EIN: 205746618
UEI: L5TLWT18NAK4
Audited by: Terry Horne, CPA
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 March 20, 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 September 20, 2026 (17 days from today).
What is a management decision? →A majority of the board members or their immediate family are not users of the health center services. Compliance conditions state that more than fifty percent of board members should “utilize the health center as their principal source of primary health care” in order for them to give substantive input into the Organization’s strategic direction and policy. Cause: The above exception resulted from the failure to follow established procedures requiring board members or their immediate families to be active users of the health center. Effect: This non-compliance with federal grant requirements could result in a reduction of grant funds or additional grant restrictions. Questioned Costs: None reported Context/Sampling: The finding appears to be a systemic issue. Repeat Finding from Prior Year: No Recommendation: It is recommended that procedures be established to ensure that more than fifty percent of board members are active users of the health center. Views of Responsible Officials: Management concurs with the audit finding. Procedures will be established to ensure that more than 50 percent of the board members are users of the health center. Contact Person: Stephanie Jones-Heath, CEO Anticipated Date of Completion: May 31, 2026
Show full finding ▾Hide full finding ▴Finding: 2025-001-Board Member Compliance Federal Programs: Department of Health and Human Services Health Center Program Cluster Assistance Listing No. - 93.224 and 93.527 Criteria: Health Center Program Compliance Manual Condition: A majority of the board members or their immediate family are not users of the health center services. Compliance conditions state that more than fifty percent of board members should “utilize the health center as their principal source of primary health care” in order for them to give substantive input into the Organization’s strategic direction and policy. Cause: The above exception resulted from the failure to follow established procedures requiring board members or their immediate families to be active users of the health center. Effect: This non-compliance with federal grant requirements could result in a reduction of grant funds or additional grant restrictions. Questioned Costs: None reported Context/Sampling: The finding appears to be a systemic issue. Repeat Finding from Prior Year: No Recommendation: It is recommended that procedures be established to ensure that more than fifty percent of board members are active users of the health center. Views of Responsible Officials: Management concurs with the audit finding. Procedures will be established to ensure that more than 50 percent of the board members are users of the health center. Contact Person: Stephanie Jones-Heath, CEO Anticipated Date of Completion: May 31, 2026
In Finding 2025-001, a condition was noted that a majority of the board members or their immediate family are not users of the health center services. Compliance conditions state that more than fifty percent of board members should “utilize the health center as their principal source of primary health care” in order for them to give substantive input into the Organization’s strategic direction and policy. Management recognizes the importance of complying with board member compliance guidelines. In response to Finding 2025-001, procedures will be established to ensure that more than 50 percent of the board members are users of the health center.
FAC accepted this audit on March 20, 2025 — management decision was due September 20, 2025.
FAC accepted this audit on March 6, 2024 — management decision was due September 6, 2024.
FAC accepted this audit on March 5, 2023 — management decision was due September 5, 2023.
FAC accepted this audit on February 24, 2022 — management decision was due August 24, 2022.
Health Centers receiving funding under the Health Center Program Cluster must prepare and apply a sliding fee discount so that the amounts owed by eligible patients are discounted based on the patient?s ability to pay. During compliance testing, it was determined that the Organization did not properly apply the sliding fee discounts for 3 patients out of a sample of 20 patients for the year ended December 31, 2020, and discounts were provided to 1 patient for which the Organization could not locate a sliding fee application. Cause: There were deficiencies in the implementation of internal controls designed to ensure that proper documentation is obtained and that proper sliding fee discounts were applied to patient accounts in accordance with the Organization?s sliding fee scale. The sliding fee scale file was not properly utilized in the application of discounts provided to patients. Effect: Discounts were not properly applied to patient accounts. Questioned Costs: None reported Context/Sampling: For 4 of 20 patients selected for testing, the account had an incorrect discount applied. This sample was not, and was not intended to be, a statistically valid sample. The finding appears to be a systemic issue. Repeat Finding from Prior Year: No Recommendation: It is recommended that proper training be given to employees and that the sliding fee discounts be reviewed by a supervisor on a periodic basis the ensure compliance with the sliding fee scale. It is also recommended that the Organization improve the implementation of the policy regarding keeping and maintaining the sliding fee application. Views of Responsible Officials: Management concurs. Efforts will be made to implement corrective actions as recommended above. Contact Person: Stephanie Jones-Heath, CEO Anticipated Date of Completion: April 30, 2022
