of Promise Healthcare’s existing procurement policy. b. Identify and revise and discrepancies or non-compliance with the requirements of the Uniform Guidance. c. Integrate industry best practices into revised policy to enhance compliance and efficiency 2. Training and Education: to start a. Provide training sessions for staff authorized to purchase along with relevant personnel on the revised procurement policy and procedures and raise awareness of the requirements of the Uniform Guidance and implications of non-compliance. b. Establish training on documentation standards for procurement activities including requisitions, solicitations, evaluations and contract awards. c. Establish training and procedure for retention of procurement-related documentation 3. Internal Controls and oversight: to start a. Implement mechanisms for monitoring and oversight to ensure compliance with the procurement policy. b. Conduct periodic internal audits to assess adherence to procurement procedures and identify areas for improvement or corrective action Name of the contact person responsible for corrective action: Keith Flores, CFO Planned completion date for corrective action plan: Winter 2025
2022-004
The Organization could not provide documentation that vendor was verified as not being suspended or debarred prior to entering into the transaction. Questioned Costs: $48,472. Context: One of one vendor selected for testing suspension and debarment did not have documentation showing that suspension and debarment had been checked prior to entering into a contract. Cause: Management turnover. Effect: The Organization could enter into transactions using federal dollars with vendors that are suspended or debarred. Repeat Finding: Yes, 2022-005. Recommendation: We recommend that the Organization verify that vendors are not suspended or debarred prior to signing contracts or create an approved vendor list. Views of Responsible Officials: There is no disagreement with the audit finding.
Show full finding ▾Hide full finding ▴2023-005 – Suspension and Debarment Federal agency: U.S. Department of Health and Human Services Federal program title: Health Centers Cluster Assistance Listing Number: 93.224/93.527 Pass-Through Agency: n/a Pass-Through Number(s): n/a Award Period: 9/1/23-8/31/25; 4/1/21-3/31/23; 6/1/19-5/31/23; 6/1/23-5/31/26; 12/1/22-5/31/23 Type of Finding: Material Noncompliance and Material Weakness in Internal Control over Compliance Criteria or Specific Requirement: § 200.214 Suspension and debarment. Non-Federal entities are subject to the non-procurement debarment and suspension regulations implementing Executive Orders 12549 and 12689, 2 CFR part 180. The regulations in 2 CFR part 180 restrict awards, subawards, and contracts with certain parties that are debarred, suspended, or otherwise excluded from or ineligible for participation in Federal assistance programs or activities. Condition: The Organization could not provide documentation that vendor was verified as not being suspended or debarred prior to entering into the transaction. Questioned Costs: $48,472. Context: One of one vendor selected for testing suspension and debarment did not have documentation showing that suspension and debarment had been checked prior to entering into a contract. Cause: Management turnover. Effect: The Organization could enter into transactions using federal dollars with vendors that are suspended or debarred. Repeat Finding: Yes, 2022-005. Recommendation: We recommend that the Organization verify that vendors are not suspended or debarred prior to signing contracts or create an approved vendor list. Views of Responsible Officials: There is no disagreement with the audit finding.
Action taken in response to finding: 1. Create procedure to verify vendors are not suspended or debarred: in progress a. Develop steps in the vendor diligence and procurement process to verify that the vendor is not suspended or debarred. b. Identify role or job that will handle responsibility for following procedure. c. Formalize the process into a written procedure and add to the procurement or other relevant policy. d. Conduct periodic audits to assess adherence to the procedure and train as necessary to ensure compliance. Name of the contact person responsible for corrective action: Keith Flores, CFO Planned completion date for corrective action plan: End of 2024
2022-005
The Organization could not provide supporting documentation showing management's review and approval of costs totaling $511 for camera supplies. Questioned Costs: None. Context: Of the three transactions selected for testing, there was no documentation available to support management's review and approval of one transaction. Cause: Management turnover. Effect: If costs are not reviewed and approved as being allowable, it could result in unallowable costs being charged to federal grants. Repeat Finding: No. Recommendation: We recommend the Organization maintain approvals electronically within Intacct. Views of Responsible Officials: There is no disagreement with the audit finding.
Show full finding ▾Hide full finding ▴2023-006 – Allowable Costs Federal agency: U.S. Department of Health and Human Services Federal program title: Health Centers Cluster Assistance Listing Number: 93.224/93.527 Pass-Through Agency: n/a Pass-Through Number(s): n/a Award Period: 9/1/23-8/31/25; 4/1/21-3/31/23; 6/1/19-5/31/23; 6/1/23-5/31/26; 12/1/22-5/31/23 Type of Finding: Significant deficiency in internal control over compliance Criteria or Specific Requirement: § 200.303(a) indicates non-federal entities must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States or the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). Condition: The Organization could not provide supporting documentation showing management's review and approval of costs totaling $511 for camera supplies. Questioned Costs: None. Context: Of the three transactions selected for testing, there was no documentation available to support management's review and approval of one transaction. Cause: Management turnover. Effect: If costs are not reviewed and approved as being allowable, it could result in unallowable costs being charged to federal grants. Repeat Finding: No. Recommendation: We recommend the Organization maintain approvals electronically within Intacct. Views of Responsible Officials: There is no disagreement with the audit finding.
