EIN: 264345390
UEI: M7JBX3QK5WJ7
Audited by: Forvis Mazars
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 August 6, 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 February 6, 2027 (152 days from today).
What is a management decision? →We noted during our testing of compliance with federal awards that the Health Center did not properly apply the sliding fee discounts approved by the board of directors for 3 patients out of a sample of 23 patients for the year ended December 31, 2025. Cause: The patients did not have a sliding fee application on file. Effect or Potential Effect: Discounts were improperly applied to patient accounts. Questioned cost: None Context: From a total of 116 sliding fee discounts for the period, 23 discounts were selected for testing. This sample was not, and was not intended to be, a statistically valid sample. The Health Center’s management did prepare a schedule of discounts adjusted on the basis of the patient’s ability to pay; such schedule was periodically updated and approved by the Health Center’s board of directors and the schedule was uploaded into the Health Center’s billing system. For 3 of the 23 accounts selected for testing, the account had an incorrect discount applied due to no completed application on file. Identification as a repeat finding, if applicable: Repeat Findings, See prior year finding 2024-002. Recommendation: We recommend management work with the billing team and staff to provide additional trainings for those billers applying the slide to patient accounts and conduct additional internal reviews to verify the patient accounts have been adjusted properly and supporting applications are retained. Views of responsible officials and planned corrective actions: The Health Center will review all applicable policies and ensure that all personnel responsible for and involved in the sliding fee discount program adequately demonstrate their understanding of the sliding fee discount application program. Management will conduct internal reviews periodically throughout the year to verify patient accounts have been adjusted properly and proper supporting applications are retained.
Show full finding ▾Hide full finding ▴Health Center Program Cluster; CFDA No. 93.224 and 93.527; HHS; grant number H80CS28961; budget periods June 1, 2024, through May 31, 2025 and June 1, 2025 through May 31, 2026 Criteria or specific requirement: Special Tests and Provisions – 42 CFR, Part 56.303(e), (f), and (g). Health Centers receiving funds under the Health Center Program Cluster are required to prepare a schedule of fees or payments for the provision of its services designed to cover its reasonable costs of operation and a corresponding schedule of discounts adjusted on the basis of the patient’s ability to pay, to make every reasonable effort, including the establishment of systems for eligibility determination, billing and collection, and to secure from patient payments for services in accordance with the schedule of fees and discounts. Condition: We noted during our testing of compliance with federal awards that the Health Center did not properly apply the sliding fee discounts approved by the board of directors for 3 patients out of a sample of 23 patients for the year ended December 31, 2025. Cause: The patients did not have a sliding fee application on file. Effect or Potential Effect: Discounts were improperly applied to patient accounts. Questioned cost: None Context: From a total of 116 sliding fee discounts for the period, 23 discounts were selected for testing. This sample was not, and was not intended to be, a statistically valid sample. The Health Center’s management did prepare a schedule of discounts adjusted on the basis of the patient’s ability to pay; such schedule was periodically updated and approved by the Health Center’s board of directors and the schedule was uploaded into the Health Center’s billing system. For 3 of the 23 accounts selected for testing, the account had an incorrect discount applied due to no completed application on file. Identification as a repeat finding, if applicable: Repeat Findings, See prior year finding 2024-002. Recommendation: We recommend management work with the billing team and staff to provide additional trainings for those billers applying the slide to patient accounts and conduct additional internal reviews to verify the patient accounts have been adjusted properly and supporting applications are retained. Views of responsible officials and planned corrective actions: The Health Center will review all applicable policies and ensure that all personnel responsible for and involved in the sliding fee discount program adequately demonstrate their understanding of the sliding fee discount application program. Management will conduct internal reviews periodically throughout the year to verify patient accounts have been adjusted properly and proper supporting applications are retained.
The Health Center will review all applicable policies and ensure that all personnel responsible for and involved in the sliding fee discount program adequately demonstrate their understanding of the sliding fee discount application program. Management will conduct internal reviews periodically throughout the year to verify patient accounts have been adjusted properly and proper supporting applications are retained.
