EIN: 200368759
UEI: VTA9YVH8P637
Data as of August 24, 2026
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on June 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 December 2, 2026 (99 days from today).
What is a management decision? →Health Center Program Cluster – Assistance Listing Number 93.224 U.S. Department of Health and Human Services Award No. 6 H80CS04286‐20, April 1, 2024 – March 31, 2025 Award No. 6 H80CS04286‐21, April 1, 2025 – March 31, 2026 Award No. 1 H8NCS53950‐01, September 1, 2024 – August 31, 2025 Award No. 4 H8JCS54721‐01, December 1, 2024 – November 30, 2025 Criteria or Specific Requirement – Special Tests and Provisions: Sliding Fee Discounts (42 USC 254(k)(3)(G); 42 CFR sections 51c.303(g); and 42 CFR sections 56.303 (f)) Condition – Sliding fee discounts applied to patient charges were inconsistent with the Organization’s sliding fee discount schedule. Cause – The Organization did not comply with its sliding fee discount policy. Effect or Potential Effect – The patients’ responsibility for services rendered by the Organization was inconsistent with the sliding fee discount schedules. Questioned costs – None Context – The population of sliding fee discounts was stratified between (1) in-house pharmacy dispensing fees and (2) all other in-scope services of the Organization. For in-house pharmacy services, a sample of 25 prescriptions was tested from a population of approximately 139,000 prescriptions dispensed through the Organization’s pharmacies, and 5 instances of inappropriate sliding fee discounts were identified. For all other in-scope services, a sample of 25 patient encounters was tested from a population of approximately 123,000 encounters, and 6 instances of inappropriate sliding fee discounts were identified. The sampling methodology employed was non-statistical and was not intended to be statistically valid. Identification as a Repeat Finding, if Applicable – Yes, see 2024-001. Recommendation – The Organization should continue educating personnel on the sliding fee discount program and consider implementing internal audits of sliding fee discounts to monitor and identify specific areas for further improvements or training. When causes to exceptions are identified, the Organization should consider retroactive corrections to remedy noncompliance.
Show full finding ▾Hide full finding ▴Health Center Program Cluster – Assistance Listing Number 93.224 U.S. Department of Health and Human Services Award No. 6 H80CS04286‐20, April 1, 2024 – March 31, 2025 Award No. 6 H80CS04286‐21, April 1, 2025 – March 31, 2026 Award No. 1 H8NCS53950‐01, September 1, 2024 – August 31, 2025 Award No. 4 H8JCS54721‐01, December 1, 2024 – November 30, 2025 Criteria or Specific Requirement – Special Tests and Provisions: Sliding Fee Discounts (42 USC 254(k)(3)(G); 42 CFR sections 51c.303(g); and 42 CFR sections 56.303 (f)) Condition – Sliding fee discounts applied to patient charges were inconsistent with the Organization’s sliding fee discount schedule. Cause – The Organization did not comply with its sliding fee discount policy. Effect or Potential Effect – The patients’ responsibility for services rendered by the Organization was inconsistent with the sliding fee discount schedules. Questioned costs – None Context – The population of sliding fee discounts was stratified between (1) in-house pharmacy dispensing fees and (2) all other in-scope services of the Organization. For in-house pharmacy services, a sample of 25 prescriptions was tested from a population of approximately 139,000 prescriptions dispensed through the Organization’s pharmacies, and 5 instances of inappropriate sliding fee discounts were identified. For all other in-scope services, a sample of 25 patient encounters was tested from a population of approximately 123,000 encounters, and 6 instances of inappropriate sliding fee discounts were identified. The sampling methodology employed was non-statistical and was not intended to be statistically valid. Identification as a Repeat Finding, if Applicable – Yes, see 2024-001. Recommendation – The Organization should continue educating personnel on the sliding fee discount program and consider implementing internal audits of sliding fee discounts to monitor and identify specific areas for further improvements or training. When causes to exceptions are identified, the Organization should consider retroactive corrections to remedy noncompliance.
