EIN: 273618164
UEI: XPL4K5F58UK5
Audited by: Forvis Mazars, LLP
Oversight agency: 93 [Department of Health and Human Services]
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Data as of September 7, 2026
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on June 30, 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 30, 2026 (109 days from today).
What is a management decision? →FAC accepted this audit on May 27, 2025 — management decision was due November 27, 2025.
FAC accepted this audit on June 29, 2024 — management decision was due December 29, 2024.
FAC accepted this audit on April 4, 2023 — management decision was due October 4, 2023.
FAC accepted this audit on June 28, 2022 — management decision was due December 28, 2022.
The clinic is required to prepare and submit an annual Uniform Data System (UDS) report for the calendar year. This report is to be prepared using accurate financial information. Questioned cost: None. Context: In the testing of the UDS report, the Health Center was unable to locate or provide supporting underlying data for two attributes (total nurse visits and total medical encounters) on Table 5. Effect: Potential errors may have been reported on the annual UDS report. Cause: The clinic was unable to produce accurate supporting information for the UDS report filed for Table 5. Identification as a repeat finding, if applicable: N/A Recommendation: We recommend management develop a procedure to compile and retain the information needed for accurate UDS reports to ensure accurate reporting. Views of responsible officials and planned corrective actions: Management agrees with the recommendation.
Show full finding ▾Hide full finding ▴Health Center Program Cluster; Federal Assistance Listing No. 93.224; U.S. Department of Health & Human Services; grant number H80CS26595; budget periods February 1, 2020, through January 31, 2021, and February 1, 2021, through January 31, 2022. Criteria or specific requirement: Reporting ? 42 CFR, Part 51c. Condition: The clinic is required to prepare and submit an annual Uniform Data System (UDS) report for the calendar year. This report is to be prepared using accurate financial information. Questioned cost: None. Context: In the testing of the UDS report, the Health Center was unable to locate or provide supporting underlying data for two attributes (total nurse visits and total medical encounters) on Table 5. Effect: Potential errors may have been reported on the annual UDS report. Cause: The clinic was unable to produce accurate supporting information for the UDS report filed for Table 5. Identification as a repeat finding, if applicable: N/A Recommendation: We recommend management develop a procedure to compile and retain the information needed for accurate UDS reports to ensure accurate reporting. Views of responsible officials and planned corrective actions: Management agrees with the recommendation.
Management agrees with the recommendation.
The Clinic is required to have minimal time elapsed between receipt of funds to the disbursement for the direct program or project costs. Questioned cost: $226,345. Context: The grant funds were drawn down in April 2021 in anticipation of paying for dental equipment that had been ordered for the Clinic. However, the vendor was unable to provide the equipment timely due to supply chain issues and was not able to fulfill the order as planned with the Clinic. Therefore, the delayed equipment was not provided to the Clinic until October 2021 and thus the Clinic was not able to pay for the equipment until they had received the dental equipment. Effect: The time elapsed from drawn down to payment was six months. Cause: The vendor had supply chain issues and was not able to deliver the equipment based on scheduled delivery, a continuation of issues from the ongoing pandemic. Identification as a repeat finding, if applicable: N/A Recommendation: We recommend management continue to monitor their draw down procedures for these unusual circumstances that can happen with supply chain issues and consider the timing of the draw downs. Views of responsible officials and planned corrective actions: Management agrees with the recommendation and will continue to have conversations with vendors when utilizing grant funds.
Show full finding ▾Hide full finding ▴Health Center Program Cluster; Federal Assistance Listing No. 93.224; U.S. Department of Health & Human Services; grant number H80CS26595; budget periods February 1, 2020, through January 31, 2021, and February 1, 2021, through January 31, 2022. Criteria or specific requirement: Cash Management ? 2 CFR, section 200.305(b). Condition: The Clinic is required to have minimal time elapsed between receipt of funds to the disbursement for the direct program or project costs. Questioned cost: $226,345. Context: The grant funds were drawn down in April 2021 in anticipation of paying for dental equipment that had been ordered for the Clinic. However, the vendor was unable to provide the equipment timely due to supply chain issues and was not able to fulfill the order as planned with the Clinic. Therefore, the delayed equipment was not provided to the Clinic until October 2021 and thus the Clinic was not able to pay for the equipment until they had received the dental equipment. Effect: The time elapsed from drawn down to payment was six months. Cause: The vendor had supply chain issues and was not able to deliver the equipment based on scheduled delivery, a continuation of issues from the ongoing pandemic. Identification as a repeat finding, if applicable: N/A Recommendation: We recommend management continue to monitor their draw down procedures for these unusual circumstances that can happen with supply chain issues and consider the timing of the draw downs. Views of responsible officials and planned corrective actions: Management agrees with the recommendation and will continue to have conversations with vendors when utilizing grant funds.