Action taken in response to finding: 1. Move all purchase and invoice approvals to Intacct: Complete 2. Establish approval matrix in accordance with delegation of authority: In progress Name of the contact person responsible for corrective action: Keith Flores, CFO Planned completion date for corrective action plan: End of 2024
The Organization did not maintain supporting documentation showing an independent review and approval of Federal Financial Reports occurring prior to the reports being filed. Questioned Costs: None. Context: Two of two reports selected for testing did not contain evidence of an independent review occurring prior to the report being filed. Cause: Management turnover. Effect: Incorrect or inaccurate reports could be submitted if they are not reviewed prior to being filed. Repeat Finding: No. Recommendation: The Organization should ensure appropriate supporting documentation is maintained which shows the person who completed the review as well as the date the review was completed. Views of Responsible Officials: There is no disagreement with the audit finding.
Show full finding ▾Hide full finding ▴2023-007 – Reporting Federal agency: U.S. Department of Health and Human Services Federal program title: Health Centers Cluster Assistance Listing Number: 93.224/93.527 Pass-Through Agency: n/a Pass-Through Number(s): n/a Award Period: 9/1/23-8/31/25; 4/1/21-3/31/23; 6/1/19-5/31/23; 6/1/23-5/31/26; 12/1/22-5/31/23 Type of Finding: Significant Deficiency in internal control over compliance Criteria or Specific Requirement: § 200.329 indicates that the non-federal entity is responsible for oversight of the operations of the Federal award supported activities. The non-Federal entity must monitor its activities under Federal awards to assure compliance with applicable Federal requirements and performance expectations are being achieved. Condition: The Organization did not maintain supporting documentation showing an independent review and approval of Federal Financial Reports occurring prior to the reports being filed. Questioned Costs: None. Context: Two of two reports selected for testing did not contain evidence of an independent review occurring prior to the report being filed. Cause: Management turnover. Effect: Incorrect or inaccurate reports could be submitted if they are not reviewed prior to being filed. Repeat Finding: No. Recommendation: The Organization should ensure appropriate supporting documentation is maintained which shows the person who completed the review as well as the date the review was completed. Views of Responsible Officials: There is no disagreement with the audit finding.
Action taken in response to finding: 1. Develop documentation procedures: In Progress a. Establish a standardized procedure for documenting the preparation and review of Federal Financial Reports. 2. Select appropriate party for independent review: Complete 3. Store and maintain documentation in a shared location for future audit and review: Complete Name of the contact person responsible for corrective action: Keith Flores, CFO Planned completion date for corrective action plan: End of 2024
2022-006
The Organization charged expenses incurred in fiscal year 2022 to the grant in fiscal year 2023. Questioned Costs: $10,402. Context: The Organization charged subscription costs for the period June 2022 - December 2022 to the grant in fiscal year 2023. Cause: Management turnover. Effect: The Organization is requesting reimbursement for costs not incurred during the fiscal year. Repeat Finding: No. Recommendation: We recommend that subscription costs spanning multiple fiscal years be tracked carefully and charged to the grant in the appropriate year. Views of Responsible Officials: There is no disagreement with the audit finding.
Show full finding ▾Hide full finding ▴2023-008 – Allowable Costs Federal agency: U.S. Department of Health and Human Services Federal program title: Health Centers Cluster Assistance Listing Number: 93.224/93.527 Pass-Through Agency: n/a Pass-Through Number(s): n/a Award Period: 9/1/23-8/31/25; 4/1/21-3/31/23; 6/1/19-5/31/23; 6/1/23-5/31/26; 12/1/22-5/31/23 Type of Finding: Immaterial Noncompliance and Significant Deficiency in internal control over compliance Criteria or Specific Requirement: Code of Federal Regulations (CFR) § 200.403(h) states that costs must be incurred during the approved budget period. Condition: The Organization charged expenses incurred in fiscal year 2022 to the grant in fiscal year 2023. Questioned Costs: $10,402. Context: The Organization charged subscription costs for the period June 2022 - December 2022 to the grant in fiscal year 2023. Cause: Management turnover. Effect: The Organization is requesting reimbursement for costs not incurred during the fiscal year. Repeat Finding: No. Recommendation: We recommend that subscription costs spanning multiple fiscal years be tracked carefully and charged to the grant in the appropriate year. Views of Responsible Officials: There is no disagreement with the audit finding.
Action taken in response to finding: 1. Create a standard procedure for tracking grant expenses: Completed 2. Train staff on procedures: Completed 3. Create an independent review process for all grant tracking: In progress Name of the contact person responsible for corrective action: Keith Flores, CFO Planned completion date for corrective action plan: End of 2024
FAC accepted this audit on June 18, 2024 — management decision was due December 18, 2024.
The Organization assessed an incorrect sliding fee discount. Questioned costs: None. Context: The Organization assessed one of forty patient encounters selected for testing, the incorrect sliding fee discount. Cause: Unknown Effect: Patients are not charged according to the Organization's sliding fee scale and their ability to pay. Repeat Finding: The finding is a repeat of a finding in the immediately prior year. Prior year finding number was 2021-008. Recommendation: Management should consider increasing the frequency of its self-reviews of patient encounters or expanding its sample sizes in addition to providing additional training for front desk staff regarding the collection and verification of patient information for each patient. Views of responsible officials: There is no disagreement with the audit finding.