Management agrees with the finding and recommendation regarding sliding fee discount compliance and has taken corrective actions to address the identified issues. For non-pharmacy in-scope services, a portion of the exceptions identified resulted from the implementation of the Organization’s new OCHIN Epic electronic health record system effective January 1, 2025. During the initial system build and configuration process, certain CPT codes that should have been designated as eligible for sliding fee discounts were not appropriately mapped as “slideable” services within the EHR. Upon discovery, a ticket was submitted to OCHIN Epic on March 15, 2026, to correct the system configuration. Affected patient accounts were subsequently identified and corrected retroactively. Additionally, during the EHR setup process, the adjustment code title “SFS Discount” was inadvertently applied to employee discount adjustments rather than the correct “Employee Discount Adjustment” designation required under Organization policy. While there was no financial impact to patient balances or charges, certain employee discounts may have been incorrectly reflected within reporting categories. Upon identifying the issue, a correction ticket was submitted to OCHIN Epic on May 21, 2025, to update the system configuration. At the time, billing staff believed the system correction would apply both prospectively and retroactively; however, during the audit process it was determined that historical transactions existing prior to the EHR correction also required manual retroactive adjustment within the system. Since that time, affected accounts have been reviewed and corrected retroactively, and management has implemented additional procedures to ensure future system correction tickets are evaluated for any required historical manual corrections. For in-house pharmacy dispensing fees, the Organization implemented Pharmacy Policy PH-113, In-House Sliding Fee Policy, which was approved by the Board of Directors in July 2025 as part of corrective actions related to the prior year audit process. Staff training on the revised policy and procedures was completed during July and August 2025. The Organization notes that all pharmacy exceptions identified during the fiscal year 2025 audit related to prescriptions dispensed prior to implementation of PH-113. Based on external audit testing of post-implementation prescriptions and ongoing internal self-audits, management believes the revised policy, training, and monitoring processes have substantially corrected the identified issues. Management will continue performing periodic internal audits, staff education, retroactive corrections when necessary, and ongoing monitoring of sliding fee discount application within both the EHR and pharmacy systems to ensure continued compliance with Health Center Program requirements. In addition, following HRSA program guidance and discussions communicated in March 2026 regarding application of sliding fee discounts to pharmacy dispensing fees, the Organization is evaluating revisions to Pharmacy Policy PH-113 to align future dispensing fee practices with current HRSA guidance and operational best practices. The Organization will continue maintaining internal monitoring, periodic self-audits, and corrective action procedures to identify and remediate potential issues timely. Anticipated Completion Date: Corrective actions related to identified fiscal year 2025 sliding fee discount exceptions, retroactive account corrections, EHR configuration updates, staff training, and implementation of enhanced monitoring procedures were substantially completed by May 31, 2026. Ongoing internal audits, monitoring, and policy evaluations will continue as part of normal compliance operations. Responsible Individuals: CFO, Pharmacy Director, Billing Supervisor, Revenue Cycle Staff, Clinical Leadership, and Information Technology/EHR Support Staff
2024-001
FAC accepted this audit on July 11, 2025 — management decision was due January 11, 2026.
