EIN: 371158318
UEI: N7PJN47ZP3Z4
Audited by: CLA
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 April 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 October 30, 2026 (62 days from today).
What is a management decision? →FAC accepted this audit on December 2, 2025 — management decision was due June 2, 2026.
FAC accepted this audit on June 13, 2024 — management decision was due December 13, 2024.
The Organization did not have documentation of multiple quotes for certain capital purchases as stated under their procurement policy. Questioned costs: None Cause: In certain circumstances the Organization utilizes a supply chain vendor for equipment and supply acquisitions, however the documentation around multiple quotes was not received and maintained. Effect: The Organization may inadvertently select vendors without regard to fair competition and cost analysis. Recommendation: Management should adhere to or revise the Organization’s existing procurement policy and implement a system of processes and internal controls to ensure that the appropriate level of documentation is maintained based on the procurement methodology selected for a transaction of contract. Views of responsible officials and planned corrective actions: There is no disagreement with the audit finding. Management identified that subsequent to the conclusion of the 2022 audit in May of 2023 procedures were implemented to the procurement process to assure adherence with the Organization’s policy on a go forward basis. The expenditures in question tested for 2023 were spent in the first quarter of 2023 prior to the procedure improvements and therefore caused the repeat finding.
Show full finding ▾Hide full finding ▴Federal Agency: U.S. Department of Health and Human Services Program Title: Consolidated Health Centers Assistance Listing Number: 93.224 and 93.527 Award Period: January 1, 2023 to December 31, 2023 Type of Finding: Compliance and Significant Deficiency in Internal Control over Compliance Criteria or specific requirement: § 200.320 Methods of procurement to be followed: The non-Federal entity must have and use documented procurement procedures, consistent with the standards of this section and §§ 200.317, 200.318, and 200.319 for any of the approved procurement methods used for the acquisition of property or services required under a Federal award or sub-award. Condition: The Organization did not have documentation of multiple quotes for certain capital purchases as stated under their procurement policy. Questioned costs: None Cause: In certain circumstances the Organization utilizes a supply chain vendor for equipment and supply acquisitions, however the documentation around multiple quotes was not received and maintained. Effect: The Organization may inadvertently select vendors without regard to fair competition and cost analysis. Recommendation: Management should adhere to or revise the Organization’s existing procurement policy and implement a system of processes and internal controls to ensure that the appropriate level of documentation is maintained based on the procurement methodology selected for a transaction of contract. Views of responsible officials and planned corrective actions: There is no disagreement with the audit finding. Management identified that subsequent to the conclusion of the 2022 audit in May of 2023 procedures were implemented to the procurement process to assure adherence with the Organization’s policy on a go forward basis. The expenditures in question tested for 2023 were spent in the first quarter of 2023 prior to the procedure improvements and therefore caused the repeat finding.
U.S. Department of Health and Human Services Southern Illinois Healthcare Foundation respectfully submits the following corrective action plan for the year ended December 31, 2023. Audit period: January 1, 2023 – December 31, 2023 The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS—FEDERAL AWARD PROGRAMS AUDITS DEPARTMENT OF HEALTH AND HUMAN SERVICES 2023 – 001 Consolidated Health Centers Recommendation: Management should adhere to or revise the Organization’s existing procurement policy and implement a system of processes and internal controls to ensure that the appropriate level of documentation is maintained based on the procurement methodology selected for a transaction of contract. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Hospital will ensure that controls are put into place to ensure procurement procedures are followed. Name of the contact person responsible for corrective action: John Jeffries, CFO. Planned completion date for corrective action plan: January 1, 2024. If the Department of Health and Human Services has questions regarding this plan, please call John Jeffries at 618-332-5324.
2022-002
FAC accepted this audit on May 22, 2023 — management decision was due November 22, 2023.
The Organization did not have documentation of multiple quotes for certain capital purchases as stated under their procurement policy. Questioned costs: None Cause: In certain circumstances the Organization utilizes a supply chain vendor for equipment and supply acquisitions, however the documentation around multiple quotes was not received and maintained. Effect: The Organization may inadvertently select vendors without regard to fair competition and cost analysis. Recommendation: Management should adhere to or revise the Organization?s existing procurement policy and implement a system of processes and internal controls to ensure that the appropriate level of documentation is maintained based on the procurement methodology selected for a transaction of contract. Views of responsible officials and planned corrective actions: There is no disagreement with the audit finding.
Show full finding ▾Hide full finding ▴2022-002 PROCUREMENT Federal Agency: U.S. Department of Health and Human Services Program Title: Consolidated Health Centers Assistance Listing Number: 93.224 Award Period: January 1, 2022 to December 31, 2022 Type of Finding: Compliance and Significant Deficiency in Internal Control over Compliance Criteria or specific requirement: ? 200.320 Methods of procurement to be followed: The non-Federal entity must have and use documented procurement procedures, consistent with the standards of this section and ?? 200.317, 200.318, and 200.319 for any of the approved procurement methods used for the acquisition of property or services required under a Federal award or sub-award. Condition: The Organization did not have documentation of multiple quotes for certain capital purchases as stated under their procurement policy. Questioned costs: None Cause: In certain circumstances the Organization utilizes a supply chain vendor for equipment and supply acquisitions, however the documentation around multiple quotes was not received and maintained. Effect: The Organization may inadvertently select vendors without regard to fair competition and cost analysis. Recommendation: Management should adhere to or revise the Organization?s existing procurement policy and implement a system of processes and internal controls to ensure that the appropriate level of documentation is maintained based on the procurement methodology selected for a transaction of contract. Views of responsible officials and planned corrective actions: There is no disagreement with the audit finding.