2024-002
Information on the federal program – Assistance Listing Number 93.224/93.527, Health Center Program Cluster from the U.S. Department of Health and Human Services, Federal Award No. H80CS28961 budget periods June 1, 2024 through May 31, 2025 and June 1, 2025 through May 31, 2026 Criteria or specific requirement – Health Centers must comply with federal reporting requirements Condition – The Health Center did not have adequate support for line items on its Uniform Data System (UDS) Report Cause – The turnover in management contributed to the supporting documentation not being accurately maintained for support of the respective line items. Effect or Potential Effect – The UDS Report was submitted with potential incorrect data for table 5 line 8 Total Physicians (b) Clinic Visits and (b2) Virtual Visits and line 10a Total NPs, PAs, and CNMs (b) Clinic Visits and (b2) Virtual Visits Questioned Costs – Not applicable Context – Out of a population of 1 special report, the UDS report, was tested. The tables 4, 5, 8A, and 9E from the UDS report are complete with Health Center statistics. However, the support for Table 5 statistics was unable to be obtained. Identification as a repeat finding, if applicable – Not a repeat finding Recommendation – We recommend management maintain the supporting documentation for their completed reports. Views of responsible officials and planned corrective actions – Management will review their process and policy for retaining supporting documentation.
Show full finding ▾Hide full finding ▴Information on the federal program – Assistance Listing Number 93.224/93.527, Health Center Program Cluster from the U.S. Department of Health and Human Services, Federal Award No. H80CS28961 budget periods June 1, 2024 through May 31, 2025 and June 1, 2025 through May 31, 2026 Criteria or specific requirement – Health Centers must comply with federal reporting requirements Condition – The Health Center did not have adequate support for line items on its Uniform Data System (UDS) Report Cause – The turnover in management contributed to the supporting documentation not being accurately maintained for support of the respective line items. Effect or Potential Effect – The UDS Report was submitted with potential incorrect data for table 5 line 8 Total Physicians (b) Clinic Visits and (b2) Virtual Visits and line 10a Total NPs, PAs, and CNMs (b) Clinic Visits and (b2) Virtual Visits Questioned Costs – Not applicable Context – Out of a population of 1 special report, the UDS report, was tested. The tables 4, 5, 8A, and 9E from the UDS report are complete with Health Center statistics. However, the support for Table 5 statistics was unable to be obtained. Identification as a repeat finding, if applicable – Not a repeat finding Recommendation – We recommend management maintain the supporting documentation for their completed reports. Views of responsible officials and planned corrective actions – Management will review their process and policy for retaining supporting documentation.
Management will review their process and policy for retaining supporting documentation.
FAC accepted this audit on September 19, 2025 — management decision was due March 19, 2026.
We noted during our testing of compliance with federal awards that the Health Center did not properly apply the sliding fee discounts approved by the board of directors for 3 patients out of a sample of 14 patients for the year ended December 31, 2024. Cause: Errors occurred when analyzing the patient accounts and the incorrect discount occurred based on the Health Center’s policy. Effect or Potential Effect: Discounts were not properly applied to patient accounts. Questioned cost: None Context: From a total of 137 sliding fee discounts for the period, 14 discounts were selected for testing. This sample was not, and was not intended to be, a statistically valid sample. The Health Center’s management did prepare a schedule of discounts adjusted on the basis of the patient’s ability to pay; such schedule was periodically updated and approved by the Health Center’s board of directors and the schedule was uploaded into the Health Center’s billing system. However, there were errors when comparing the approved schedule to certain actual adjustments to patient accounts during the year ended December 31, 2024. For 3 of the 14 accounts selected for testing, the account had an incorrect discount applied. Identification as a repeat finding, if applicable: Not a repeat finding. Recommendation: We recommend management work with the billing team and staff to provide additional trainings for those billers applying the slide to patient accounts and conduct additional internal reviews to verify the patient accounts have been adjusted properly. Views of responsible officials and planned corrective actions: The Health Center will review all applicable policies and ensure that all personnel responsible for and involved in the sliding fee discount program adequately demonstrate their understanding of the sliding fee discount application program. Management will conduct internal reviews periodically throughout the year to verify patient accounts have been adjusted properly.