Show full finding ▾Hide full finding ▴Finding: 2021-002 Sliding Fee Discounts Federal Programs: Department of Health and Human Services Health Center Program Cluster CFDA 93.224 and 93.527 Criteria: Uniform Guidance, Special Tests & Provisions, Sliding Fee Discounts, 42 CFR, 56.303 Condition: Health Centers receiving funding under the Health Center Program Cluster must prepare and apply a sliding fee discount so that the amounts owed by eligible patients are discounted based on the patient?s ability to pay. During compliance testing, it was determined that the Organization did not properly apply the sliding fee discounts for 3 patients out of a sample of 20 patients for the year ended December 31, 2020, and discounts were provided to 1 patient for which the Organization could not locate a sliding fee application. Cause: There were deficiencies in the implementation of internal controls designed to ensure that proper documentation is obtained and that proper sliding fee discounts were applied to patient accounts in accordance with the Organization?s sliding fee scale. The sliding fee scale file was not properly utilized in the application of discounts provided to patients. Effect: Discounts were not properly applied to patient accounts. Questioned Costs: None reported Context/Sampling: For 4 of 20 patients selected for testing, the account had an incorrect discount applied. This sample was not, and was not intended to be, a statistically valid sample. The finding appears to be a systemic issue. Repeat Finding from Prior Year: No Recommendation: It is recommended that proper training be given to employees and that the sliding fee discounts be reviewed by a supervisor on a periodic basis the ensure compliance with the sliding fee scale. It is also recommended that the Organization improve the implementation of the policy regarding keeping and maintaining the sliding fee application. Views of Responsible Officials: Management concurs. Efforts will be made to implement corrective actions as recommended above. Contact Person: Stephanie Jones-Heath, CEO Anticipated Date of Completion: April 30, 2022
In Finding 2021-002, a condition was noted that during compliance testing, it was determined that the Organization did not properly apply the sliding fee discounts for 3 patients out of a sample of 20 patients for the year ended December 31, 2021, and discounts were provided to 1 patient for which the Organization could not locate a sliding fee application. Management recognizes the importance of complying with grant guidelines. In response to Finding 2021-002, management will give proper training to employees and that the sliding fee discounts be reviewed by a supervisor on a periodic basis the ensure compliance with the sliding fee scale. It is also recommended that the Organization improve the implementation of the policy regarding keeping and maintaining the sliding fee application. This review will be performed by the Chief Executive Officer and completed by April 30, 2022.
The Organization did not verify that vendors were not suspended, debarred, or otherwise excluded from participating in federal programs before entering into transactions with them. Cause: The Organization did not have proper procedures in place to ensure debarment searches were performed as required. Effect: The Organization did not verify that certain vendors were not suspended, debarred, or otherwise excluded from participating in federal programs before entering into transactions with them. Questioned Costs: None reported Context/Sampling: The finding appears to be a systemic issue. Repeat Finding from Prior Year: No Recommendation: It is recommended that the Organization establish procedures to ensure that debarment searches are performed as required. Views of Responsible Officials: Management concurs. The Organization will establish procedures to ensure that debarment searches are completed to verify that all vendors subject to debarment requirements are not suspended, debarred, or otherwise excluded from participating in Federal programs before the Organization enters into transactions with them. Contact Person: Stephanie Jones-Heath, CEO Anticipated Date of Completion: April 30, 2022
Show full finding ▾Hide full finding ▴Finding: 2021-003 Procurement, Suspension, and Debarment Federal Programs: Department of Health and Human Services Health Center Program Cluster CFDA 93.224 and 93.527 Criteria: Procurement 45 CFR 75.329 and 45 CFR 75.213 Condition: The Organization did not verify that vendors were not suspended, debarred, or otherwise excluded from participating in federal programs before entering into transactions with them. Cause: The Organization did not have proper procedures in place to ensure debarment searches were performed as required. Effect: The Organization did not verify that certain vendors were not suspended, debarred, or otherwise excluded from participating in federal programs before entering into transactions with them. Questioned Costs: None reported Context/Sampling: The finding appears to be a systemic issue. Repeat Finding from Prior Year: No Recommendation: It is recommended that the Organization establish procedures to ensure that debarment searches are performed as required. Views of Responsible Officials: Management concurs. The Organization will establish procedures to ensure that debarment searches are completed to verify that all vendors subject to debarment requirements are not suspended, debarred, or otherwise excluded from participating in Federal programs before the Organization enters into transactions with them. Contact Person: Stephanie Jones-Heath, CEO Anticipated Date of Completion: April 30, 2022
In Finding 2021-003, a condition was noted that The Organization did not verify that vendors and certain employees were not suspended, debarred, or otherwise excluded from participating in federal programs before entering into transactions with them. Management recognizes the importance of complying with grant guidelines. In response to Finding 2021-003, The Organization will establish procedures to ensure that debarment searches are completed to verify that all vendors subject to debarment requirements are not suspended, debarred, or otherwise excluded from participating in Federal programs before the Organization enters into transactions with them. This review will be performed by the Chief Executive Officer and completed by April 30, 2022.