U.S. Department of Health and Human Services Southern Illinois Healthcare Foundation (?SIHF?) respectfully submits the following corrective action plan for the year ended December 31, 2022. Audit period: January 1, 2022 ? December 31, 2022 The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS?FEDERAL AWARD PROGRAMS AUDITS DEPARTMENT OF HEALTH AND HUMAN SERVICES 2022 ? 002 PROCUREMENT Recommendation: Management should adhere to or revise the Organization?s existing procurement policy and implement a system of processes and internal controls to ensure that the appropriate level of documentation is maintained based on the procurement methodology selected for a transaction of contract. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: SIHF will ensure that controls are put into place to assure the organization?s policy around procurement is being followed. Name of the contact person responsible for corrective action: John Jeffries, CFO. Planned completion date for corrective action plan: June 30, 2023 If the Department of Health and Human Services has questions regarding this plan, please call John Jeffries at 618-332-5324.
FAC accepted this audit on May 17, 2022 — management decision was due November 17, 2022.
For a sample of 60 sliding fee discounts tested, we identified the following: - Four sliding fee discounts were incorrectly applied due to an error in calculating the patient?s income, either due to data entry or judgement error. - Four sliding fee discounts were applied with an incomplete application or no support for income verification in the patient file. Questioned costs: None Cause: Due to the COVID-19 pandemic, employee turnover experienced by the Organization resulted in non-conformity of the slide fee discount to be applied in a few instances. Effect: The Organization?s application of the sliding fee discounts could have inadvertently under or over charged patients. Recommendation: We recommend the Organization review the policy for providing sliding fee adjustments to patients and provide the necessary training to ensure the Organization?s policy is being adhered to on a continuous basis.
Show full finding ▾Hide full finding ▴2021-001 PROGRAM INCOME REQUIREMENT Federal Agency: U.S. Department of Health and Human Services Program Title: Consolidated Health Centers Assistance Listing Number: 93.224 Award Period: January 1, 2021 to December 31, 2021 Type of Finding: Significant Deficiency in Internal Control over Compliance Criteria or specific requirement: As required by 42 United States Code (USC) Part 254, the Organization must prepare and maintain a schedule of fees or payments for the provision of its services with a discount schedule applied according to the patient?s ability to pay as determined by the US Department of Health and Human Services official poverty guidelines. Condition: For a sample of 60 sliding fee discounts tested, we identified the following: - Four sliding fee discounts were incorrectly applied due to an error in calculating the patient?s income, either due to data entry or judgement error. - Four sliding fee discounts were applied with an incomplete application or no support for income verification in the patient file. Questioned costs: None Cause: Due to the COVID-19 pandemic, employee turnover experienced by the Organization resulted in non-conformity of the slide fee discount to be applied in a few instances. Effect: The Organization?s application of the sliding fee discounts could have inadvertently under or over charged patients. Recommendation: We recommend the Organization review the policy for providing sliding fee adjustments to patients and provide the necessary training to ensure the Organization?s policy is being adhered to on a continuous basis.
Views of responsible officials and planned corrective actions: In 2021 the Organization?s Board of Directors approved a revised Sliding Fee Discount Policy as well as Application, Affidavit, and 2021 FPG Sliding Fee Discount Schedule. These revisions shall assist the Organization in properly implementing the updated slide program. The policies and procedures met all compliance requirements. The Organization will continue to train locations on these policy changes to ensure compliance. In addition, a Sliding Fee Discount Program Operating Procedure Manual and Training Program were implemented. All current and new employees involved in the revenue cycle are required to participate in the training program. The Organization has focused significant efforts in providing ongoing training of sliding fees at all locations and to all applicable personnel. Internal audits are being conducted at all Health Center locations. Sliding Fee transactions will be audited by the individual centers. The corporate office will also audit a sample of the transactions. Proper documentation, household income and Sliding Fee Discounts will be tested. Audit instructions are being communicated by the Central Business Office. Management is also considering regionalizing or centralizing the Sliding Fee processes in order to ensure the Organization?s policy is being adhered to on a continuous basis.
FAC accepted this audit on September 28, 2021 — management decision was due March 28, 2022.
FAC accepted this audit on December 9, 2020 — management decision was due June 9, 2021.
FAC accepted this audit on July 7, 2019 — management decision was due January 7, 2020.
FAC accepted this audit on May 24, 2018 — management decision was due November 24, 2018.
FAC accepted this audit on May 1, 2017 — management decision was due November 1, 2017.
GSA_MIGRATION
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GSA_MIGRATION
2015-002
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