EIN: 202779327
UEI: WH6YFXJVM3K7
Audited by: Warren Averett, LLC
Oversight agency: 93 [Department of Health and Human Services]
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Data as of September 2, 2026
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on November 13, 2025. Under 2 CFR 200.521(d), a pass-through entity that provided federal funds to this organization for this audit period must issue a management decision on these findings by May 13, 2026 (113 days ago).
What is a management decision? →FINDING 2024-002 – SPECIAL TESTS AND PROVISIONS Identification of Federal Program U.S. Department of Health and Human Services 93.224 / 93.527 – Health Center Cluster MATERIAL WEAKNESS Criteria – Health centers are required to have a corresponding schedule of discounts applied and adjusted on the basis of patients’ ability to pay and their eligibility. A patient’s eligibility to pay is determined on the basis of the official poverty guideline, as revised by DHHS (42 CFR Sections 51c, 107(b)(5), 56.108(b)(5), and 56.303(f). The Organization should be implementing and monitoring procedures to properly determine, calculate, and review sliding fee discounts to patients in accordance with the Organization’s sliding fee scale.Condition – While performing our audit, we noted that the Organization did not properly determine the sliding fee discount given to patients selected for testing based on the sliding fee scale in effect for the year ended April 30, 2024. Cause – Policies and procedures were not followed to ensure that the appropriate sliding fee discount adjustment was properly applied to all eligible transactions. Effect or Potential Effect – The Organization did not comply with the determination of sliding fee discounts based on the federal poverty guidelines in effect for the year ended April 30, 2024. In addition, the Organization may not have properly calculated the sliding fee discount given to the patients, and the discount given, if any, may not have been based on the patient’s ability to pay. Questioned Costs – None Context – While performing our audit, we noted that the Organization did not have proper documentation to support the sliding fee discount given to 16 out of 40 patients selected for testing based on the sliding fee scale in effect for the year ended April 30, 2024. Repeat Findings – Yes Recommendation – We recommend that the Organization continue to train and develop new personnel on specific processes related to compliance requirements. In addition, the Organization should establish a review process to ensure that sliding scale charges are monitored and reviewed by a supervisor on a periodic basis to ensure compliance. Views of Responsible Officials See accompanying Corrective Action Plan
Show full finding ▾Hide full finding ▴FINDING 2024-002 – SPECIAL TESTS AND PROVISIONS Identification of Federal Program U.S. Department of Health and Human Services 93.224 / 93.527 – Health Center Cluster MATERIAL WEAKNESS Criteria – Health centers are required to have a corresponding schedule of discounts applied and adjusted on the basis of patients’ ability to pay and their eligibility. A patient’s eligibility to pay is determined on the basis of the official poverty guideline, as revised by DHHS (42 CFR Sections 51c, 107(b)(5), 56.108(b)(5), and 56.303(f). The Organization should be implementing and monitoring procedures to properly determine, calculate, and review sliding fee discounts to patients in accordance with the Organization’s sliding fee scale.Condition – While performing our audit, we noted that the Organization did not properly determine the sliding fee discount given to patients selected for testing based on the sliding fee scale in effect for the year ended April 30, 2024. Cause – Policies and procedures were not followed to ensure that the appropriate sliding fee discount adjustment was properly applied to all eligible transactions. Effect or Potential Effect – The Organization did not comply with the determination of sliding fee discounts based on the federal poverty guidelines in effect for the year ended April 30, 2024. In addition, the Organization may not have properly calculated the sliding fee discount given to the patients, and the discount given, if any, may not have been based on the patient’s ability to pay. Questioned Costs – None Context – While performing our audit, we noted that the Organization did not have proper documentation to support the sliding fee discount given to 16 out of 40 patients selected for testing based on the sliding fee scale in effect for the year ended April 30, 2024. Repeat Findings – Yes Recommendation – We recommend that the Organization continue to train and develop new personnel on specific processes related to compliance requirements. In addition, the Organization should establish a review process to ensure that sliding scale charges are monitored and reviewed by a supervisor on a periodic basis to ensure compliance. Views of Responsible Officials See accompanying Corrective Action Plan
Finding 2024-002 – Special Tests and Provisions The Organization did not properly determine the sliding fee discount given to patients selected for testing based on the sliding fee scale in effect for the year ended April 30, 2024. Since this occurrence, a new position has been created and staffed- Patient Service Representative Team Lead. This staff member oversees and trains the Patient Service Representatives in their responsibilities, including the sliding fee discount schedule application and compliance. A focus of this newly created position is training and compliance of the sliding fee schedule throughout all the clinics, which is ongoing from Oct. 15, 2024. The Patient Service Team Lead will be supervised by the Revenue Cycle Manager as part of the Finance Department reporting to the Interim CEO Bob Rodriguez, who will oversee this effort. The new position and implementation of training to correct the finding commenced Oct. 15, 2024.
