EIN: 237182584
UEI: DX1MBBNQCLM7
Audited by: Davis & Hodgdon Associates CPAs, PLC
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 September 30, 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 March 30, 2026 (162 days ago).
What is a management decision? →The Organization did not have a record of the sliding fee application used to determine sliding fee eligibility for six patients selected for testing. Questioned Costs: None Repeat Finding: No Cause and Effect: The Organization does not have procedures in place to ensure that sliding fee applications are electronically scanned and filed. Sliding fee applications are reviewed by one individual and a sliding fee level determination is entered into the patient’s medical records and the Organization’s billing software, but there is no documented process for a second individual at the Organization to verify that the application was filed and the sliding fee level for that patient was appropriately entered into the patient’s medical records. Lack of strict enforcement of the policy of sliding fee eligibility determination and compliance may have resulted in the Organization providing discounted services greater to or less than the appropriate amounts to beneficiaries. Recommendation: The Organization should establish a review process for all patient information entered into the Organization’s billing software to ensure that a sliding fee application is on file and the sliding fee applied to the patient is in line with the information verified on the application. Views of Responsible Official and Corrective Action Plan Management acknowledges and understands this finding. A response to the finding is noted in the Corrective Action Plan on page 40.
Show full finding ▾Hide full finding ▴Finding Number: 2025-001 Finding Type: Internal Control over Compliance – Special Tests and Provisions (Sliding Fee Discounts) Information on the Federal Program: Cluster Name: Health Center Cluster – 330 Grant Federal Awards: H80CS00311 Federal Agency: U.S. Department of Health and Human Services Criteria: Federal grant compliance provisions require that the Organization correctly identify a patient's ability to pay and that the rates for services be adjusted accordingly based on the sliding fee schedule. The Organization is required to follow its sliding fee policy when providing discounts to eligible patients. Condition: The Organization did not have a record of the sliding fee application used to determine sliding fee eligibility for six patients selected for testing. Questioned Costs: None Repeat Finding: No Cause and Effect: The Organization does not have procedures in place to ensure that sliding fee applications are electronically scanned and filed. Sliding fee applications are reviewed by one individual and a sliding fee level determination is entered into the patient’s medical records and the Organization’s billing software, but there is no documented process for a second individual at the Organization to verify that the application was filed and the sliding fee level for that patient was appropriately entered into the patient’s medical records. Lack of strict enforcement of the policy of sliding fee eligibility determination and compliance may have resulted in the Organization providing discounted services greater to or less than the appropriate amounts to beneficiaries. Recommendation: The Organization should establish a review process for all patient information entered into the Organization’s billing software to ensure that a sliding fee application is on file and the sliding fee applied to the patient is in line with the information verified on the application. Views of Responsible Official and Corrective Action Plan Management acknowledges and understands this finding. A response to the finding is noted in the Corrective Action Plan on page 40.
Response to FY2025 Audit Finding: Impact: "Lack of policy enforcement may have resulted in the Organization providing discounted services greater to or less than the appropriate amounts to beneficiaries" Why: 1. Were staff not consistently collecting the required income and family size documentation? 2. Was training not comprehensive enough or did staff turnover lead to a knowledge gap? 3. Is the Organizations policy or process for documenting income unclear or not consistently enforced? 4. Was there a system in place to audit patient files internally to catch documentation errors? 5. Is the culture of compliance not strong enough to prioritize consistent documentation? Action: 1. Update/Revise sliding fee policy and procedure to clearly define acceptable documentation process for income verification and annual re-evaluation 2. Create and deliver comprehensive training to all relevant staff (front desk, enrollment specialist, and billing) 3. Implement ongoing monitoring – • Establish a new scheduled internal audit process to regularly review a sample of patient documentation for sliding fee documentation compliance. • Establish metrics to track progress, such as percentage of patient files with complete sliding fee documentation, for new and annual sliding fee applications. 4. Once all actions are complete and the issue is resolved, document these improvements to continue the cycle of compliance 5. Continue to audit files at random to ensure documentation compliance continues
FAC accepted this audit on October 1, 2024 — management decision was due April 1, 2025.
FAC accepted this audit on October 3, 2023 — management decision was due April 3, 2024.
FAC accepted this audit on October 19, 2022 — management decision was due April 19, 2023.
FAC accepted this audit on October 18, 2021 — management decision was due April 18, 2022.
FAC accepted this audit on October 4, 2020 — management decision was due April 4, 2021.
FAC accepted this audit on October 16, 2019 — management decision was due April 16, 2020.
FAC accepted this audit on September 17, 2018 — management decision was due March 17, 2019.
FAC accepted this audit on September 24, 2017 — management decision was due March 24, 2018.
FAC accepted this audit on December 15, 2016 — management decision was due June 15, 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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