Show full finding ▾Hide full finding ▴Health Center Program Cluster; CFDA No. 93.224 and 93.527; HHS; grant number H80CS28961; budget periods June 1, 2023, through May 31, 2024 and June 1, 2024 through May 31, 2025 Criteria or specific requirement: Special Tests and Provisions – 42 CFR, Part 56.303(e), (f), and (g). Health Centers receiving funds under the Health Center Program Cluster are required to prepare a schedule of fees or payments for the provision of its services designed to cover its reasonable costs of operation and a corresponding schedule of discounts adjusted on the basis of the patient’s ability to pay, to make every reasonable effort, including the establishment of systems for eligibility determination, billing and collection, and to secure from patient payments for services in accordance with the schedule of fees and discounts. Condition: We noted during our testing of compliance with federal awards that the Health Center did not properly apply the sliding fee discounts approved by the board of directors for 3 patients out of a sample of 14 patients for the year ended December 31, 2024. Cause: Errors occurred when analyzing the patient accounts and the incorrect discount occurred based on the Health Center’s policy. Effect or Potential Effect: Discounts were not properly applied to patient accounts. Questioned cost: None Context: From a total of 137 sliding fee discounts for the period, 14 discounts were selected for testing. This sample was not, and was not intended to be, a statistically valid sample. The Health Center’s management did prepare a schedule of discounts adjusted on the basis of the patient’s ability to pay; such schedule was periodically updated and approved by the Health Center’s board of directors and the schedule was uploaded into the Health Center’s billing system. However, there were errors when comparing the approved schedule to certain actual adjustments to patient accounts during the year ended December 31, 2024. For 3 of the 14 accounts selected for testing, the account had an incorrect discount applied. Identification as a repeat finding, if applicable: Not a repeat finding. Recommendation: We recommend management work with the billing team and staff to provide additional trainings for those billers applying the slide to patient accounts and conduct additional internal reviews to verify the patient accounts have been adjusted properly. Views of responsible officials and planned corrective actions: The Health Center will review all applicable policies and ensure that all personnel responsible for and involved in the sliding fee discount program adequately demonstrate their understanding of the sliding fee discount application program. Management will conduct internal reviews periodically throughout the year to verify patient accounts have been adjusted properly.
The Health Center will review all applicable policies and ensure that all personnel responsible for and involved in the sliding fee discount program adequately demonstrate their understanding of the sliding fee discount application program. Management will conduct internal reviews periodically throughout the year to verify patent accounts have been adjusted properly.
Information on the federal program – Assistance Listing Number 93.224/93.527, Health Center Program Cluster from the U.S. Department of Health and Human Services, Federal Award No. H80CS28961 budget periods June 1, 2023 through May 31, 2024 and June 1, 2024 through May 31, 2025 Criteria or specific requirement – Health Centers must comply with federal reporting requirements Condition – The Health Center did not have adequate support for a line item on its Federal Financial Report Cause – The turnover in management contributed to the supporting documentation not being accurately maintained for support of the line item. Effect or Potential Effect – The Federal Financial Report was submitted reported with potential incorrect data for line 10 (l) – Total Federal share of program income earned Questioned Costs – Not applicable Context – Out of a population of 2 financial reports required to be submitted during the year under audit, 1 financial report was tested. Identification as a repeat finding, if applicable – Not a repeat finding Recommendation – We recommend management maintain the supporting documentation for their completed reports. Views of responsible officials and planned corrective actions – Management will review their process and policy for retaining supporting documentation.
Show full finding ▾Hide full finding ▴Information on the federal program – Assistance Listing Number 93.224/93.527, Health Center Program Cluster from the U.S. Department of Health and Human Services, Federal Award No. H80CS28961 budget periods June 1, 2023 through May 31, 2024 and June 1, 2024 through May 31, 2025 Criteria or specific requirement – Health Centers must comply with federal reporting requirements Condition – The Health Center did not have adequate support for a line item on its Federal Financial Report Cause – The turnover in management contributed to the supporting documentation not being accurately maintained for support of the line item. Effect or Potential Effect – The Federal Financial Report was submitted reported with potential incorrect data for line 10 (l) – Total Federal share of program income earned Questioned Costs – Not applicable Context – Out of a population of 2 financial reports required to be submitted during the year under audit, 1 financial report was tested. Identification as a repeat finding, if applicable – Not a repeat finding Recommendation – We recommend management maintain the supporting documentation for their completed reports. Views of responsible officials and planned corrective actions – Management will review their process and policy for retaining supporting documentation.
Management will review their process and policy for retaining supporting documentation.
FAC accepted this audit on November 14, 2024 — management decision was due May 14, 2025.
FAC accepted this audit on February 27, 2024 — management decision was due August 27, 2024.
FAC accepted this audit on September 28, 2022 — management decision was due March 28, 2023.
