EIN: 411235064
UEI: WLXLCSZ5Y4C8
Audited by: Wipfli LLP
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 June 2, 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 2, 2026 (89 days from today).
What is a management decision? →FAC accepted this audit on June 23, 2025 — management decision was due December 23, 2025.
FAC accepted this audit on June 21, 2024 — management decision was due December 21, 2024.
The Health Center did not meet its financial reporting obligations under the grant during the year. During the audit, it was determined the Health Center did not file the annual Federal Financial Report within 90 days of the required reporting end date. Criteria: The Health Center is required to file the annual Federal Financial Report within 90 days of the required reporting end date. Cause: The annual Federal Financial Report was not filed within the required period due to issues with staffing. Effect: The Health Center was not in compliance with federal regulations and the Health Center Program grant. Recommendation: We recommend Federal Financial Reports are submitted on a timely basis to ensure that the reporting deadline is met. View of Responsible Officials: Management acknowledges there were significant capacity issues because of the COVID-19 pandemic and its effect on staffing as it relates to the late audit completion and filing the Federal Financial Report. Management has been in contact with HRSA and the Office of Federal Assistance Management Division of Financial Integrity to keep them abreast of our progress.
Show full finding ▾Hide full finding ▴Finding 2023-001 Repeat Finding: Yes Program Name: Health Center Cluster Assistance Listing Numbers: 93.224 / 93.527 Federal Agency: U.S. Department of Health and Human Services Federal Award No: H80CS00516 Questioned Costs: N/A Type of Finding: Noncompliance, Significant Deficiency Compliance Requirement: Reporting Condition: The Health Center did not meet its financial reporting obligations under the grant during the year. During the audit, it was determined the Health Center did not file the annual Federal Financial Report within 90 days of the required reporting end date. Criteria: The Health Center is required to file the annual Federal Financial Report within 90 days of the required reporting end date. Cause: The annual Federal Financial Report was not filed within the required period due to issues with staffing. Effect: The Health Center was not in compliance with federal regulations and the Health Center Program grant. Recommendation: We recommend Federal Financial Reports are submitted on a timely basis to ensure that the reporting deadline is met. View of Responsible Officials: Management acknowledges there were significant capacity issues because of the COVID-19 pandemic and its effect on staffing as it relates to the late audit completion and filing the Federal Financial Report. Management has been in contact with HRSA and the Office of Federal Assistance Management Division of Financial Integrity to keep them abreast of our progress.
Finding # 2023-001 Condition The Health Center did not meet its financial reporting obligations under the grant during the year. During the audit, it was determined the Health Center did not file the annual Federal Financial Report within 90 days of the required reporting end date. Response The Federal Financial Report was filed late in 2023 due to an extended vacancy of a key finance position. The position has now been filled and should not be an issue going forward. Responsible Party Curt Engels, Finance Director Estimated Completion On-going
FAC accepted this audit on February 5, 2024 — management decision was due August 5, 2024.
The Health Center did not meet its financial reporting obligations under the grant during the year. During the audit, it was determined the Health Center did not file the Data Collection Form (SFSAC) by the due date of September 30, 2023. Criteria: The Health Center is required to file the Data Collection Form (SFSAC) within 30 days after receipt of audit or 9 months after year end, whichever is first. Cause: The Data Collection Form was not filed within the required period due to a delay in preparations for the audit. Effect: The Health Center was not in compliance with federal regulations and the Health Center Program grant. Recommendation: We recommend audit preparations are completed on a timely basis to ensure that the reporting deadline is met. View of Responsible Officials: Management acknowledges there were significant capacity issues because of the COVID-19 pandemic and its effect on staffing as it relates to the late audit completion and filing the SFSAC. Management has been in contact with HRSA and the Office of Federal Assistance Management Division of Financial Integrity to keep them abreast of our progress.
Show full finding ▾Hide full finding ▴Finding 2022-001 Repeat Finding: Yes Program Name: Health Center Cluster Assistance Listing Numbers: 93.224 / 93.527 Federal Agency: U.S. Department of Health and Human Services Federal Award No: H80CS00516 Questioned Costs: N/A Type of Finding: Noncompliance, Significant Deficiency Compliance Requirement: Reporting Condition: The Health Center did not meet its financial reporting obligations under the grant during the year. During the audit, it was determined the Health Center did not file the Data Collection Form (SFSAC) by the due date of September 30, 2023. Criteria: The Health Center is required to file the Data Collection Form (SFSAC) within 30 days after receipt of audit or 9 months after year end, whichever is first. Cause: The Data Collection Form was not filed within the required period due to a delay in preparations for the audit. Effect: The Health Center was not in compliance with federal regulations and the Health Center Program grant. Recommendation: We recommend audit preparations are completed on a timely basis to ensure that the reporting deadline is met. View of Responsible Officials: Management acknowledges there were significant capacity issues because of the COVID-19 pandemic and its effect on staffing as it relates to the late audit completion and filing the SFSAC. Management has been in contact with HRSA and the Office of Federal Assistance Management Division of Financial Integrity to keep them abreast of our progress.