Show full finding ▾Hide full finding ▴2022-003 – Special Tests and Provisions Federal agency: U.S. Department of Health and Human Services Federal program title: Health Centers Cluster Assistance Listing Number: 93.224/93.527 Pass-Through Agency: n/a Pass-Through Number(s): n/a Award Period: 6/1/21-5/31/22 & 6/1/22-5/31/23 Type of Finding: Significant Deficiency in Internal Control over Compliance and Other Matters Criteria or specific requirement: Health centers must prepare and apply a sliding fee discount schedule so that the amounts owed for health center services by eligible patients are adjusted (discounted) based on the patient’s ability to pay. (42 USC 254(k)(3)(E), (F), and (G); 42 CFR sections 51c.303(e), (f), and (g); and 42 CFR sections 56.303(e), (f), and (g)). Condition: The Organization assessed an incorrect sliding fee discount. Questioned costs: None. Context: The Organization assessed one of forty patient encounters selected for testing, the incorrect sliding fee discount. Cause: Unknown Effect: Patients are not charged according to the Organization's sliding fee scale and their ability to pay. Repeat Finding: The finding is a repeat of a finding in the immediately prior year. Prior year finding number was 2021-008. Recommendation: Management should consider increasing the frequency of its self-reviews of patient encounters or expanding its sample sizes in addition to providing additional training for front desk staff regarding the collection and verification of patient information for each patient. Views of responsible officials: There is no disagreement with the audit finding.
Special Tests and Provisions – Assistance Listing No. 93.224/93.527 Recommendation: Management should consider increasing the frequency of its self-reviews of patient encounters or expanding its sample sizes in addition to providing additional training for front desk staff regarding the collection and verification of patient information for each patient. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: to start 1. Review current policies and procedures: in progress a. Conduct a comprehensive review of existing procedures for collection and verification of patient information to identify weaknesses, gaps, and areas for improvement. b. Conduct review of current front desk workflow to determine if policies and procedures are followed correctly. c. Enhance policies and procedures as necessary to improve accuracy and consistency of patient information 2. Verification Process: to start a. Review documentation requirements for verifying accuracy of sliding fee information and standardize/improve where necessary. 3. Training and Education: to start a. Review training materials and create/improve where necessary to provide clear instructions and comply with policy and procedure b. Train front desk staff on standardized forms, templates and scripts for collecting information from patients c. Require periodic training and re-training to improve front desk workflow and retention of process to consistently collect and verify information from patients 4. Quality Assurance: to start a. Conduct regular audits and quality assurance checks to monitor the accuracy and integrity of sliding fee information and implementation of sliding fee discount b. Implement corrective actions to address any discrepancies or deficiencies identified during audits or reviews Name of the contact person responsible for corrective action: Keith Flores, CFO Planned completion date for corrective action plan: Summer/Fall 2024
2021-008
The Organization assessed an incorrect sliding fee discount. Questioned costs: None. Context: The Organization assessed one of forty patient encounters selected for testing, the incorrect sliding fee discount. Cause: Unknown Effect: Patients are not charged according to the Organization's sliding fee scale and their ability to pay. Repeat Finding: The finding is a repeat of a finding in the immediately prior year. Prior year finding number was 2021-008. Recommendation: Management should consider increasing the frequency of its self-reviews of patient encounters or expanding its sample sizes in addition to providing additional training for front desk staff regarding the collection and verification of patient information for each patient. Views of responsible officials: There is no disagreement with the audit finding.
Show full finding ▾Hide full finding ▴2022-003 – Special Tests and Provisions Federal agency: U.S. Department of Health and Human Services Federal program title: Health Centers Cluster Assistance Listing Number: 93.224/93.527 Pass-Through Agency: n/a Pass-Through Number(s): n/a Award Period: 6/1/21-5/31/22 & 6/1/22-5/31/23 Type of Finding: Significant Deficiency in Internal Control over Compliance and Other Matters Criteria or specific requirement: Health centers must prepare and apply a sliding fee discount schedule so that the amounts owed for health center services by eligible patients are adjusted (discounted) based on the patient’s ability to pay. (42 USC 254(k)(3)(E), (F), and (G); 42 CFR sections 51c.303(e), (f), and (g); and 42 CFR sections 56.303(e), (f), and (g)). Condition: The Organization assessed an incorrect sliding fee discount. Questioned costs: None. Context: The Organization assessed one of forty patient encounters selected for testing, the incorrect sliding fee discount. Cause: Unknown Effect: Patients are not charged according to the Organization's sliding fee scale and their ability to pay. Repeat Finding: The finding is a repeat of a finding in the immediately prior year. Prior year finding number was 2021-008. Recommendation: Management should consider increasing the frequency of its self-reviews of patient encounters or expanding its sample sizes in addition to providing additional training for front desk staff regarding the collection and verification of patient information for each patient. Views of responsible officials: There is no disagreement with the audit finding.