2023-002
FAC accepted this audit on December 26, 2024 — management decision was due June 26, 2025.
2023-02 - U.S. Department of Human Health and Services- Condition - The Organization placed one of its patients on a sliding fee for a different service than the one ultimately provided. Criteria - The Organization should maintain sliding fee applications and supporting finacial records for patients treated during the audit period to determine whether patient charges were appropriately adjusted. These patient charges are based on income and family size by applying the health center's sliding fee discount schedule according to the service that is provided. Cause - High turnover in the finance and accounting department as well as inadequate communication and training for the related processes at the Organization. Effect - The patient was charged on the correct sliding fee discount level, but for a lab visit instead of a medical visit. Recommendation - We recommend that the Organization continue to train and develop new personnel on specific processes related to compliance requirements.
Show full finding ▾Hide full finding ▴2023-02 - U.S. Department of Human Health and Services- Condition - The Organization placed one of its patients on a sliding fee for a different service than the one ultimately provided. Criteria - The Organization should maintain sliding fee applications and supporting finacial records for patients treated during the audit period to determine whether patient charges were appropriately adjusted. These patient charges are based on income and family size by applying the health center's sliding fee discount schedule according to the service that is provided. Cause - High turnover in the finance and accounting department as well as inadequate communication and training for the related processes at the Organization. Effect - The patient was charged on the correct sliding fee discount level, but for a lab visit instead of a medical visit. Recommendation - We recommend that the Organization continue to train and develop new personnel on specific processes related to compliance requirements.
Finding 2023-02 - U.S. Department of Human Health and Services- The Organization placed one of its patients on a sliding fee for a different service than the one ultimately provided. Since this occurrence, a new position has been created and staffed-- ‘Patient Service Representative Team Lead’. This staff member will oversee and train the Patient Service Representatives in their responsibilities, including the sliding fee discount schedule application and compliance. A focus of this newly created position is training and compliance of the sliding fee schedule throughout all the clinics, is ongoing since Oct. 15. The Patient Service Team Lead will be supervised by the Revenue Cycle Manager as part of the Finance Department reporting to the Interim CEO Anna Ferguson, who will oversee this effort. The new position and implementation of training to correct the finding commenced Oct. 15 2024.
FAC accepted this audit on September 28, 2023 — management decision was due March 28, 2024.
Finding 2022-02 - U.S. Department of Human Health and Services- Special Tests and Provisions: Sliding Fee Discounts Condition - The Organization was unable to locate appropriate support for the sliding fee placement for two of its patients who received sliding fee discounts. Criteria - The Organization should maintain sliding fee applications and supporting finacial records for patients treated during the audit period to determine whether patient charges were appropriately adjusted. These patient charges are based on income and family size by applying the health center's sliding fee discount schedule. Cause - High turnover in the finance and accounting department as well as inadequate communication and training for the related processes at the Organization. Effect - Auditors were unable to determine if a patient was put on the correct sliding fee schedule and, therefore, given the correct discount. Recommendation - We recommend that the Organization continue to train and develop new personnel on specific processes related to compliance requirements.
Show full finding ▾Hide full finding ▴Finding 2022-02 - U.S. Department of Human Health and Services- Special Tests and Provisions: Sliding Fee Discounts Condition - The Organization was unable to locate appropriate support for the sliding fee placement for two of its patients who received sliding fee discounts. Criteria - The Organization should maintain sliding fee applications and supporting finacial records for patients treated during the audit period to determine whether patient charges were appropriately adjusted. These patient charges are based on income and family size by applying the health center's sliding fee discount schedule. Cause - High turnover in the finance and accounting department as well as inadequate communication and training for the related processes at the Organization. Effect - Auditors were unable to determine if a patient was put on the correct sliding fee schedule and, therefore, given the correct discount. Recommendation - We recommend that the Organization continue to train and develop new personnel on specific processes related to compliance requirements.
As one patient file was missing their sliding fee application and another was placed on an inappropriate slide based on their provided income, CPH has offered the following recommended management changes: The Sliding Fee Scale Discount Program was reviewed in-depth with the Patient Service Representatives (PSR?s), providing further information, training, and documents, on the internal process for assessing patients and qualifying patients for the Sliding Fee Scale Discount Program up to and including, the required documents and how to place patients on the correct Sliding Fee Scale. With the staff properly trained, we do not foresee further issues or findings concerning our sliding fee discounts. Anticipated Completion Date: Implemented as of 04/30/2023
FAC accepted this audit on July 31, 2022 — management decision was due January 31, 2023.
FAC accepted this audit on January 5, 2021 — management decision was due July 5, 2021.
FAC accepted this audit on February 23, 2020 — management decision was due August 23, 2020.
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