Response: Completing the 2022 audit on a timely basis was compromised by the COVID pandemic and its effect on staffing that delayed the 2021 audit which then impacted the timing of completing the 2022 audit. This will not impact our ability to complete the 2023 audit timely. Responsible Party: Curt Engels, Finance Director Estimated Completion: On-going
2021-001
The Health Center did not meet the procurement obligations under the grant during the year. During the audit, it was determined the Health Center did not perform or maintain the support for the required vendor suspension and debarment procedures that are outlined under Uniform Guidance. Criteria: The Health Center is required to follow Suspension & Debarment, Sole Source, and Small Acquisitions procedures to conform to Uniform Guidance standards. Cause: Procurement procedures were not performed for the required vendors and purchases made in 2022. Effect: The Health Center was not in compliance with federal regulation and the Health Center Program grant. Recommendation: We recommend procedures as noted in the Health Center's procurement policy be followed and documented on the required purchases and vendors. View of Responsible Officials: Management acknowledges there were significant capacity issues because of the small accounting team.
Show full finding ▾Hide full finding ▴Finding 2022-002 Repeat Finding: No Program Name: Health Center Cluster Assistance Listing Numbers: 93.224 / 93.527 Federal Agency: U.S. Department of Health and Human Services Federal Award No: H80CS00516 Questioned Costs: N/A Type of Finding: Noncompliance, Significant Deficiency Compliance Requirement: Procurement Condition: The Health Center did not meet the procurement obligations under the grant during the year. During the audit, it was determined the Health Center did not perform or maintain the support for the required vendor suspension and debarment procedures that are outlined under Uniform Guidance. Criteria: The Health Center is required to follow Suspension & Debarment, Sole Source, and Small Acquisitions procedures to conform to Uniform Guidance standards. Cause: Procurement procedures were not performed for the required vendors and purchases made in 2022. Effect: The Health Center was not in compliance with federal regulation and the Health Center Program grant. Recommendation: We recommend procedures as noted in the Health Center's procurement policy be followed and documented on the required purchases and vendors. View of Responsible Officials: Management acknowledges there were significant capacity issues because of the small accounting team.
Response: In 2022 we could not determine if the prior Finance Director reviewed vendors for suspension or debarment as no evidence of this could be located. This process will be done regularly going forward and will be documented. Responsible Party: Curt Engels, Finance Director Estimated Completion: On-going
FAC accepted this audit on November 29, 2023 — management decision was due May 29, 2024.
The Health Center did not meet its financial reporting obligations under the grant during the year. During the audit, it was determined the Health Center did not file the Data Collection Form (SFSAC) by the due date of September 30, 2022. Criteria: The Health Center is required to file the Data Collection Form (SFSAC) within 30 days after receipt of audit or 9 months after year end, whichever is first. Cause: The Data Collection Form was not filed within the required period due to a delay in preparations for the audit. Effect: The Health Center was not in compliance with federal regulations and the Health Center Program grant. Recommendation: We recommend audit preparations are completed on a timely basis to ensure that the reporting deadline is met. View of Responsible Officials: Management acknowledges there were significant capacity issues because of the COVID-19 pandemic and its effect on staffing as it relates to the late audit completion and filing the SFSAC. Management has been in contact with HRSA and the Office of Federal Assistance Management Division of Financial Integrity to keep them abreast of our progress. The significant tardiness of the 2021 audit will also impact the completion of the 2022 audit and the ability of the Health Center to submit the SFSAC by the due date of September 30, 2023.
Show full finding ▾Hide full finding ▴Finding 2021-001 Repeat Finding: Yes Program Name: Health Center Cluster Assistance Listing Numbers: 93.224 / 93.527 Federal Agency: U.S. Department of Health and Human Services Federal Award No: H80CS00516 Questioned Costs: N/A Type of Finding: Noncompliance, Significant Deficiency Compliance Requirement: Reporting Condition: The Health Center did not meet its financial reporting obligations under the grant during the year. During the audit, it was determined the Health Center did not file the Data Collection Form (SFSAC) by the due date of September 30, 2022. Criteria: The Health Center is required to file the Data Collection Form (SFSAC) within 30 days after receipt of audit or 9 months after year end, whichever is first. Cause: The Data Collection Form was not filed within the required period due to a delay in preparations for the audit. Effect: The Health Center was not in compliance with federal regulations and the Health Center Program grant. Recommendation: We recommend audit preparations are completed on a timely basis to ensure that the reporting deadline is met. View of Responsible Officials: Management acknowledges there were significant capacity issues because of the COVID-19 pandemic and its effect on staffing as it relates to the late audit completion and filing the SFSAC. Management has been in contact with HRSA and the Office of Federal Assistance Management Division of Financial Integrity to keep them abreast of our progress. The significant tardiness of the 2021 audit will also impact the completion of the 2022 audit and the ability of the Health Center to submit the SFSAC by the due date of September 30, 2023.