Procurement – Assistance Listing No. 93.224/93.527 Recommendation: We recommend that Promise Healthcare revise its procurement policy to be consistent with the requirements of the Uniform Guidance and follow the stated procedures. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: 1. Review Current Procurement Policy: in progress a. Conduct a comprehensive review of Promise Healthcare’s existing procurement policy. b. Identify and revise and discrepancies or non-compliance with the requirements of the Uniform Guidance. c. Integrate industry best practices into revised policy to enhance compliance and efficiency 2. Training and Education: to start a. Provide training sessions for staff authorized to purchase along with relevant personnel on the revised procurement policy and procedures and raise awareness of the requirements of the Uniform Guidance and implications of non-compliance. b. Establish training on documentation standards for procurement activities including requisitions, solicitations, evaluations and contract awards. c. Establish training and procedure for retention of procurement-related documentation 3. Internal Controls and oversight: to start a. Implement mechanisms for monitoring and oversight to ensure compliance with the procurement policy. b. Conduct periodic internal audits to assess adherence to procurement procedures and identify areas for improvement or corrective action
2021-006
The Organization could not provide documentation that vendors were verified as not being suspended or debarred prior to entering into the transaction. Questioned costs: $133,105 Context: Two of two vendors selected for testing suspension and debarment, did not have documentation showing that suspension and debarment had been checked prior to entering into a contract. Cause: Management turnover Effect: The Organization could enter into transactions using federal dollars with vendors that are suspended or debarred. Repeat Finding: The finding is a repeat of a finding in the immediately prior year. Prior year finding number was 2021-006. Recommendation: We recommend that the Organization verify that vendors are not suspended or debarred prior to signing contracts or create an approved vendor list. Views of responsible officials: There is no disagreement with the audit finding.
Show full finding ▾Hide full finding ▴Federal agency: U.S. Department of Health and Human Services Federal program title: Health Centers Cluster Assistance Listing Number: 93.224/93.527 Pass-Through Agency: n/a Pass-Through Number(s): n/a Award Period: 6/1/21-5/31/22 & 6/1/22-5/31/23 Type of Finding: Material Noncompliance and Material Weakness in Internal Control over Compliance Criteria or specific requirement: § 200.214 Suspension and debarment. Non-Federal entities are subject to the non-procurement debarment and suspension regulations implementing Executive Orders 12549 and 12689, 2 CFR part 180. The regulations in 2 CFR part 180 restrict awards, subawards, and contracts with certain parties that are debarred, suspended, or otherwise excluded from or ineligible for participation in Federal assistance programs or activities. Condition: The Organization could not provide documentation that vendors were verified as not being suspended or debarred prior to entering into the transaction. Questioned costs: $133,105 Context: Two of two vendors selected for testing suspension and debarment, did not have documentation showing that suspension and debarment had been checked prior to entering into a contract. Cause: Management turnover Effect: The Organization could enter into transactions using federal dollars with vendors that are suspended or debarred. Repeat Finding: The finding is a repeat of a finding in the immediately prior year. Prior year finding number was 2021-006. Recommendation: We recommend that the Organization verify that vendors are not suspended or debarred prior to signing contracts or create an approved vendor list. Views of responsible officials: There is no disagreement with the audit finding.
Suspension and Debarment – Assistance Listing No. 93.224/93.527 Recommendation: We recommend that Promise Healthcare verify that vendors are not suspended or debarred prior to signing contracts or create an approved vendor list. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: 1. Create procedure to verify vendors are not suspended or debarred: in progress a. Develop steps in the vendor diligence and procurement process to verify that the vendor is not suspended or debarred. b. Identify role or job that will handle responsibility for following procedure. c. Formalize the process into a written procedure and add to the procurement or other relevant policy. d. Conduct periodic audits to assess adherence to the procedure and train as necessary to ensure compliance.
2121-006
There were two instances in which documentation was not available to support amounts included within reports submitted. These instances affected the Federal Financial Report and the UDS report. Questioned costs: None. Context: Documentation was not available to support the amount reported on line E, Federal share of expenditures, of the ARPA Federal Financial Report. In addition, there was no documentation to support two key lines items of the UDS report, Table 9E, Lines 1g and 1q, Column A. Cause: Management turnover Effect: Inaccurate reports could be file if there is no underlying documentation to support the amounts reported. Repeat Finding: The finding is a repeat of a finding in the immediately prior year. Prior year finding number was 2021-07. Recommendation: We recommend that the Organization maintain supporting documentation for all reports required to be filed to the federal agency. Views of responsible officials: There is no disagreement with the audit finding.
Show full finding ▾Hide full finding ▴2022-006 – Reporting Federal agency: U.S. Department of Health and Human Services Federal program title: Health Centers Cluster Assistance Listing Number: 93.224/93.527 Pass-Through Agency: n/a Pass-Through Number(s): n/a Award Period: 6/1/21-5/31/22 & 6/1/22-5/31/23 Type of Finding: Significant Deficiency in Internal Control over Compliance Criteria or specific requirement: § 200.329 indicates that the non-federal entity is responsible for oversight of the operations of the Federal award supported activities. The non-Federal entity must monitor its activities under Federal awards to assure compliance with applicable Federal requirements and performance expectations are being achieved. Condition: There were two instances in which documentation was not available to support amounts included within reports submitted. These instances affected the Federal Financial Report and the UDS report. Questioned costs: None. Context: Documentation was not available to support the amount reported on line E, Federal share of expenditures, of the ARPA Federal Financial Report. In addition, there was no documentation to support two key lines items of the UDS report, Table 9E, Lines 1g and 1q, Column A. Cause: Management turnover Effect: Inaccurate reports could be file if there is no underlying documentation to support the amounts reported. Repeat Finding: The finding is a repeat of a finding in the immediately prior year. Prior year finding number was 2021-07. Recommendation: We recommend that the Organization maintain supporting documentation for all reports required to be filed to the federal agency. Views of responsible officials: There is no disagreement with the audit finding.
