EIN: 237146768
UEI: ZJ7TSX5Y9FC4
Audited by: BDMP ASSURANCE, LLP
Oversight agency: 93 [Department of Health and Human Services]
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Data as of August 28, 2026
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on June 3, 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 3, 2026 (93 days from today).
What is a management decision? →FAC accepted this audit on June 2, 2025 — management decision was due December 2, 2025.
FAC accepted this audit on June 3, 2024 — management decision was due December 3, 2024.
The Organization has not applied sliding fee discounts to patient charges consistent with its sliding fee discount program. Through testing a statistically valid sample of transactions for the appropriate application of the Organization's sliding fee discount program to 25 individual patient balances, we noted the sliding fee discount applied was not consistent with the Organization's sliding fee discount policy for one patient. Based on income and family size, the patient received a discount of $317 but qualified for a discount of $243, resulting in a $74 difference. Cause: Approval of the sliding fee discount applications involves manual processes and errors can occur. To help mitigate errors, the Organization has implemented semi annual monitoring procedures which include the sampling of discounts provided to ensure the discounts were applied to patient accounts appropriately. The volume of discounts provided to patients annually does not allow for 100% review of all patient discounts. Due to the inherent nature of sampling, all errors may not be identified and corrected. Effect: It is possible the Organization may not apply sliding fee discounts to patient charges consistent with its sliding fee discount program. Questioned Costs: None Repeat Finding: No Recommendation: We recommend management consider increasing the number of transactions reviewed as part of the Organization's internal monitoring procedures and the frequency of monitoring procedures. Views of a Responsible Official and Corrective Action Plan: Management agrees with the finding and will review internal monitoring procedures for opportunities for improvement to increase compliance with the program requirements.
Show full finding ▾Hide full finding ▴Finding Number: 2023 001 Finding Type: Compliance - Special Tests and Provisions Information on the Federal Program: Program Name: Health Center Program Cluster (AL numbers 93.224 and 93.527) Grant Award: H80CS00150 from January 1, 2023 through December 31, 2023 Agency: U.S. Department of Health and Human Services, HRSA Pass Through Entity: N/A Criteria: In accordance with Section 330(k)(3)(G) of the Public Health Services Act (42 U.S. Code § 254b), as an FQHC, the Organization must have a sliding fee discount program in which the Organization’s fee schedule is discounted based on a patient’s ability to pay. Condition: The Organization has not applied sliding fee discounts to patient charges consistent with its sliding fee discount program. Through testing a statistically valid sample of transactions for the appropriate application of the Organization's sliding fee discount program to 25 individual patient balances, we noted the sliding fee discount applied was not consistent with the Organization's sliding fee discount policy for one patient. Based on income and family size, the patient received a discount of $317 but qualified for a discount of $243, resulting in a $74 difference. Cause: Approval of the sliding fee discount applications involves manual processes and errors can occur. To help mitigate errors, the Organization has implemented semi annual monitoring procedures which include the sampling of discounts provided to ensure the discounts were applied to patient accounts appropriately. The volume of discounts provided to patients annually does not allow for 100% review of all patient discounts. Due to the inherent nature of sampling, all errors may not be identified and corrected. Effect: It is possible the Organization may not apply sliding fee discounts to patient charges consistent with its sliding fee discount program. Questioned Costs: None Repeat Finding: No Recommendation: We recommend management consider increasing the number of transactions reviewed as part of the Organization's internal monitoring procedures and the frequency of monitoring procedures. Views of a Responsible Official and Corrective Action Plan: Management agrees with the finding and will review internal monitoring procedures for opportunities for improvement to increase compliance with the program requirements.
Finding: 2023-001 Condition: The Organization has not applied sliding fee discounts to patient charges consistent with its sliding fee discount program. Individual(s) Responsible for Corrective Action: Elizabeth Kelly – Reimbursement Supervisor Michelle Tuttle - CFO Planned Corrective Action: - On a monthly basis 20% of all sliding scale transactions will be audited for accuracy. o A report will be run to reflect all patients where a sliding scale was applied within the period. o A random sample representing the 20% will be chosen, using Excels random sample formula. o Any discounts applied in error will be documented and researched, a write-up will be done on the findings. o Any application of the sliding scale that results in a credit balance with the patient will be reviewed and a ticket will be created with eCW to determine the root cause for the error. o The audit will be conducted by the Reimbursement Supervisor and reviewed by the CFO. o All audited data will be kept as part of the accounting records and made available as requested. Anticipated Completion Date: 06/01/2024
FAC accepted this audit on June 1, 2023 — management decision was due December 1, 2023.
FAC accepted this audit on July 11, 2022 — management decision was due January 11, 2023.
FAC accepted this audit on May 31, 2021 — management decision was due December 1, 2021.
FAC accepted this audit on July 6, 2020 — management decision was due January 6, 2021.
FAC accepted this audit on June 20, 2019 — management decision was due December 20, 2019.
FAC accepted this audit on December 10, 2018 — management decision was due June 10, 2019.
FAC accepted this audit on January 2, 2018 — management decision was due July 2, 2018.
FAC accepted this audit on January 5, 2017 — management decision was due July 5, 2017.
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.
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