Completing the 2021 audit on a timely basis was compromised by the Covid pandemic and its effect on staffing. With the 2021 audit being so late, this will also impact the timeliness of the 2022 audit. It will not be completed in time to upload the SFSAC by the 9/30/23 deadline. Responsible party is Curt Engels, Finance Director and estimated completion is ongoing.
2020-001
FAC accepted this audit on August 25, 2022 — management decision was due February 25, 2023.
The Health Center lacked adequate controls over its sliding fee discount program to ensure applications were properly processed, recorded, and received the correct discount. For three of 25 patient files reviewed who received a sliding fee discount, the patient was charged an incorrect copay amount based on the Health Center?s policy. Criteria: Health centers must prepare and apply a sliding fee discount schedule and policy so that the amounts owed for health center services by eligible patients are adjusted based on the patient?s ability to pay (42 USC 254(k)(3)(E), (F), and (G); 42 CFR sections 51c.303(e), (f), and (g); and 42 CFR sections 56.303(e), (f), and (g)). Cause: The Health Center did not always follow the review process in place to verify that eligible patients received the applicable sliding fee discount according to the Health Center?s policy. Effect: The Health Center's SFS patients' services were not properly discounted; therefore, those patients were not charged the correct copays in accordance with federal requirements. Recommendation: We recommend the Health Center develop proper controls around the collection of sliding fee applications, verifying required patient information is present and complete, and apply the sliding fee discount in accordance with written policies. This will ensure the Health Center can detect and prevent ineligible patients from receiving the discount and comply with federal compliance requirements. In order to ensure that SFS discounts are properly calculated and documented, we also recommend the Health Center should increase the frequency of random reviews of its SFS applications in order to help detect and correct errors or incomplete applications on a timely basis. View of Responsible Officials: Management acknowledges this condition related to lack of adequate controls over the sliding fee discount program and is creating controls that will assure compliance with requirements.
Show full finding ▾Hide full finding ▴Finding 2020.001 Repeat Finding: No Program Name/CFDA Title: Community Health Centers Cluster CFDA Number: 93.224 Federal Agency: U.S. Department of Health and Human Services Federal Award No: H80CS00516 Questioned Costs: N/A Type of Finding: Noncompliance, Significant Deficiency Compliance Requirement: Special Tests and Provisions Condition: The Health Center lacked adequate controls over its sliding fee discount program to ensure applications were properly processed, recorded, and received the correct discount. For three of 25 patient files reviewed who received a sliding fee discount, the patient was charged an incorrect copay amount based on the Health Center?s policy. Criteria: Health centers must prepare and apply a sliding fee discount schedule and policy so that the amounts owed for health center services by eligible patients are adjusted based on the patient?s ability to pay (42 USC 254(k)(3)(E), (F), and (G); 42 CFR sections 51c.303(e), (f), and (g); and 42 CFR sections 56.303(e), (f), and (g)). Cause: The Health Center did not always follow the review process in place to verify that eligible patients received the applicable sliding fee discount according to the Health Center?s policy. Effect: The Health Center's SFS patients' services were not properly discounted; therefore, those patients were not charged the correct copays in accordance with federal requirements. Recommendation: We recommend the Health Center develop proper controls around the collection of sliding fee applications, verifying required patient information is present and complete, and apply the sliding fee discount in accordance with written policies. This will ensure the Health Center can detect and prevent ineligible patients from receiving the discount and comply with federal compliance requirements. In order to ensure that SFS discounts are properly calculated and documented, we also recommend the Health Center should increase the frequency of random reviews of its SFS applications in order to help detect and correct errors or incomplete applications on a timely basis. View of Responsible Officials: Management acknowledges this condition related to lack of adequate controls over the sliding fee discount program and is creating controls that will assure compliance with requirements.