Reporting – Assistance Listing No. 93.224/93.527 Recommendation: We recommend that Promise Healthcare maintain supporting documentation for all reports required to be filed to the federal agency. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: 1. Create procedure to deposit all supporting files and schedules in a shared and accessible location: in progress a. Develop steps in the UDS process that outlines where working and final supporting schedules will be stored for future access b. Identify role or job that will handle responsibility for following the procedure. c. Formalize the process into a written procedure and add to the UDS Report or other relevant policy. d. After UDS submission, review data folders to check that all relevant supporting schedules and documents have been deposited.
2021-007
FAC accepted this audit on January 9, 2023 — management decision was due July 9, 2023.
Lack of supporting documentation showing management's review and approval of costs as being allowable under the grant terms, prior to being charged to the grant and drawn down. Questioned costs: None Context: For 60 of the 60 allowable cost transactions selected for testing, there was no documentation showing management's review and approval of the expense as being allowable, prior to the grant drawn down occurring. Cause: Management turnover Effect: If costs are not reviewed and approved as being allowable, it could result in unallowable costs being charged to federal grants. Repeat Finding: No Recommendation: We recommend the organization enhance its internal controls in order to require the maintaining of appropriate supporting documentation to show the review and approval of expenses charged to grants, prior to drawing down grant funds. Views of responsible officials: There is no disagreement with the audit finding.
Show full finding ▾Hide full finding ▴Federal agency: U.S. Department of Health and Human Services Federal program title: Health Centers Cluster Assistance Listing Number: 93.224/93.527 Pass-Through Agency: n/a Pass-Through Number(s): n/a Award Period: 6/1/20-5/31/21 & 6/1/21-5/31/22 Type of Finding: Material Weakness in Internal Control over Compliance Criteria or specific requirement: Code of Federal Regulations (CFR) ? 200.303(a) indicates non-federal entities must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). Condition: Lack of supporting documentation showing management's review and approval of costs as being allowable under the grant terms, prior to being charged to the grant and drawn down. Questioned costs: None Context: For 60 of the 60 allowable cost transactions selected for testing, there was no documentation showing management's review and approval of the expense as being allowable, prior to the grant drawn down occurring. Cause: Management turnover Effect: If costs are not reviewed and approved as being allowable, it could result in unallowable costs being charged to federal grants. Repeat Finding: No Recommendation: We recommend the organization enhance its internal controls in order to require the maintaining of appropriate supporting documentation to show the review and approval of expenses charged to grants, prior to drawing down grant funds. Views of responsible officials: There is no disagreement with the audit finding.
Allowable Costs and Activities ? Assistance Listing No. 93.224/93.527 Recommendation: We recommend the organization enhance its internal controls to require the maintaining of appropriate supporting documentation to show the review and approval of expenses charged to grants, prior to drawing down grant funds. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Promise Healthcare has adopted a draw down policy and new procedures to outline and adopt HRSA guidelines, as directed by CFR part 75 Subpart E to ensure that costs are allowable, reasonable, allocable, and accurately documented. Promise Healthcare has implemented the process for all drawdowns to be reviewed and approved by the CFO and the Executive Director as final authority within the organization prior to draw request submission. The revenue and expenditures as related to all grants will be tracked, documented, and recorded in the accounting system with built in electronic workflows and internal controls to ensure proper reporting and approvals. Promise Healthcare has also implemented procedures to ensure that reconciliations are conducted as needed to ensure all documentation and expenditures are being tracked accurately. Name of the contact person responsible for corrective action: Jamie Dahlman, CFO Planned completion date for corrective action plan: January 2023
The Organization could not provide documentation showing an independent review and approval of grant drawdowns prior to the drawn down occurring. Questioned costs: None Context: For 8 of the 14 drawdowns selected for testing, there was no documentation of management review and approval of the drawdown. Cause: Management turnover Effect: Not maintaining sufficient documentation for the approval of drawdowns, could result in the Organization drawing down funds in advance of incurring eligible expense. Repeat Finding: No Recommendation: We recommend the Organization revise its internal controls to require an independent review and approval of all grant drawdowns, prior to the drawdown being initiated. This approval should include a review of appropriate supporting documentation which evidences the incurring of allowable costs. Views of responsible officials: There is no disagreement with the audit finding.