Management agrees with the recommendation and will continue to have conversations with vendors when utilizing grant funds.
FAC accepted this audit on October 10, 2021 — management decision was due April 10, 2022.
We noted during our testing of compliance with federal awards that the Clinic did not apply the sliding fee discounts properly to 7 patients out of a sample of 40 patients for the year ended September 30, 2020. Questioned cost: None. Context: From financial records for patients treated during the audit period, we selected 40 discounts for testing. This sample was not, and was not intended, to be a statistically valid sample. The Clinic?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 Clinic?s board of directors; and the schedule was uploaded into the Clinic?s billing system. However, there were errors when comparing the approved schedule to certain actual adjustments to patient accounts during the year ended September 30, 2020. For 7 of the 40 accounts selected for testing, the account had an incorrect discount applied. Effect: Discounts were not properly applied to patient accounts. Cause: The errors for the 7 patients? accounts where the fee schedule was applied inappropriately were due to a contractual third-party billing company incorrectly applying the discount for patients, not according to the Board-approved policy for implementing the sliding fee schedule. Identification as a repeat finding, if applicable: Repeat finding; see 2019-003, 2018-003 and 2017-003. Recommendation: We recommend management develop a procedure to properly enable each updated sliding fee scale in the patient billing system, and management should periodically test the application of the sliding fee to patient accounts.
Show full finding ▾Hide full finding ▴Health Center Program Cluster; CFDA No. 93.224; U.S. Department of Health & Human Services; grant number H80CS26595; budget periods February 1, 2019, through January 31, 2020, and February 1, 2020, through January 31, 2021. 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 have prepared 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 patients 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 Clinic did not apply the sliding fee discounts properly to 7 patients out of a sample of 40 patients for the year ended September 30, 2020. Questioned cost: None. Context: From financial records for patients treated during the audit period, we selected 40 discounts for testing. This sample was not, and was not intended, to be a statistically valid sample. The Clinic?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 Clinic?s board of directors; and the schedule was uploaded into the Clinic?s billing system. However, there were errors when comparing the approved schedule to certain actual adjustments to patient accounts during the year ended September 30, 2020. For 7 of the 40 accounts selected for testing, the account had an incorrect discount applied. Effect: Discounts were not properly applied to patient accounts. Cause: The errors for the 7 patients? accounts where the fee schedule was applied inappropriately were due to a contractual third-party billing company incorrectly applying the discount for patients, not according to the Board-approved policy for implementing the sliding fee schedule. Identification as a repeat finding, if applicable: Repeat finding; see 2019-003, 2018-003 and 2017-003. Recommendation: We recommend management develop a procedure to properly enable each updated sliding fee scale in the patient billing system, and management should periodically test the application of the sliding fee to patient accounts.
The accounting department, under the direction of the chief financial officer, will conduct monthly audits of random patients' accounts for whom the sliding fee schedule has been applied, as well as training for receptionists to minimize errors. Receptionists have been mandated, along with assistance from internal billing staff, to review all patients accounts (including income verification) at least annually. Additionally, starting on October 1, 2021, billing will be transferred to an external billing company due to the internal billing supervisor's resignation and efforts to rectify billing concerns. This will help prevent the vulnerability of relying only on such few numbers of internal billing staff.
2019-003
FAC accepted this audit on June 29, 2020 — management decision was due December 29, 2020.