FAC accepted this audit on October 17, 2021 — management decision was due April 17, 2022.
During 2020, the Health Center did not consistently maintain evidence of a review or approval by key management of program draws. Questioned cost: None Context: From a total of 66 cash draws for the year, 7 were selected for testing. This sample was not, and was not intended to be, a statistically valid sample. The Health Center?s management prepared a drawdown packet; however, there was no documentation of approval of 3 of the 7 drawdowns. Effect: Potential material misstatements in the financial statements or misappropriations of assets due to error or fraud could occur and not be prevented or detected in a timely manner. Cause: Documentation of approvals were not properly maintained during the year to support adherence to internal control policies. Identification as a repeat finding, if applicable: Not a repeat finding. Recommendation: Management should continue to review their internal control policies and verify policies and procedures are followed continuously throughout the year.
Show full finding ▾Hide full finding ▴Health Center Program Cluster; Federal Assistance Listing Numbers 93.224 and 93.527; U.S. Department of Health and Human Services; grant number H80CS28961; budget periods June 1, 2019, through May 31, 2020, and June 1, 2020, through May 31, 2021. Criteria or specific requirement: Cash Management ? 2 CF Section 200.514 (c) ? Management is responsible for establishing and maintaining effective internal control over cash management and federal drawdowns. Condition: During 2020, the Health Center did not consistently maintain evidence of a review or approval by key management of program draws. Questioned cost: None Context: From a total of 66 cash draws for the year, 7 were selected for testing. This sample was not, and was not intended to be, a statistically valid sample. The Health Center?s management prepared a drawdown packet; however, there was no documentation of approval of 3 of the 7 drawdowns. Effect: Potential material misstatements in the financial statements or misappropriations of assets due to error or fraud could occur and not be prevented or detected in a timely manner. Cause: Documentation of approvals were not properly maintained during the year to support adherence to internal control policies. Identification as a repeat finding, if applicable: Not a repeat finding. Recommendation: Management should continue to review their internal control policies and verify policies and procedures are followed continuously throughout the year.
By August 1, 2021, management will implement current internal control policies consistently. The Director of Finance will ensure all drawdowns are printed and signed by the Chief Executive Officer, until additional staff may be hired to assist with this review process. Internal control policies will continue being reviewed by the Board of Directors annually. By December 31, 2021, the health center will hire additional personnel to support existing staff in the segregation of duties.
The Health Center had no review of the quarterly and annual Federal Financial Report (FFR) and annual Uniform Data System (UDS) report by key management other than the preparer. Questioned cost: None Context: The Health Center had no review of the quarterly and annual Federal Financial Report (FFR) and annual Uniform Data System (UDS) report by key management other than the preparer. Effect: Potential material misstatements in the quarterly and annual FFR and the UDS report. Cause: A change in management occurred during the year and internal control policies and procedures were not properly followed. Identification as a repeat finding, if applicable: Not a repeat finding. Recommendation: Management should continue to review their internal control policies and verify policies and procedures are followed continuously throughout the year.
Show full finding ▾Hide full finding ▴Health Center Program Cluster; Federal Assistance Listing Numbers 93.224 and 93.527; U.S. Department of Health and Human Services; grant number H80CS28961; budget periods June 1, 2019, through May 31, 2020, and June 1, 2020, through May 31, 2021. Criteria or specific requirement: Reporting ? 42 CFR, Part 51c and Part 75.342 Condition: The Health Center had no review of the quarterly and annual Federal Financial Report (FFR) and annual Uniform Data System (UDS) report by key management other than the preparer. Questioned cost: None Context: The Health Center had no review of the quarterly and annual Federal Financial Report (FFR) and annual Uniform Data System (UDS) report by key management other than the preparer. Effect: Potential material misstatements in the quarterly and annual FFR and the UDS report. Cause: A change in management occurred during the year and internal control policies and procedures were not properly followed. Identification as a repeat finding, if applicable: Not a repeat finding. Recommendation: Management should continue to review their internal control policies and verify policies and procedures are followed continuously throughout the year.
By August 1, 2021, management will implement current internal control policies consistently. The Director of Finance will ensure all quarterly and annual reports such as FFR and UDS are printed, reviewed, and signed by the Chief Executive Officer. In addition, The FFR and UDS will be shared with the Board's finance committee for review and approval. Internal control policies will continue being reviewed by the Board of Directors annually. By December 31, 2021, the health center will hire additional personnel to support existing staff in the segregation of duties.