Health Center Program Cluster – Assistance Listing Numbers 93.224 and 93.527 U.S. Department of Health and Human Services Award No. 6 H80CS04286-19, April 1, 2023 – March 31, 2024 Award No. 6 H80CS04286‐20, April 1, 2024 – March 31, 2025 Award No. 6 H8FCS41015‐01, April 1, 2021 – March 31, 2024 Award No. 6 H8GCS47983‐01, December 1, 2022 – December 31, 2023 Award No. 5 H8HCSHealth Center Program Cluster – Assistance Listing Numbers 93.224 and 93.527 U.S. Department of Health and Human Services Award No. 6 H80CS04286-19, April 1, 2023 – March 31, 2024 Award No. 6 H80CS04286-20, April 1, 2024 – March 31, 2025 Award No. 6 H8FCS41015-01, April 1, 2021 – March 31, 2024 Award No. 6 H8GCS47983-01, December 1, 2022 – December 31, 2023 Award No. 5 H8HCS45036-02, September 1, 2022 – August 31, 2023 Award No. 1 H8ICS46994-01, September 1, 2022 – August 31, 2024 Award No. 1 H8LCS51874-01, September 1, 2023 – December 31, 2024 Criteria or Specific Requirement – Special Tests and Provisions: Sliding Fee Discounts (42 USC 254(k)(3)(g); 42 CFR sections 51c.303(g); and 42 CFR sections 56.303 (f)) Condition – Sliding fee discounts applied to patient charges were inconsistent with the Organization’s sliding fee discount schedule. The Organization’s sliding fee discount policy is not compliant with the Health Center Compliance Manual for dispense fees of its in-house pharmacies, which are within the scope of the Health Center Program. Cause – The Organization did not comply with its sliding fee discount policy. The Organization also expanded it’s in-house pharmacy services in recent years without ensuring the informal policy and information system were set up in compliance with the Health Center Compliance Manual. Effect or potential effect – The patients’ responsibility for services rendered by the Organization was inconsistent with the sliding fee discount schedules. Additionally, the Organization’s sliding fee discount schedules for in-house pharmacy dispense fees did not contain the required number of categories between 100% and 200% of the federal poverty levels (FPL) or differentiate dispense fees based on FPL for certain prescription drugs. Further, not all patients of the Organization’s in-house pharmacies were given the opportunity for the sliding fee discount program. Questioned costs – None Context – The population of sliding fee discounts was stratified between in-house pharmacy dispense fees and all other in-scope services of the Organization. A sample of 25 prescriptions were tested out of a population of approximately 52,000 prescriptions dispensed through the in-house pharmacies and 7 instances of inappropriate sliding fee discounts were identified. A sample of 25 encounters were tested out of the population of approximately 146,000 encounters for all other inscope services and 2 instances of inappropriate sliding fee discounts were identified. The sampling methodology used is not and is not intended to be statistically valid. Additionally, the Organization’s informal policy for sliding fee discounts of in-house pharmacy dispense fees contains 2 categories instead of the minimum of 3 between 100% and 200% of the FPL. The Organization also maintains 2 lists of prescription drugs that are dispensed for a flat dispensing fee if covered under the 340B program, rather than applying discounts based on the patient’s ability to pay. Finally, the Organization only offers sliding fee discounts on prescriptions that also qualify under the 340B program. Identification as a repeat finding, if applicable – No. Recommendation – The Organization should review the sliding fee discount policy and schedules to ensure compliance with the Health Center Program Compliance Manual for all services within the scope of the program while considering improvements that can be made to improve compliance with the policy and schedules and increased accuracy of system-generated adjustments. The Organization should also continue educating personnel on the sliding fee discount program and consider implementing internal audits of sliding fee discounts to monitor and identify specific areas for further improvements or training.
Show full finding ▾Hide full finding ▴Health Center Program Cluster – Assistance Listing Numbers 93.224 and 93.527 U.S. Department of Health and Human Services Award No. 6 H80CS04286-19, April 1, 2023 – March 31, 2024 Award No. 6 H80CS04286‐20, April 1, 2024 – March 31, 2025 Award No. 6 H8FCS41015‐01, April 1, 2021 – March 31, 2024 Award No. 6 H8GCS47983‐01, December 1, 2022 – December 31, 2023 Award No. 5 H8HCSHealth Center Program Cluster – Assistance Listing Numbers 93.224 and 93.527 U.S. Department of Health and Human Services Award No. 6 H80CS04286-19, April 1, 2023 – March 31, 2024 Award No. 6 H80CS04286-20, April 1, 2024 – March 31, 2025 Award No. 6 H8FCS41015-01, April 1, 2021 – March 31, 2024 Award No. 6 H8GCS47983-01, December 1, 2022 – December 31, 2023 Award No. 5 H8HCS45036-02, September 1, 2022 – August 31, 2023 Award No. 1 H8ICS46994-01, September 1, 2022 – August 31, 2024 Award No. 1 H8LCS51874-01, September 1, 2023 – December 31, 2024 Criteria or Specific Requirement – Special Tests and Provisions: Sliding Fee Discounts (42 USC 254(k)(3)(g); 42 CFR sections 51c.303(g); and 42 CFR sections 56.303 (f)) Condition – Sliding fee discounts applied to patient charges were inconsistent with the Organization’s sliding fee discount schedule. The Organization’s sliding fee discount policy is not compliant with the Health Center Compliance Manual for dispense fees of its in-house pharmacies, which are within the