POMONA COMMUNITY HEALTH CENTER

Federal Agency: U.S Department of Health and Human Services Federal Program Name: Health Center Program Cluster Assistance Listing Number: 93.224 Award Period: 1/1/2025 – 12/31/2026 Type of Finding: Significant Deficiency in Internal Control over Compliance and Compliance Criteria or specific requirement: Under the compliance requirement for Special Tests and Provisions for ALN 93.224, “health centers must prepare and apply a sliding fee discount schedule (SFDS) so that the amounts owed for health center services by eligible patients are adjusted (discounted) based on the patient’s ability to pay”. Condition: Encounters eligible for a sliding fee adjustment did not receive the appropriate adjustment per the patient’s approved sliding fee discount level. Context: During our testing of sliding fee discounts for health center patients qualifying for reduced charge visits, we identified three visits in a sample of forty, which received the incorrect sliding fee discount. Cause: Internal control process and procedures were not followed resulting in a discount applied in the billing system that did not match the sliding fee determination per the approved patient application. Effect: Patient would receive an incorrect sliding fee discount. Recommendation: We recommend implementation of a second level independent review of the demographic data and income verification information entered into the patient billing system in order to ensure the financial classification is correct. Views of responsible officials: There is no disagreement with the audit finding.

Department of Health and Human Services: ParkTree Community Health Center (PCHC) respectfully submits the following corrective action plan for the year ended December 31, 2025. Audit period: 01/1/25 – 12/31/25 The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS—FEDERAL AWARD PROGRAMS AUDITS Department of Health and Human Services 2025-01 Health Center Cluster– Assistance Listing No. 93.HCP Recommendation: CLA recommends that PCHC implement a second-level, independent review of demographic data and income verification information entered into the patient billing system to help ensure each patient’s sliding fee classification and corresponding discount is accurate. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Corrective Action Plan: ParkTree Community Health Center will implement a second-level independent review process for all new Sliding Fee Discount Program (SFDP) applications and annual renewals. Under this process, demographic information, household income documentation, family size, and the assigned sliding fee classification will be independently verified by a designated supervisor or other qualified staff member before the sliding fee discount is finalized in NextGen. Front desk receptionists and enrollment staff receive ongoing training and best practice reminders to ensure that all SFDP applications and supporting documentation are completed accurately and in a timely manner. Management has also implemented a weekly internal review process to verify that applications are complete, that appropriate supporting documentation is retained in each patient's file, and that assigned sliding fee classifications are accurate and consistent with PCHC's Board-approved SFDP policies and procedures. In addition, periodic quality assurance reviews will continue to be conducted to monitor compliance, identify trends, and provide corrective coaching when discrepancies are identified. These enhanced controls are designed to strengthen internal controls, improve compliance with the SFDP, and help ensure that each patient's sliding fee classification and corresponding discount are accurately applied in NextGen. Name of Contact Person Responsible for Corrective Action: Alfonso Aguilera Planned Completion Date: December 31, 2026 If the U.S Department of Health and Human Services has any questions regarding this Corrective Action Plan, please contact Alfonso Aguilera at (909)-865-9501, Ext. 3970.

2024-001

Federal Agency: U.S Department of Health and Human Services Federal Program Name: Health Center Program Cluster Assistance Listing Number: 93.224 and 93.527 Award Period: 1/1/2024 – 12/31/2024 Type of Finding: Significant Deficiency in Internal Control over Compliance and Compliance Criteria or specific requirement: Under the compliance requirement for Special Tests and Provisions for ALN 93.224-93.527, “health centers must prepare and apply a sliding fee discount schedule (SFDS) so that the amounts owed for health center services by eligible patients are adjusted (discounted) based on the patient’s ability to pay”. Condition: Encounters eligible for a sliding fee adjustment did not receive the appropriate adjustment per the patient’s approved sliding fee discount level. Context: During our testing of sliding fee discounts for health center patients qualifying for reduced charge visits, we identified three visits in a sample of forty, which received the incorrect sliding fee discount. We did not proceed with testing after instances were identified. Cause: Internal control process and procedures were not followed resulting in a discount applied in the billing system that did not match the sliding fee determination per the approved patient application. Effect: Patient would receive an incorrect sliding fee discount. Recommendation: We recommend implementation of a second level independent review of the demographic data and income verification information entered into the patient billing system in order to ensure the financial classification is correct. Views of responsible officials: There is no disagreement with the audit finding.

2024-001 Health Center Program Cluster– Assistance Listing Nos. 93.224 and 93.527 Recommendation: PCHC should implement a second level independent review over demographic data and income verification information entered into the patient billing system in order to ensure the financial classification is correct. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Front desk receptionist and Enrollment staff were retrained on the sliding fee discount scale and the federal poverty level policy and procedure. Commencing in August 2025, PCHC implemented a weekly internal review process of prior period patient sliding fee applications and approved slide adjustment calculations. Weekly audits of patient applications are conducted under the supervision of management to ensure the financial classification is correct. Improvements will be reported quarterly at the Board of Directors Finance Committee meetings. Name(s) of the contact person(s) responsible for corrective action: Alfonso Aguilera, Chief Financial Officer Planned completion date for corrective action plan: 12/31/2025.