Show full finding ▾Hide full finding ▴2021-005 ? Cash Management Federal agency: U.S. Department of Health and Human Services Federal program title: Health Centers Cluster Assistance Listing Number: 93.224/93.527 Pass-Through Agency: n/a Pass-Through Number(s): n/a Award Period: 6/1/20-5/31/21 & 6/1/21-5/31/22 Type of Finding: Material Weakness in Internal Control over Compliance Criteria or specific requirement: CFR ? 200.305(b)(3) indicates reimbursement of costs previously occurred as an acceptable method for requesting payment of Federal funds. However, the Organization is responsible for determining that the organization paid for the costs for which reimbursement is being requested, prior to the date of the reimbursement request. Condition: The Organization could not provide documentation showing an independent review and approval of grant drawdowns prior to the drawn down occurring. Questioned costs: None Context: For 8 of the 14 drawdowns selected for testing, there was no documentation of management review and approval of the drawdown. Cause: Management turnover Effect: Not maintaining sufficient documentation for the approval of drawdowns, could result in the Organization drawing down funds in advance of incurring eligible expense. Repeat Finding: No Recommendation: We recommend the Organization revise its internal controls to require an independent review and approval of all grant drawdowns, prior to the drawdown being initiated. This approval should include a review of appropriate supporting documentation which evidences the incurring of allowable costs. Views of responsible officials: There is no disagreement with the audit finding.
Cash Management ? Assistance Listing No. 93.224/93.527 Recommendation: We recommend the Organization revise its internal controls to require an independent review and approval of all grant drawdowns, prior to the drawdown being initiated. This approval should include a review of appropriate supporting documentation which evidences the incurring of allowable costs. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Promise Healthcare has adopted a draw down policy and new procedures to outline and adopt HRSA guidelines, as directed by CFR part 75 Subpart E to ensure that costs are allowable, reasonable, allocable, and accurately documented. Promise Healthcare has implemented the process for all drawdowns to be reviewed and approved by initialing by the CFO, and then the Executive Director with final approval authority within the organization prior to draw request submission. The revenue and expenditures as related to all grants will be tracked, documented, and recorded in the accounting system with built in electronic workflows and internal controls to ensure proper reporting and approvals. Promise Healthcare has also implemented procedures to ensure that reconciliations are conducted as needed to ensure all documentation and expenditures are being tracked accurately. Name of the contact person responsible for corrective action: Jamie Dahlman, CFO Planned completion date for corrective action plan: January 2023
The Organization did not have a procurement policy or suspension and debarment policy in place which was consistent with the requirements of the Uniform Guidance. As a result, the Organization could not provide supporting documentation showing that engaged vendors had gone through an appropriate procurement process. Questioned costs: $384,727 Context: 2 of 2 vendors selected for procurement testing, did not have documentation showing that the cost had been procured in accordance with the Uniform Guidance. Additionally, 2 of 2 vendors selected for testing suspension and debarment, did not have documentation showing that suspension and debarment had been checked prior to entering into a contract. Cause: Management turnover Effect: Lack of appropriate procurement, suspension and debarment policies could result in the Organization engaging vendors who are debarred from doing business with the United States Government and/or using federal funds in manner that is not the most efficient or economical. Repeat Finding: No Recommendation: We recommend the Organization revised its internal controls related to procurement, suspension and debarment such that they align with the requirements of the Uniform Guidance. Views of responsible officials: There is no disagreement with the audit finding.
Show full finding ▾Hide full finding ▴2021-006 ? Procurement, Suspension and Debarment Federal agency: U.S. Department of Health and Human Services Federal program title: Health Centers Cluster Assistance Listing Number: 93.224/93.527 Pass-Through Agency: n/a Pass-Through Number(s): n/a Award Period: 6/1/20-5/31/21 & 6/1/21-5/31/22 Type of Finding: Material Noncompliance and Material Weakness in Internal Control over Compliance Criteria or specific requirement: CFR ? 200.320 indicates the various methods of procurement to be followed. The non-Federal entity must have and use documented procurement procedures, consistent with the standards of this section and ? 200.317, 200.318, and 200.319 for any of the approved procurement methods used for the acquisition of property or services required under a Federal award or sub-award. ? 200.214 Suspension and debarment indicates non-Federal entities are subject to the non-procurement debarment and suspension regulations implementing Executive Orders 12549 and 12689, 2 CFR part 180. The regulations in 2 CFR part 180 restrict awards, subawards, and contracts with certain parties that are debarred, suspended, or otherwise excluded from or ineligible for participation in Federal assistance programs or activities. Condition: The Organization did not have a procurement policy or suspension and debarment policy in place which was consistent with the requirements of the Uniform Guidance. As a result, the Organization could not provide supporting documentation showing that engaged vendors had gone through an appropriate procurement process. Questioned costs: $384,727 Context: 2 of 2 vendors selected for procurement testing, did not have documentation showing that the cost had been procured in accordance with the Uniform Guidance. Additionally, 2 of 2 vendors selected for testing suspension and debarment, did not have documentation showing that suspension and debarment had been checked prior to entering into a contract. Cause: Management turnover Effect: Lack of appropriate procurement, suspension and debarment policies could result in the Organization engaging vendors who are debarred from doing business with the United States Government and/or using federal funds in manner that is not the most efficient or economical. Repeat Finding: No Recommendation: We recommend the Organization revised its internal controls related to procurement, suspension and debarment such that they align with the requirements of the Uniform Guidance. Views of responsible officials: There is no disagreement with the audit finding.