scope of the Health Center Program. Cause – The Organization did not comply with its sliding fee discount policy. The Organization also expanded it’s in-house pharmacy services in recent years without ensuring the informal policy and information system were set up in compliance with the Health Center Compliance Manual. Effect or potential effect – The patients’ responsibility for services rendered by the Organization was inconsistent with the sliding fee discount schedules. Additionally, the Organization’s sliding fee discount schedules for in-house pharmacy dispense fees did not contain the required number of categories between 100% and 200% of the federal poverty levels (FPL) or differentiate dispense fees based on FPL for certain prescription drugs. Further, not all patients of the Organization’s in-house pharmacies were given the opportunity for the sliding fee discount program. Questioned costs – None Context – The population of sliding fee discounts was stratified between in-house pharmacy dispense fees and all other in-scope services of the Organization. A sample of 25 prescriptions were tested out of a population of approximately 52,000 prescriptions dispensed through the in-house pharmacies and 7 instances of inappropriate sliding fee discounts were identified. A sample of 25 encounters were tested out of the population of approximately 146,000 encounters for all other inscope services and 2 instances of inappropriate sliding fee discounts were identified. The sampling methodology used is not and is not intended to be statistically valid. Additionally, the Organization’s informal policy for sliding fee discounts of in-house pharmacy dispense fees contains 2 categories instead of the minimum of 3 between 100% and 200% of the FPL. The Organization also maintains 2 lists of prescription drugs that are dispensed for a flat dispensing fee if covered under the 340B program, rather than applying discounts based on the patient’s ability to pay. Finally, the Organization only offers sliding fee discounts on prescriptions that also qualify under the 340B program. Identification as a repeat finding, if applicable – No. Recommendation – The Organization should review the sliding fee discount policy and schedules to ensure compliance with the Health Center Program Compliance Manual for all services within the scope of the program while considering improvements that can be made to improve compliance with the policy and schedules and increased accuracy of system-generated adjustments. The Organization should also continue educating personnel on the sliding fee discount program and consider implementing internal audits of sliding fee discounts to monitor and identify specific areas for further improvements or training.
Background: SHWC previously lacked a formal sliding fee discount schedule (SFDS) policy specific to pharmacy services. Additionally, two non-pharmacy encounters failed to receive appropriate SFDS adjustments due to procedural errors when Proof of Income (POI) was submitted post-visit. Pharmacy-Specific Corrections Implemented Policies and Tools: • PH-113: In-House Pharmacy Sliding Fee Policy o Establishes a six-tier SFDS structure compliant with HRSA guidelines. o Applies consistent pricing formulas and automated EHR-driven tier adjustments. o Ensures access for all eligible patients, including those >200% FPL. o Complies with EO 14273 for critical medication pricing. • PH-114: Co-Pay Assistance Policy o Standardizes process for helping insured patients with unaffordable copays. o Uses a centralized pharmacy calculator and dual pricing logic (SFS Match, HCDRC). o Captures patient declarations via PH-113-F104 form and documents in EHR. Monitoring & Training: • Staff training on new workflows and tools. • Weekly and quarterly audits (e.g., price code validation, override reports, EHR cross-checks). • Pharmacy SFS policies now included in SHWC’s annual HRSA sliding fee review. Non-Pharmacy Corrections Revised Post-Visit POI Handling: • POI submitted after the visit must now be routed directly to the Billing Supervisor, who will: o Scan documents into the chart o Assess for SFS eligibility o Apply retroactive adjustments as appropriate Compliance Oversight: • The Compliance Officer will audit post-visit SFS adjustments, address documentation issues, and provide staff training as needed. Anticipated Completion Date: All corrective actions, policies, and audit mechanisms were implemented by July 31, 2025. Responsible Individuals: CFO, Pharmacy Director, Pharmacy Staff, Billing Supervisor, Compliance Officer, Registration Staff
Coronavirus State and Local Fiscal Recovery Funds – Assistance Lising No. 21.027 U.S Department of Treasury Oklahoma State Department of Health Criteria or Specific Requirement – Reporting (2 CFR 200.329) Condition – The Organization’s internal controls over compliance were not able to ensure progress reporting required to be submitted to the pass-through entity was completed timely. Cause – The Organization does not have internal controls over compliance in place to ensure all grant reporting requirements are satisfied timely. Effect or potential effect – The Organization did not submit the required quarterly progress reports in a timely manner. Questioned costs – None Context – The Organization is required to submit quarterly progress reports to the pass-through entity in a timely manner. Identification as a repeat finding, if applicable – No. Recommendation – The Organization should consider implementing a grant reporting calendar for all grants with reporting requirements.