The Clinic is required to submit an annual data collection form (DCF) by the required due date. In addition, the Clinic is required to prepare and submit an annual Uniform Data System (UDS) report for the calendar year. These reports are to be prepared using accurate financial information. Questioned cost: None. Context: In the testing of the UDS report, four attributes (total number of patients, total costs for medical staff and other direct and total accrued costs) reported on the UDS were not supported by accurate underlying data. Our testing found the DCF was not submitted by the deadline. Effect: Potential errors may have been reported on the annual UDS, and certain reports were not submitted timely to the grantor. Cause: The Clinic was unable to compile the financial information needed to prepare the DCF report in a timely manner and was unable to produce accurate supporting financial information for the UDS report filed. Identification as a repeat finding, if applicable: Repeat finding; see 2018-002, 2017-002 and 2016-002. Recommendation: We recommend management develop a procedure to compile and retain the information needed for accurate UDS and DCF reports to ensure accurate and timely reporting. Views of responsible officials and planned corrective actions: Management agrees with the recommendation. The DCF reporting for the period was late. With the continued insourcing of accounting personnel, this issue should be addressed.
Show full finding ▾Hide full finding ▴Health Center Program Cluster; CFDA No. 93.224; U.S. Department of Health & Human Services; grant number H80CS26595; budget periods February 1, 2018, through January 31, 2019, and February 1, 2019, through January 31, 2020. Criteria or specific requirement: Reporting ? 42 CFR, Part 51c and Part 75.342 Condition: The Clinic is required to submit an annual data collection form (DCF) by the required due date. In addition, the Clinic is required to prepare and submit an annual Uniform Data System (UDS) report for the calendar year. These reports are to be prepared using accurate financial information. Questioned cost: None. Context: In the testing of the UDS report, four attributes (total number of patients, total costs for medical staff and other direct and total accrued costs) reported on the UDS were not supported by accurate underlying data. Our testing found the DCF was not submitted by the deadline. Effect: Potential errors may have been reported on the annual UDS, and certain reports were not submitted timely to the grantor. Cause: The Clinic was unable to compile the financial information needed to prepare the DCF report in a timely manner and was unable to produce accurate supporting financial information for the UDS report filed. Identification as a repeat finding, if applicable: Repeat finding; see 2018-002, 2017-002 and 2016-002. Recommendation: We recommend management develop a procedure to compile and retain the information needed for accurate UDS and DCF reports to ensure accurate and timely reporting. Views of responsible officials and planned corrective actions: Management agrees with the recommendation. The DCF reporting for the period was late. With the continued insourcing of accounting personnel, this issue should be addressed.
Corrective Actio11: The annual data collection form (DCF) was intentionally delayed in its submission for the 2017-2018 audit due to desiring to include the terms of a debt settlement with the founding corporation, Pennyroyal Regional MH-MR Board Inc., also known as the Pennyroyal Center. The DCF is completed a year in arrears. Going forward the DCF will be submitted annually and on time as evidenced by the 20 I 9 audit submission. Any discrepancies noted in the UDS reporting are evaluated and discussed with the UDS auditor until completed to satisfaction. All records utilized to compile the UDS report and the subsequent email interactions with the UDS auditor are retained by the CFO and CEO. These were maintained this past year and will be going forward. Any discrepancies noted by the auditor may not have been perceived by the UDS auditor as such, and were completed to satisfaction initially. All records will continue to be maintained for the compilation of the UDS reporting, including all reports as well as emails with the UDS auditor, and maintained in the offices of the CFO and CEO.