Response: Management will re-train all patient reception staff on the sliding fee policy and procedures. Management will also re-state the process of conducting random audits on a monthly basis to examine sliding fee visits at each of the clinics in order to determine if staff are following policy and procedures. If particular staff are not following policy and procedures, those staff will be re-trained again. Responsible Party: John Patrikus, Finance Director Estimated Completion: On-going
The Health Center did not meet its financial reporting obligations under the grant during the year. During the audit, it was determined the Health Center did not file one of the required quarterly SF-425 reports. In addition, the Health Center did not file the Data Collection Form (SFSAC) by the extended due date of March 31, 2022. Criteria: The Health Center is required to file the Federal Financial Report, SF-425. Quarterly and semi-annual reports are required to be submitted no later than 30 days after the end of each reporting period. These reports should be supported by appropriate documentation. The Health Center is required to file the Data Collection Form (SFSAC) within 30 days after receipt of audit or 9 months after year end, with an additional 6 months available for 2020, whichever is first. Cause: The Health Center did not have a review process in place to verify that reporting requirements were being met and reports issued timely. The Data Collection Form was not filed within the required period due to a delay in preparations for the audit. Effect: The Health Center was not in compliance with federal regulations and the Health Center Program grant. Recommendation: We recommend the Health Center develop proper controls around federal grant related reporting requirements. The Health Center should file the Federal Financial Report, SF-425 in a timely manner. We recommend audit preparations are completed on a timely basis to ensure that the reporting deadline is met. View of Responsible Officials: Management acknowledges there were significant capacity issues because of the COVID-19 pandemic and its effect on staffing as it relates to the late audit completion and filing the SFSAC. Management has been in contact with HRSA and the Office of Federal Assistance Management-Division of Financial Integrity to keep them abreast of our progress. The significant tardiness of the 2020 audit will also impact the completion of the 2021 audit and the ability of the Health Center to submit the SFSAC by the due date of September 20, 2022. We expect to have the 2021 audit completed and the SFSAC forms submitted by calendar year end of 2022.
Show full finding ▾Hide full finding ▴Finding 2020.002 Repeat Finding: No Program Name/CFDA Title: Community Health Centers Cluster CFDA Number: 93.224 Federal Agency: U.S. Department of Health and Human Services Federal Award No: H80CS00516 Questioned Costs: N/A Type of Finding: Noncompliance, Significant Deficiency Compliance Requirement: Reporting Requirement Condition: The Health Center did not meet its financial reporting obligations under the grant during the year. During the audit, it was determined the Health Center did not file one of the required quarterly SF-425 reports. In addition, the Health Center did not file the Data Collection Form (SFSAC) by the extended due date of March 31, 2022. Criteria: The Health Center is required to file the Federal Financial Report, SF-425. Quarterly and semi-annual reports are required to be submitted no later than 30 days after the end of each reporting period. These reports should be supported by appropriate documentation. The Health Center is required to file the Data Collection Form (SFSAC) within 30 days after receipt of audit or 9 months after year end, with an additional 6 months available for 2020, whichever is first. Cause: The Health Center did not have a review process in place to verify that reporting requirements were being met and reports issued timely. The Data Collection Form was not filed within the required period due to a delay in preparations for the audit. Effect: The Health Center was not in compliance with federal regulations and the Health Center Program grant. Recommendation: We recommend the Health Center develop proper controls around federal grant related reporting requirements. The Health Center should file the Federal Financial Report, SF-425 in a timely manner. We recommend audit preparations are completed on a timely basis to ensure that the reporting deadline is met. View of Responsible Officials: Management acknowledges there were significant capacity issues because of the COVID-19 pandemic and its effect on staffing as it relates to the late audit completion and filing the SFSAC. Management has been in contact with HRSA and the Office of Federal Assistance Management-Division of Financial Integrity to keep them abreast of our progress. The significant tardiness of the 2020 audit will also impact the completion of the 2021 audit and the ability of the Health Center to submit the SFSAC by the due date of September 20, 2022. We expect to have the 2021 audit completed and the SFSAC forms submitted by calendar year end of 2022.
Response: Finance Director missed the first quarter SF-425 amidst the early stages of the Covid pandemic. The information missed in the first quarter was rolled into the second quarter SF-425. Quarterly SF-425s are no longer required. Completing the 2020 audit on a timely basis was compromised by the Covid pandemic and its effect on staffing. With the 2020 audit being so late, this will also impact the timeliness of the 2021 audit. It will not be completed in time to upload the SFSAC by the 9/30/22 deadline. We have a goal of having the audit completed and the SFSAC filed by 12/31/22. Responsible Party: John Patrikus, Finance Director Estimated completion: 12/31/22
FAC accepted this audit on October 1, 2020 — management decision was due April 1, 2021.
FAC accepted this audit on August 3, 2019 — management decision was due February 3, 2020.
GSA_MIGRATION
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GSA_MIGRATION
FAC accepted this audit on July 31, 2018 — management decision was due January 31, 2019.
FAC accepted this audit on July 24, 2017 — management decision was due January 24, 2018.
GSA_MIGRATION
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