EIN: 237085643
UEI: MM85YEHUCL39
Data as of August 23, 2026
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on October 29, 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 April 29, 2026 (117 days ago).
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. The Organization has reestablished compliance, and as of the date of the audit, more than fiftytuiy percent of the board members are users of the health center. Contact Person: Kyle Herbert, CFO Anticipated Date of Completion: October 3, 2025
Show full finding ▾Hide full finding ▴Finding: 2025-001-Board Member Compliance Federal Programs: Department of Health and Human Services Health Center Program Cluster CFDA 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. The Organization has reestablished compliance, and as of the date of the audit, more than fiftytuiy percent of the board members are users of the health center. Contact Person: Kyle Herbert, CFO Anticipated Date of Completion: October 3, 2025
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 have been established to ensure that more than 50 percent of the board members are users of the health center, and compliance is now achieved as of the date of this corrective action plan.
Health Centers receiving funding under the Health Center Program Cluster must prepare and apply a sliding fee discount so that the amounts owed for health center services 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 discount for five sliding fee patients tested. In addition, one patient who qualified for a discount did not receive a discount. Cause: There were deficiencies in the internal controls related to the application of the sliding fee discounts in accordance with the Organization’s sliding fee policy and sliding fee scale. Effect: Discounts were not properly applied to certain patient accounts. Questioned Costs: None reported. Context/Sampling: For 6 of 48 sliding fee 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 to ensure compliance with the Organization’s sliding fee scale and policy. Views of Responsible Officials: Management concurs. Efforts will be made to implement corrective actions as recommended above. Contact Person: Kyle Herbert, CFO Anticipated Date of Completion: November 30, 2025
Show full finding ▾Hide full finding ▴Finding: 2025-002 Sliding Fee Discounts Federal Programs: Department of Health and Human Services Health Center Program Cluster Assistance Listing No. - 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 for health center services 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 discount for five sliding fee patients tested. In addition, one patient who qualified for a discount did not receive a discount. Cause: There were deficiencies in the internal controls related to the application of the sliding fee discounts in accordance with the Organization’s sliding fee policy and sliding fee scale. Effect: Discounts were not properly applied to certain patient accounts. Questioned Costs: None reported. Context/Sampling: For 6 of 48 sliding fee 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 to ensure compliance with the Organization’s sliding fee scale and policy. Views of Responsible Officials: Management concurs. Efforts will be made to implement corrective actions as recommended above. Contact Person: Kyle Herbert, CFO Anticipated Date of Completion: November 30, 2025
In Finding 2025-002, it was reported that the Organization did not properly apply sliding fee discounts for certain patients with visits to the Organization during the year ended May 31, 2025. Management recognizes the importance of complying with sliding fee guidelines. In response to Finding 2025-002, proper training will be given to employees and sliding fee discounts will be reviewed by a supervisor on a periodic basis to ensure compliance with the sliding fee scale.
FAC accepted this audit on October 11, 2024 — management decision was due April 11, 2025.
During the year, the Organization made several advance draws of federal funds that were not disbursed in a timely manner for program expenditures. The Organization is required to minimize the time elapsing between the transfer of funds to the Organization from the U.S. Treasury and the issuance of payments for program purposes. Cause: The Organization made draws of federal grant funds in advance of making the qualifying expenditures. Effect: The Organization held federal funds for time periods in excess of one business day. Questioned Costs: None reported. Context/Sampling: The finding appears to be a systemic issue. Repeat Finding from Prior Year: No Recommendation: Efforts should be made to ensure advance draws of federal funds do not occur prior to the Organization making the related qualifying expenditures. Views of Responsible Officials: The Organization understands the requirements to disburse federal funds in a timely manner. Procedures will be established to minimize the time elapsing between the transfer of funds to the Organization from the U.S. Treasury and the issuance of payments for program purposes by the Organization to ensure that advance draws of federal funds do not occur. Contact Person: Donald Branum, CEO Anticipated Date of Completion: October 31, 2024
Show full finding ▾Hide full finding ▴Finding: 2024-001 Cash Management – Federal Grants Federal Programs: Department of Health and Human Services Health Center Program Cluster Assistance Listing No. - 93.224 and 93.527 Criteria: Cash Management, 45 CFR 75.305 Condition: During the year, the Organization made several advance draws of federal funds that were not disbursed in a timely manner for program expenditures. The Organization is required to minimize the time elapsing between the transfer of funds to the Organization from the U.S. Treasury and the issuance of payments for program purposes. Cause: The Organization made draws of federal grant funds in advance of making the qualifying expenditures. Effect: The Organization held federal funds for time periods in excess of one business day. Questioned Costs: None reported. Context/Sampling: The finding appears to be a systemic issue. Repeat Finding from Prior Year: No Recommendation: Efforts should be made to ensure advance draws of federal funds do not occur prior to the Organization making the related qualifying expenditures. Views of Responsible Officials: The Organization understands the requirements to disburse federal funds in a timely manner. Procedures will be established to minimize the time elapsing between the transfer of funds to the Organization from the U.S. Treasury and the issuance of payments for program purposes by the Organization to ensure that advance draws of federal funds do not occur. Contact Person: Donald Branum, CEO Anticipated Date of Completion: October 31, 2024
In Finding 2024-001, a condition was noted that during the year, the Organization made several draws of federal funds that were not disbursed in a timely manner for program expenditures. Management recognizes the importance of the requirements to disburse federal funds in a timely manner. In response to Finding 2024-001, procedures will be established to minimize the time elapsing between the transfer of funds to the Organization from the U.S. Treasury and the issuance of payments for program purposes by the Organization.