2018-002
We noted during our testing of compliance with federal awards that the Clinic did not apply the sliding fee discounts properly to 5 patients out of a sample of 40 patients for the year ended September 30, 2019. Questioned cost: None. Context: From financial records for patients treated during the audit period, we selected 40 discounts for testing. This sample was not, and was not intended, to be a statistically valid sample. The Clinic?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 Clinic?s board of directors; and the schedule was uploaded into the Clinic?s billing system. However, there were errors when comparing the approved schedule to certain actual adjustments to patient accounts during the year ended September 30, 2019. For 5 of the 40 accounts selected for testing, the account had an incorrect discount applied. Effect: Discounts were not properly applied to patient accounts. Cause: The errors for the 5 patients accounts where the fee schedule was applied inappropriately were due to a contractual third-party billing company incorrectly applying the discount for patients, not according to the Board-approved policy for implementing the sliding fee schedule. The errors were actually in favor of the patients, discounting 100% of the patients' charges after a nominal fee was applied. Identification as a repeat finding, if applicable: Repeat finding; see 2018-003 and 2017-003. Recommendation: We recommend management develop a procedure to properly enable each updated sliding fee scale in the patient billing system, and management should periodically test the application of the sliding fee to patient accounts. Views of responsibile officials and planned corrective actions: The accounting department, under the direction of the CFO, will conduct monthly audits of random patients' accounts for whom the sliding fee schedule has been applied, as well as training for receptionists to look for errors, has been completed. Receptionists have been mandated, along with assistance from the internal billing department, to review all patients accounts (including income verification) at least annually. Additionally, in the coming calendar year, billing will be brought in-house with the assistance of a different clearinghouse in efforts to rectify billing concerns.
Show full finding ▾Hide full finding ▴Health Center Program Cluster; CFDA No. 93.224; U.S. Department of Health & Human Services; grant number H80CS26595; budget periods February 1, 2018, through January 31, 2019, and February 1, 2019, through January 31, 2020. 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 have prepared 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 patients 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 Clinic did not apply the sliding fee discounts properly to 5 patients out of a sample of 40 patients for the year ended September 30, 2019. Questioned cost: None. Context: From financial records for patients treated during the audit period, we selected 40 discounts for testing. This sample was not, and was not intended, to be a statistically valid sample. The Clinic?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 Clinic?s board of directors; and the schedule was uploaded into the Clinic?s billing system. However, there were errors when comparing the approved schedule to certain actual adjustments to patient accounts during the year ended September 30, 2019. For 5 of the 40 accounts selected for testing, the account had an incorrect discount applied. Effect: Discounts were not properly applied to patient accounts. Cause: The errors for the 5 patients accounts where the fee schedule was applied inappropriately were due to a contractual third-party billing company incorrectly applying the discount for patients, not according to the Board-approved policy for implementing the sliding fee schedule. The errors were actually in favor of the patients, discounting 100% of the patients' charges after a nominal fee was applied. Identification as a repeat finding, if applicable: Repeat finding; see 2018-003 and 2017-003. Recommendation: We recommend management develop a procedure to properly enable each updated sliding fee scale in the patient billing system, and management should periodically test the application of the sliding fee to patient accounts. Views of responsibile officials and planned corrective actions: The accounting department, under the direction of the CFO, will conduct monthly audits of random patients' accounts for whom the sliding fee schedule has been applied, as well as training for receptionists to look for errors, has been completed. Receptionists have been mandated, along with assistance from the internal billing department, to review all patients accounts (including income verification) at least annually. Additionally, in the coming calendar year, billing will be brought in-house with the assistance of a different clearinghouse in efforts to rectify billing concerns.
Corrective Actio11: The errors for the 5 patients accounts where the fee schedule was applied inappropriately were due to a contractual third-party billing company incorrectly applying the discount for patients, not according to the Board-approved policy for implementing the sliding fee schedule. The errors were actually in favor of the patients, discounting 100% of the patients' charges after a nominal fee was applied. These errors have been corrected. Corrective plans to help prevent such errors in the future are for the accounting department, under the direction of the CFO, to conduct monthly audits of random patients ' accounts for whom the sliding fee schedule has been applied, as well as training for receptionists to look for errors, has been completed. Receptionists have been mandated, along with assistance from the internal billing department, to review all patients accounts (including income verification) at a minimum of annually. Additionally, in the coming calendar year, billing will be brought in-house with the assistance of a different clearinghouse in efforts to rectify billing concerns.
2018-003
FAC accepted this audit on October 20, 2019 — management decision was due April 20, 2020.
GSA_MIGRATION
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2017-002, 2016-002
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2017-003
FAC accepted this audit on August 29, 2018 — management decision was due March 1, 2019.
GSA_MIGRATION
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2016-002
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GSA_MIGRATION
FAC accepted this audit on July 1, 2018 — management decision was due January 1, 2019.
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GSA_MIGRATION
2015-003
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