Show full finding ▾Hide full finding ▴Coronavirus State and Local Fiscal Recovery Funds – Assistance Lising No. 21.027 U.S Department of Treasury Oklahoma State Department of Health Criteria or Specific Requirement – Reporting (2 CFR 200.329) Condition – The Organization’s internal controls over compliance were not able to ensure progress reporting required to be submitted to the pass-through entity was completed timely. Cause – The Organization does not have internal controls over compliance in place to ensure all grant reporting requirements are satisfied timely. Effect or potential effect – The Organization did not submit the required quarterly progress reports in a timely manner. Questioned costs – None Context – The Organization is required to submit quarterly progress reports to the pass-through entity in a timely manner. Identification as a repeat finding, if applicable – No. Recommendation – The Organization should consider implementing a grant reporting calendar for all grants with reporting requirements.
Background: The audit identified a need for stronger internal controls to ensure the timely submission of all required grant reports. Corrective Measures Implemented Centralized Tracking System: • A comprehensive, living grant reporting list is now maintained in Microsoft Teams. • The list includes: o All required grant reports categorized by program o A chronological tab with due dates, responsible staff, and report status Oversight & Monitoring: • The list is reviewed biweekly by the CFO, Grant Accountant, and other designated staff. • Upcoming deadlines are proactively flagged, and submission progress is tracked to ensure compliance. Outcome: This system improves SHWC’s ability to meet federal and state grant reporting deadlines and is subject to continuous review and updating. Anticipated Completion Date: Implemented as of Q1 FY2025 and reviewed on an ongoing basis. Responsible Individuals: CFO, Grant Accountant, and Grant Writer
FAC accepted this audit on November 16, 2022 — management decision was due May 16, 2023.
Criteria or Specific Requirement ? Reporting (45 CFR 75.342) and Activities Allowed or Unallowed and Allowable Costs/Cost Principles (Pub. L. No. 116-136, 134 Stat. 563 and Pub. L. No. 116-139, 134 Stat. 622 and 623). Condition ? Within the Provider Relief Fund Reporting Portal for Period 1, the Organization reported other Provider Relief Fund (PRF) expenses and lost revenues calculated using option i. The Organization did not maintain adequate documentation to support that certain other PRF expenses were attributable to coronavirus, incurred following the accrual basis of accounting during the period of availability, and/or not eligible to be reimbursed by other sources. The Organization also did not calculate lost revenues following the accrual basis of accounting and other guidance issued by HHS. Questioned Costs ? $1,113,496. Questioned costs of $288,260 were determined based on the listing of expenditures charged to PRF. Questioned costs of $825,236 were determined by comparing reported lost revenues to lost revenues attributable to coronavirus recalculated following HHS guidance for option i. Context ? The Period 1 PRF report was tested. The Organization utilized PRF payments received on annual insurance premiums, without identifying the portion of the increased premiums attributable to coronavirus and without excluding the portion relating to coverage beyond the period of performance. The Organization allocated salaries and employee benefits to PRF for time associated with COVID-19 vaccination clinics; however, a portion of these salaries and benefits were also reimbursed by other sources. Additionally, the Organization utilized PRF payments received on COVID testing supplies; however, the Organization had not fully drawn down Health Center Program COVID-19 supplemental grant funding fully prior to using PRF payments received on these expenses. The Organization did not adhere to the same internal controls as other federal grants that typically prevent expenditures from being charged to more than one funding stream and following the correct order of spending. Finally, the Organization calculated lost revenues based on patient service revenue information from the practice management system rather than accrual basis financial records. The Organization included management fee income in patient service revenue and did not make normalizations for net patient revenue payments received or payments made to third parties relating to care not provided in the reporting period. Effect ? Based on the Period 1 PRF report filed, the Organization utilized PRF payments received on expenses and lost revenues that were not attributable to coronavirus, were reimbursed by other sources, and/or were not allowable in accordance with other guidance issued by HHS. Cause ? Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution is a new program with complex and evolving regulations and compliance requirements. Internal controls were not in place to ensure the Organization correctly applied the guidance. Identification As a Repeat Finding ? Not a repeat finding. Recommendation ? Policies and procedures over allowable activities and federal grant reporting should be modified to ensure expenditures charged to grants are for activities allowed and federal grant reports are prepared using complete and accurate information.
