Shawnee Health Service & Development CorporationNon-Profit

DEPARTMENT OF HEALTH AND HUMAN SERVICES 2022-001 Health Center Program-Cluster Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) ? CFDA #93.224 Grants for New and Expanded Services Under the Health Center Program ? CFDA #93.527 Recommendation: We recommend management review their internal control procedures and determine where modifications may be needed in the proper training, education, approval, and application process. Planned Corrective Action: Shawnee Health Service and Development Corporation (Shawnee) has a longstanding process in place to complete internal audits on 20 sliding fee applications per month. The results of the audits are discussed with staff who are involved in the sliding fee process, forwarded to the Leadership team, and then to the Board of Directors through our compliance reporting process. Shawnee has in place a comprehensive 9 module annual training program that all staff involved in the sliding fee application process must complete. Additionally, all new hires that are involved in the sliding fee process complete this training and then are added to the annual training schedule. Finally, any employee who does not demonstrate adequate competency must complete additional training during the year. The findings for FY2022 resulted in one patient?s income being incorrectly entered into the electronic patient management system resulting in the patient being incorrectly categorized. Based on the actual income level in the supporting documentation, the patient should have been charged $5 less in nominal fees. The patient did not have an income in excess of 200% of poverty. The findings also include two patients who had an incorrect sliding fee discount effective date entered into the electronic patient management system. The patients in question did not have incomes greater than 200% poverty. The findings in the sliding fee program do no affect Shawnee?s ability to initiate, authorize, record process, or report external financial data reliably in accordance with generally accepted accounting principles and are no in an amount that is material to the financial statements. As Shawnee has a comprehensive internal audit and compliance reporting process in place, the corrective action plan will consist of improving the current process by increasing the monthly audit sample from 20 applications per month to 30 applications per month. Additionally, Shawnee will implement a process to complete a 100% review of the sliding fee effective dates entered into the electronic patient management system. Finally, prior to the anticipated completion date, Shawnee will require all staff who are involved in the sliding fee process to complete the established training module on data entry. Name of Contact Person: Jeff Cooper, CFO Anticipated completion date: September 30, 2023

DEPARTMENT OF HEALTH AND HUMAN SERVICES 2022-002 Pandemic Health Navigator Pandemic Health Navigator ? CFDA #93.323, sub-grant of Illinois Public Health Region 4 and Region 5 Recommendation: We recommend management review their internal control procedures and determine where modifications may be needed in the reporting and oversight process to ensure timely submission of reports. Planned Corrective Action: Shawnee Health Service and Development Corporation (Shawnee) has in place a financial reporting calendar. The findings for FY2022 is that one report entitiled "Monthly Expenditure Report for Sub-Recipient" was filed one business day late based on the agreement with the Illinois Primary Health Care Association. There were no other required reports with any agency filed late during FY2022. The finding does not indicate that there is any likelihood of a misstatement, material or inconsequential, to the financial statements of the corporation. As Shawnee has a financial reporting calendar in place, the corrective action plan will consist of improving the current process by adding a second staff person to monitor the reporting calendar. Second, the primary monitor of the reporting calendar will issue electronic calendar invites with report due dates to appropriate staff who are charged with completing the report. Third, staff responsible for submitting reports will update a consolidated monthly calendar, viewable by all finance staff and monitors, with the actual dates that the reports were submitted. The monitors will routinely review the reporting calendar and follow-up with appropriate staff for any reports with an upcoming due date that have not yet been submitted. Name of Contact Person: Jeff Cooper, CFO Anticipated completion date: September 30, 2023