FAC accepted this audit on March 15, 2021 — management decision was due September 15, 2021.
The Uniform Data System report submitted to DHHS for the year ended December 31, 2020 contained incorrect data for patient revenue. The Table 9D adjustments amount disclosed incorrect information. Criteria: Uniform Guidance, Special Reporting ? Uniform Data System Context: The charges and adjustments were incorrectly reported on Table 9D of the UDS report. The charges were overstated by $131,434 and the adjustments were understated by $1,491,787. Cause: The above exception resulted from an error in preparing table 9D of the Uniform Data System report. Effect: The Department of Health and Human Services reviews the UDS data for financial analysis for grant recipients. Errors in this data causes incorrect financial analysis results and distorted performance indicators. Recommendation: It is recommended that a system be developed to ensure actual charges and adjustments from all sources are reported and reconciled to the UDS report. HRSA should be informed of the error, and the 2020 Table 9D should be revised and resubmitted if requested. Auditee?s Response and Corrective Action Plan: Management concurs. The 2020 UDS will be corrected as noted above, and efforts will be made to ensure that revenue reported is reconciled to the revenue on the UDS report. Contact Person: Stephanie Jones-Heath, CEO Anticipated Date of Completion: March 31, 2021
Show full finding ▾Hide full finding ▴Finding: 2020-002 Uniform Data System Report Federal Programs: Department of Health and Human Services Health Center Program Cluster CFDA 93.224 and 93.527 Condition: The Uniform Data System report submitted to DHHS for the year ended December 31, 2020 contained incorrect data for patient revenue. The Table 9D adjustments amount disclosed incorrect information. Criteria: Uniform Guidance, Special Reporting ? Uniform Data System Context: The charges and adjustments were incorrectly reported on Table 9D of the UDS report. The charges were overstated by $131,434 and the adjustments were understated by $1,491,787. Cause: The above exception resulted from an error in preparing table 9D of the Uniform Data System report. Effect: The Department of Health and Human Services reviews the UDS data for financial analysis for grant recipients. Errors in this data causes incorrect financial analysis results and distorted performance indicators. Recommendation: It is recommended that a system be developed to ensure actual charges and adjustments from all sources are reported and reconciled to the UDS report. HRSA should be informed of the error, and the 2020 Table 9D should be revised and resubmitted if requested. Auditee?s Response and Corrective Action Plan: Management concurs. The 2020 UDS will be corrected as noted above, and efforts will be made to ensure that revenue reported is reconciled to the revenue on the UDS report. Contact Person: Stephanie Jones-Heath, CEO Anticipated Date of Completion: March 31, 2021
In Finding 2020-002, a condition was noted in the Uniform Data System report submitted to DHHS for the year ended December 31, 2020 contained incorrect data for patient revenue. The Table 9D adjustments amount disclosed incorrect information. Management recognizes the importance of complying with grant guidelines. In response to Finding 2020-002, the 2020 UDS will be corrected as noted above and efforts will be made to ensure that revenue reported is reconciled to the revenue on the UDS report. This review will be performed by the Chief Executive Officer and completed by March 31, 2021.
FAC accepted this audit on March 19, 2020 — management decision was due September 19, 2020.
FAC accepted this audit on March 10, 2019 — management decision was due September 10, 2019.
FAC accepted this audit on May 2, 2018 — management decision was due November 2, 2018.
FAC accepted this audit on February 23, 2017 — management decision was due August 23, 2017.
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