The Organization did not follow Uniform Guidance procurement requirements for the purchase of goods or services. Cause: The Organization did not obtain quotes or bids for certain capital expenditures over $10,000 as required by Uniform Guidance. Effect: Purchases were made that did not adhere to the Uniform Guidance requirements. 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 procurement controls be implemented to ensure that quotes or bids are obtained as required by Uniform Guidance. The Organization’s procurement policies should also be updated to conform to the Uniform Guidance procurement thresholds. Views of Responsible Officials: Management concurs. Policies will be updated, and employees will be trained to ensure compliance of the procurement requirements. Contact Person: Donald Branum, CEO Anticipated Date of Completion: October 31, 2024
Show full finding ▾Hide full finding ▴Finding: 2024-002 Procurement, Suspension and Debarment Federal Programs: Department of Health and Human Services Health Center Program Cluster Assistance Listing No. - 93.224 and 93.527 Criteria: Procurement 45 CFR 75.329 and 45 CFR 75.213 Condition: The Organization did not follow Uniform Guidance procurement requirements for the purchase of goods or services. Cause: The Organization did not obtain quotes or bids for certain capital expenditures over $10,000 as required by Uniform Guidance. Effect: Purchases were made that did not adhere to the Uniform Guidance requirements. 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 procurement controls be implemented to ensure that quotes or bids are obtained as required by Uniform Guidance. The Organization’s procurement policies should also be updated to conform to the Uniform Guidance procurement thresholds. Views of Responsible Officials: Management concurs. Policies will be updated, and employees will be trained to ensure compliance of the procurement requirements. Contact Person: Donald Branum, CEO Anticipated Date of Completion: October 31, 2024
In Finding 2024-002, a condition was noted in which the Organization did not obtain quotes or bids for certain expenditures as required by Uniform Guidance procurement requirements. Management recognizes the importance of complying with procurement guidelines. In response to Finding 2024-002, procedures will be implemented to ensure bids are obtained and properly documented as required by Uniform Guidance.
FAC accepted this audit on November 7, 2021 — management decision was due May 7, 2022.
Health Centers receiving funding under the Health Center Program Cluster must prepare and apply a sliding fee scale so that the amounts owed for health center services 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 5 patients out of a sample of 20 patients for the year ended May 31, 2021. Cause: There were deficiencies in internal controls to ensure that proper documentation was 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 system was not properly utilized in the application of discounts provided to patients. Effect: Discounts were not properly applied to patient accounts. Questioned Costs: None. Context/Sampling: For 5 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 employees are properly trained to apply the sliding fee discounts, and that the sliding fee discounts are reviewed by a supervisor on a periodic basis to ensure compliance with the sliding fee scale. Views of Responsible Officials: Management concurs. Efforts will be made to implement corrective actions as recommended above. Contact Person: Shiow wen Terranova, CFO Anticipated Date of Completion: December 31, 2021
Show full finding ▾Hide full finding ▴Finding: 2021-001 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 scale so that the amounts owed for health center services 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 5 patients out of a sample of 20 patients for the year ended May 31, 2021. Cause: There were deficiencies in internal controls to ensure that proper documentation was 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 system was not properly utilized in the application of discounts provided to patients. Effect: Discounts were not properly applied to patient accounts. Questioned Costs: None. Context/Sampling: For 5 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 employees are properly trained to apply the sliding fee discounts, and that the sliding fee discounts are reviewed by a supervisor on a periodic basis to ensure compliance with the sliding fee scale. Views of Responsible Officials: Management concurs. Efforts will be made to implement corrective actions as recommended above. Contact Person: Shiow wen Terranova, CFO Anticipated Date of Completion: December 31, 2021
In Finding 2021-001, it was reported that the Organization did not properly apply the sliding fee discounts for certain patients for the year ended May 31, 2021. Management recognizes the importance of correctly calculating income for sliding fee discounts. In response to Finding 2021-001, policies and procedures will be reviewed and updated to ensure that personnel are properly trained so that income and related discounts are correctly calculated for all patients receiving sliding fee discounts. This review will be performed by the Chief Financial Officer and completed by December 31, 2021.
FAC accepted this audit on October 25, 2018 — management decision was due April 25, 2019.
GSA_MIGRATION
Show full finding ▾Hide full finding ▴FAC accepted this audit on October 22, 2017 — management decision was due April 22, 2018.
GSA_MIGRATION
Show full finding ▾Hide full finding ▴GSA_MIGRATION
GSA_MIGRATION
2016-001
FAC accepted this audit on September 11, 2016 — management decision was due March 11, 2017.
GSA_MIGRATION
Show full finding ▾Hide full finding ▴GSA_MIGRATION
GSA_MIGRATION
2015-002
GSA_MIGRATION
Show full finding ▾Hide full finding ▴GSA_MIGRATION
GSA_MIGRATION
2015-003
Data source: This information comes from the Federal Audit Clearinghouse, the official repository of Single Audit data. All data is public domain. Verify this organization's audit history at fac.gov.
Track your findings and corrective action plans across audit cycles.
Start tracking findings →Monitor subrecipient audit findings and compliance status.
Start monitoring →© 2026 Single Audit Intelligence. All data is public domain.