Federal Agency: U.S Department of Health and Human Services Federal Program Name: Health Center Program Cluster Assistance Listing Number: 93.224 and 93.527 Award Period: 1/1/2024 – 12/31/2024 Type of Finding: Significant Deficiency in Internal Control over Compliance Criteria or specific requirement: Under the compliance requirement for Special Tests and Provisions for ALN 93.224-93.527, “health centers must prepare and apply a sliding fee discount schedule (SFDS) so that the amounts owed for health center services by eligible patients are adjusted (discounted) based on the patient’s ability to pay”. Condition: Patients eligible for a sliding fee discount received a discount without documentation supporting eligibility and qualification for reduced charges. Context: During our testing of sliding fee discounts for health center patients qualifying for reduced charge visits, we identified three visits in a sample of forty, where supporting documentation to determine the appropriate sliding fee discount was not retained. We did not proceed with testing after instances were identified. Cause: Supporting documentation, approved patient application for sliding fee discount, was not retained to verify patient’s eligibility per the health center’s policies and procedures. Effect: Patients not eligible for the sliding fee discount would receive a sliding fee discount or patients approved for a sliding fee discount would receive an incorrect discount. Recommendation: We recommend implementation of a second level independent review over the demographic data and income verification information entered into the patient billing system in order to ensure the financial documents are retained. Views of responsible officials: There is no disagreement with the audit finding.

2024-002 Health Center Program Cluster– Assistance Listing Nos. 93.224 and 93.527 Recommendation: PCHC should implement a second level independent review over the demographic data and income verification information entered into the patient billing system in order to ensure that financial documents are retained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Front desk receptionist and Enrollment staff were retrained on document retention policies in relation to the sliding fee discount scale and the federal poverty level policy and procedure. Commencing in August 2025, PCHC implemented a weekly internal review of current patient sliding fee applications to ensure all required documents are maintained and retained for the appropriate length of time as per PCHC Board of Director approved policies. Weekly audits verifying supporting documents for the sliding fee applications are conducted under the supervision of management, and improvements will be reported quarterly at the Board of Directors Finance Committee meetings. Name(s) of the contact person(s) responsible for corrective action: Alfonso Aguilera, Chief Financial Officer Planned completion date for corrective action plan: 12/31/2025

2020 ? 001 Federal agency: U.S. Department of Health and Human Services Federal program title: Health Center Program Cluster CFDA numbers: 93.224 and 93.527 Award period: January 1, 2020 through December 31, 2020 Type of finding: Significant Deficiency in Internal Control over Compliance and Compliance Criteria or specific requirement: Special Tests and Provisions: Sliding Fee Discounts (42 USC 254(k)(3)(g); 42 CFR section 51c.303(g) and 42 CFR section 56.303(f)). Condition: PCHC?s sliding fee discount program provides discounts to uninsured patients based on the patient?s income and poverty levels. During our audit we noted instances of an inaccurate sliding fee discount provided. Additionally, under the Organization?s policy supporting documentation used to determine a patient?s eligibility for a sliding fee discount should be maintained as part of the patient?s record. There were instances noted where a lack of sliding fee application documentation was maintained. Questioned costs: None. Context: A sample of 25 encounters were tested in relation to the sliding fee discount program. Of the 25 encounters tested four of the selections did not have a sliding fee application retained in the patient record per PCHC?s policy to document verification of a patient?s eligibility for the sliding fee discount. Additionally, two selections were found to not have received the proper sliding fee discount based upon the patient?s application, and one selection was found to have charged the patient with an incorrect copayment amount per sliding fee scale. There were 7 total errors identified in the sample. Cause: PCHC did not comply with their sliding fee policy or maintain proper documentation of sliding fee eligibility. Effect: Improper sliding fee discounts were given to patients. Repeat finding: No. Recommendation: Management should review their policies and procedures with the personnel responsible for providing the sliding fee discount and for ensuring that documentation is maintained to support the eligibility of sliding fee discount. We also recommend that management implement, monthly or quarterly, a self-audit process of newly approved sliding fee discount recipients and their associated patient record. Views of responsible officials: There is no disagreement with the audit finding.

U.S. Department of Health and Human Services Pomona Community Health Center dba: Parktree Community Health Center (PCHC) respectfully submits the following corrective action plan for the year ended December 31, 2020. Audit period: January 1, 2020 through December 31, 2020 The finding from the schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. FINDINGS?FINANCIAL STATEMENT AUDIT There were no financial statement findings in the audit period. FINDINGS?FEDERAL AWARD PROGRAMS AUDITS Significant Deficiency 2020-001 Health Center Program Cluster ? CFDA No. 93.224 and 93.527 Recommendation: PCHC should review their policies and procedures with personnel responsible for determination of a patient?s sliding fee discount and for ensuring that documentation is maintained to support the eligibility of sliding fee discount. Additionally, PCHC should implement, either monthly or quarterly, a self-audit process of newly approved sliding fee discounts to the support maintained in the associated patient record. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Front desk receptionists were retrained on sliding fee and the federal poverty level policy and procedure. Going forward weekly audits of the sliding fee applications will be conducted by management, and improvements will be reported at the monthly Quality Improvement meetings. Name of the contact person responsible for corrective action: Alfonso Aguilera, Chief Financial Officer Planned completion date for corrective action plan: April 30, 2022 If the U.S. Department of Health and Human Services has questions regarding this plan, please call Alfonso Aguilera, Chief Financial Officer at (909) 630-7927.