Procurement, Suspension and Debarment ? Assistance Listing No. 93.224/93.527 Recommendation: We recommend the Organization revised its internal controls related to procurement, suspension, and debarment such that they align with the requirements of the Uniform Guidance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Promise Healthcare has adopted a new policy and procedures to ensure that all vendors are appropriately run through the national database to align with HRSA regulations. Promise Healthcare has developed a new position titled Compliance Officer to ensure that we have met all guidelines set forth by regulating agencies. Additionally Promise purchased a software program, Compliatric in December of 2022. This program has several modules that assist us with compliance. One of the platforms that we purchased is a fully automated exclusion monitoring platform that has the flexibility to run continuous exclusion checks against the OIG?s List of Excluded Individuals and Entities (LEIE), General Services Administration?s (GSA) System for Award Management (SAM), and other federal and state exclusion lists at any continuous time interval. Unlike manual methods of looking up on websites or basic-use systems that require lists to be repeatedly loaded and maintained, this platform contains an active listing of all employees, contractors, and vendors that engage with our organization, and runs checks as frequently as required by governmental entities or contractual obligations. Name of the contact person responsible for corrective action: Jamie Dahlman, CFO, Zina Soltis, Compliance Officer Planned completion date for corrective action plan: January 2023
The Organization did not maintain supporting documentation showing an independent review and approval of Federal Financial Reports occurring prior to the reports being filed. Questioned costs: None Context: 3 of 3 reports selected for testing did not contain evidence of an independent review occurring prior to the report being filed. Cause: Management turnover Effect: Incorrect or inaccurate reports could be filed if they are not reviewed prior to being filed. Repeat Finding: No Recommendation: We recommend the Organization revise its internal controls to require an independent review of financial and performance reports prior to the reports being filed. The Organization should also ensure appropriate supporting documentation is maintained which shows the person who completed the review as well as the date the review was completed. Views of responsible officials: There is no disagreement with the audit finding.
Show full finding ▾Hide full finding ▴2021-007 ? Reporting Federal agency: U.S. Department of Health and Human Services Federal program title: Health Centers Cluster Assistance Listing Number: 93.224/93.527 Pass-Through Agency: n/a Pass-Through Number(s): n/a Award Period: 6/1/20-5/31/21 & 6/1/21-5/31/22 Type of Finding: Significant Deficiency in Internal Control over Compliance Criteria or specific requirement: CFR ? 200.329 indicates that the non-federal entity is responsible for oversight of the operations of the Federal award supported activities. The non-Federal entity must monitor its activities under Federal awards to assure compliance with applicable Federal requirements and performance expectations are being achieved. Condition: The Organization did not maintain supporting documentation showing an independent review and approval of Federal Financial Reports occurring prior to the reports being filed. Questioned costs: None Context: 3 of 3 reports selected for testing did not contain evidence of an independent review occurring prior to the report being filed. Cause: Management turnover Effect: Incorrect or inaccurate reports could be filed if they are not reviewed prior to being filed. Repeat Finding: No Recommendation: We recommend the Organization revise its internal controls to require an independent review of financial and performance reports prior to the reports being filed. The Organization should also ensure appropriate supporting documentation is maintained which shows the person who completed the review as well as the date the review was completed. Views of responsible officials: There is no disagreement with the audit finding.
Reporting ? Assistance Listing No. 93.224/93.527 Recommendation: We recommend the Organization revise its internal controls to require an independent review of financial and performance reports prior to the reports being filed. The Organization should also ensure appropriate supporting documentation is maintained which shows the person who completed the review and the date it was completed. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Promise Healthcare has developed a framework process where all financial statements are reviewed and approved by the Executive Director prior to release to the Board Finance Committee. The CFO will present the Financial Statements with appropriate documentation to the Executive Director monthly for review. The final step will be approval for filing. Name of the contact person responsible for corrective action: Jamie Dahlman, CFO Planned completion date for corrective action plan: January 2023
The Organization assessed an incorrect sliding fee discount. Questioned costs: None Context: The organization assessed 1 of 40 patient encounters selected for testing, the incorrect sliding fee discount. Cause: Management turnover Effect: Patients are not charged according to the Organization's sliding fee scale and their ability to pay. Repeat Finding: No Recommendation: Management should consider increasing the frequency of its self-reviews of patient encounters or expanding its sample sizes in addition to providing additional training for front desk staff regarding the collection and verification of patient information for each patient. Views of responsible officials: There is no disagreement with the audit finding.
Show full finding ▾Hide full finding ▴2021-008 ? Special Tests and Provisions Federal agency: U.S. Department of Health and Human Services Federal program title: Health Centers Cluster Assistance Listing Number: 93.224/93.527 Pass-Through Agency: n/a Pass-Through Number(s): n/a Award Period: 6/1/20-5/31/21 & 6/1/21-5/31/22 Type of Finding: Significant Deficiency in Internal Control over Compliance and Other Matters (Immaterial Non-Compliance) Criteria or specific requirement: Health centers must prepare and apply a sliding fee discount schedule so that the amounts owed for health center services by eligible patients are adjusted (discounted) based on the patient?s ability to pay. (42 USC 254(k)(3)(E), (F), and (G); 42 CFR sections 51c.303(e), (f), and (g); and 42 CFR sections 56.303(e), (f), and (g)). Condition: The Organization assessed an incorrect sliding fee discount. Questioned costs: None Context: The organization assessed 1 of 40 patient encounters selected for testing, the incorrect sliding fee discount. Cause: Management turnover Effect: Patients are not charged according to the Organization's sliding fee scale and their ability to pay. Repeat Finding: No Recommendation: Management should consider increasing the frequency of its self-reviews of patient encounters or expanding its sample sizes in addition to providing additional training for front desk staff regarding the collection and verification of patient information for each patient. Views of responsible officials: There is no disagreement with the audit finding.