FAC accepted this audit on February 2, 2021 — management decision was due August 2, 2021.
Condition ? During our Single Audit testing of patient records with regard to the Special Tests and Provisions compliance requirement, we noted that 3 out of 40 patients selected for sample testing had received the incorrect sliding fee discount based on the effective sliding fee discount schedule (SFDS) and related internal policy. Criteria ? Under the federal program, eligible patients are entitled to receive a sliding fee discount according to the federal poverty guidelines, and as allowed per the applicable internal sliding fee discount policy. Cause ? A variety of causes produced the 3 errors noted during testing. The primary causes of each of the 3 errors resulted from the improper classification of patients as sliding fee eligible or ineligible, or the improper class for the discount applied. Effect ? The effect of this significant deficiency could be an over or understatement of net revenues. Recommendation ? We recommend that SCHC continue its detailed review procedures of the individual patient accounts in the NextGen system to ensure that they are properly classified as sliding fee eligible or ineligible based on applicable policies. We also recommend SCHC continues thorough and sufficient training of billing and administrative personnel who apply the sliding fee discounts for individual patients to ensure appropriate application of the sliding fee discounts. Management?s Response ? SCHC will continue to conduct on-going internal reviews and training of staff.
Show full finding ▾Hide full finding ▴Condition ? During our Single Audit testing of patient records with regard to the Special Tests and Provisions compliance requirement, we noted that 3 out of 40 patients selected for sample testing had received the incorrect sliding fee discount based on the effective sliding fee discount schedule (SFDS) and related internal policy. Criteria ? Under the federal program, eligible patients are entitled to receive a sliding fee discount according to the federal poverty guidelines, and as allowed per the applicable internal sliding fee discount policy. Cause ? A variety of causes produced the 3 errors noted during testing. The primary causes of each of the 3 errors resulted from the improper classification of patients as sliding fee eligible or ineligible, or the improper class for the discount applied. Effect ? The effect of this significant deficiency could be an over or understatement of net revenues. Recommendation ? We recommend that SCHC continue its detailed review procedures of the individual patient accounts in the NextGen system to ensure that they are properly classified as sliding fee eligible or ineligible based on applicable policies. We also recommend SCHC continues thorough and sufficient training of billing and administrative personnel who apply the sliding fee discounts for individual patients to ensure appropriate application of the sliding fee discounts. Management?s Response ? SCHC will continue to conduct on-going internal reviews and training of staff.
CORRECTIVE ACTION PLAN DATE, 2020 U.S. Department of Health and Human Services Shawnee Christian Healthcare Center , Inc. respectively submits the following corrective action plan for the year ended December 31, 2019. Name and address of independent public accounting firm: Blue & Co., LLC 2650 Eastpoint Pkwy., Suite 300 Louisville, Kentucky 40223 Audit period: Year ended December 31, 2019. The findings from the schedule of findings and questioned costs for the year ended December 31, 2019 are discussed below. The findings are numbered consistently with the numbers assigned in the Schedule. FINDINGS - FINANCIAL STATEMENT AUDIT None FINDINGS ? FEDERAL AWARD PROGRAM AUDITS 2019-001 Condition: Sliding fee scale discounts: Based on the 40 patients selected for testing, we noted 3 errors, whereby the effective sliding fee discount schedule was inadequately applied or improperly provided. Action: Stan Wardlaw, CEO, will oversee continued training for necessary billing and administrative personnel on the application of the sliding fee discount schedule based on the related policy in place. Susan will also continue reviewing individual patient accounts for the correct application of sliding fee discounts. The implementation of these procedures is anticipated to be by December 31, 2020. If the U.S. Department of Health and Human Services has questions regarding this plan, please call Daniel Huhnerkoch, at (502) 778-0001. Sincerely, Daniel Huhnerkoch, Finance Coordinator
2018-002
FAC accepted this audit on August 12, 2019 — management decision was due February 12, 2020.
GSA_MIGRATION
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GSA_MIGRATION
2017-002
FAC accepted this audit on September 18, 2018 — management decision was due March 18, 2019.
GSA_MIGRATION
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GSA_MIGRATION
2016-002
FAC accepted this audit on September 28, 2017 — management decision was due March 28, 2018.
GSA_MIGRATION
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