Show full finding ▾Hide full finding ▴Criteria or Specific Requirement ? Reporting (45 CFR 75.342) and Activities Allowed or Unallowed and Allowable Costs/Cost Principles (Pub. L. No. 116-136, 134 Stat. 563 and Pub. L. No. 116-139, 134 Stat. 622 and 623). Condition ? Within the Provider Relief Fund Reporting Portal for Period 1, the Organization reported other Provider Relief Fund (PRF) expenses and lost revenues calculated using option i. The Organization did not maintain adequate documentation to support that certain other PRF expenses were attributable to coronavirus, incurred following the accrual basis of accounting during the period of availability, and/or not eligible to be reimbursed by other sources. The Organization also did not calculate lost revenues following the accrual basis of accounting and other guidance issued by HHS. Questioned Costs ? $1,113,496. Questioned costs of $288,260 were determined based on the listing of expenditures charged to PRF. Questioned costs of $825,236 were determined by comparing reported lost revenues to lost revenues attributable to coronavirus recalculated following HHS guidance for option i. Context ? The Period 1 PRF report was tested. The Organization utilized PRF payments received on annual insurance premiums, without identifying the portion of the increased premiums attributable to coronavirus and without excluding the portion relating to coverage beyond the period of performance. The Organization allocated salaries and employee benefits to PRF for time associated with COVID-19 vaccination clinics; however, a portion of these salaries and benefits were also reimbursed by other sources. Additionally, the Organization utilized PRF payments received on COVID testing supplies; however, the Organization had not fully drawn down Health Center Program COVID-19 supplemental grant funding fully prior to using PRF payments received on these expenses. The Organization did not adhere to the same internal controls as other federal grants that typically prevent expenditures from being charged to more than one funding stream and following the correct order of spending. Finally, the Organization calculated lost revenues based on patient service revenue information from the practice management system rather than accrual basis financial records. The Organization included management fee income in patient service revenue and did not make normalizations for net patient revenue payments received or payments made to third parties relating to care not provided in the reporting period. Effect ? Based on the Period 1 PRF report filed, the Organization utilized PRF payments received on expenses and lost revenues that were not attributable to coronavirus, were reimbursed by other sources, and/or were not allowable in accordance with other guidance issued by HHS. Cause ? Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution is a new program with complex and evolving regulations and compliance requirements. Internal controls were not in place to ensure the Organization correctly applied the guidance. Identification As a Repeat Finding ? Not a repeat finding. Recommendation ? Policies and procedures over allowable activities and federal grant reporting should be modified to ensure expenditures charged to grants are for activities allowed and federal grant reports are prepared using complete and accurate information.
SHWC incorrectly chose Option 1 Lost Revenue Calculation and should have chosen the Option 3 Lost Revenue Calculation. Due to this error it appears that SHWC did not have enough lost revenue or expenses to keep the PRF Funds. However, when calculating Lost Revenue Attributable to Coronavirus Option 3 "Alternate Reasonable Methodology". SHWC can demonstrate that the organization did have enough lost revenues, therefore should not be required to payback any funds. In regards to the expenses reported, SHWC had already allocated Covid-19 testing supplies expense to the PRF funds prior to guidance being released and was unaware that Rescue funds were to be spent prior to PRF funds. SHWC was able to identify expense not budgeted for on the Rescue grant that could be used to replace a portion of the previously unreimbursed expenses. When you add the lost revenues in Quarter 2 2020 and specifically identified expenses, this total exceeds PRF payments used when choosing Option 3.
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