Special Tests and Provisions ? Assistance Listing No. 93.224/93.527 Recommendation: Management should consider increasing the frequency of its self reviews of patient encounters or expanding its sample sizes in addition to providing additional training for front desk staff regarding the collection and verification of patient information for each patient. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Promise Healthcare has developed a sliding fee training program to presented to all new Patient Service Representative (PSR?s) to be completed for employee orientation. All established PSR?s were trained in the Sliding Fee training as well as part of the ongoing training program. Promise Health will establish a complete training program to help train in all competencies related to the collection and verification of patient information. Promise Health has developed checklists and will implement random audit reviews of PSR?s for evaluation of knowledge, completeness, and accuracy. Also, all sliding fee applications will be reviewed/revised by the department Director weekly to assure that every application is within policy. Any deficiencies or errors will be corrected and then the PSR(s) will receive additional training as needed so all are completely competent to deliver the sliding fee discount. Monthly reports will be delivered to the CFO and quarterly progress on our sliding fee scale policy performance will be reported to the board's finance committee. Name of the contact person responsible for corrective action: Jamie Dahlman, CFO, Department Director Planned completion date for corrective action plan: January 2023
FAC accepted this audit on October 6, 2021 — management decision was due April 6, 2022.
FAC accepted this audit on August 11, 2021 — management decision was due February 11, 2022.
We did not receive the Organization?s December 31, 2019 trial balance until March of 2021, and consequently we were not able to begin the audit field work until that time. The Organization was required to complete and submit its data collection form by September 30, 2020, but the form did not get completed and submitted until 2021. Questioned Costs: None Context: Not applicable Effect: The Organization was not in compliance with U.S. Code of Federal Regulations Title 2 CFR 200.512 which requires that the data collection form be submitted with nine months after the end of the audit period. In addition, the Organization was not in compliance with many of its grant agreements and contracts with funders. Cause: The Organization did not have the finance staffing levels, controls, and procedures in place necessary to close its books after year end and compile supporting schedules for the audit in a timely manner. Recommendation: We recommend that the Organization review finance staffing levels, internal controls, and procedures in place to determine what changes are necessary to ensure that its financial statements are ready to be audited in a more timely manner. Management Response: See corrective action plan on pages 35-37.
Show full finding ▾Hide full finding ▴SECTION III ? FEDERAL AWARD FINDINGS AND QUESTIONED COSTS Compliance: FINDING 2019-05 Timely Submission of Audit Report to Grantors and Timely Completion of Data Collection Form Federal Program Name: Health Center Program, Maternal and Child Health Services Block Grant to the States CFDA Number: 93.224, 93.994 Federal Agency: U.S. Department of Health and Human Services Criteria/Specific Requirement: U.S. Code of Federal Regulations Title 2 CFR 200.512 requires the Organization to complete and submit the data collection form within nine months after the end of the audit period. In addition, the Organization should comply with its grant agreements and contracts with funders, many of which require the Organization to submit an audit report within approximately 6 months of the end of its fiscal year. Condition: We did not receive the Organization?s December 31, 2019 trial balance until March of 2021, and consequently we were not able to begin the audit field work until that time. The Organization was required to complete and submit its data collection form by September 30, 2020, but the form did not get completed and submitted until 2021. Questioned Costs: None Context: Not applicable Effect: The Organization was not in compliance with U.S. Code of Federal Regulations Title 2 CFR 200.512 which requires that the data collection form be submitted with nine months after the end of the audit period. In addition, the Organization was not in compliance with many of its grant agreements and contracts with funders. Cause: The Organization did not have the finance staffing levels, controls, and procedures in place necessary to close its books after year end and compile supporting schedules for the audit in a timely manner. Recommendation: We recommend that the Organization review finance staffing levels, internal controls, and procedures in place to determine what changes are necessary to ensure that its financial statements are ready to be audited in a more timely manner. Management Response: See corrective action plan on pages 35-37.
FINDING 2019-05 Timely Submission of Audit Report to Grantors and Timely Completion of Data Collection Form Given the delays in the financial audits being performed at Promise, the 2018 audit was complete in December 2020 and as such this finding remains for the 2019 audit that is being completed in late May of 2021. Many of the factors that contributed to this finding are not expected to repeat. Promise has resolved many financial resource issues and added two additional financial staff members to support daily operations and allow for the audit preparation to be completed in a timely manner going forward. In addition, the Promise Board intends to bid out the audit functions for the organization moving forward to allow for assurance of independence, competitive pricing and more experienced firm(s) with FQHC specific knowledge.
2018-003
FAC accepted this audit on December 9, 2020 — management decision was due June 9, 2021.
GSA_MIGRATION
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