Richland Medical Center, Inc. d/b/a Central Ozarks Medical Center

Finding 2024.003: Special Tests and Provisions - Significant Deficiency Grantor: U.S. Department of Health and Human Services Federal Program Names: Health Center Program Cluster, COVID-19 Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care), Grants for New and Expanded Services under the Health Center Program, COVID-19 Grants for New and Expanded Services under the Health Center Program. Federal Assistance Listing Numbers: 93.224 and 93.527 Federal Award Identification Number and Year: H80CS00132-2022 and 2023 Criteria Health centers are required to have a corresponding schedule of discounts applied and adjusted on the basis of patients' ability to pay and their eligibility. A patient's eligibility to pay is determined on the basis of the official poverty guideline, as revised by DHHS (42 CFR Sections 51c, 107(b)(5), 56.108(b)(5) and 56.303(f)). The Organization should be implementing and monitoring procedures to properly determine, calculate and review sliding fee discounts issued to patients in accordance with the Organization's sliding fee scale. Condition The Organization did not always appropriately apply the sliding fee discount based on income levels. Cause The Organization did not have adequate internal controls in place to effectively ensure that patients receive the correct sliding fee discount. Effect or Potential Effect The Organization did not comply with the appropriate rules and regulations as per the Uniform Guidance. Questioned Costs None. Context A test of 40 slide fee discount transactions was performed and resulted in two instances of sliding fee discounts not being properly calculated based on the respective patient family size and income or was not in agreement with the supporting documentation. Our sample was a statistically valid sample. Identification as a Repeat Finding Yes - Finding 2023.001. Recommendation The Organization should strengthen internal controls in place to effectively ensure that patients receive the correct sliding fee discount. Views of Responsible Officials and Planned Corrective Actions Management agrees with the audit finding and will strengthen internal controls and accountability to correct the deficiency.

Finding 2024.004: Activities Allowed or Unallowed - Significant Deficiency Grantor: U.S. Department of Health and Human Services Federal Program Names: Health Center Program Cluster, COVID-19 Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care), Grants for New and Expanded Services under the Health Center Program, COVID-19 Grants for New and Expanded Services under the Health Center Program. Federal Assistance Listing Numbers: 93.224 and 93.527 Federal Award Identification Number and Year: H80CS00132-2022 and 2023 Criteria According to 2 CFR, Part 200.430(i)(1) charges to Federal awards for salaries and wages must be based on records that accurately reflect the actual work performed, which must, among other things: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) and reasonably reflect the total activity for which the employee is compensated by the non-Federal entity. Condition Charges to Federal Awards for salaries and wages were not supported by properly approved timesheets that agreed to payroll registers. Cause The Center's internal controls over payroll were not consistently followed. Effect or Potential Effect Unallowable expenses could be charged to the grant. Questioned Costs None. Context Out of the 25 payroll transactions selected for testing, we noted one instance in which the timesheet did not agree to the payroll register. Identification as a Repeat Finding Yes - Finding 2023.002. Recommendation We recommend that the Organization consistently enforce its internal controls over payroll to ensure that timesheets are reviewed and approved by the appropriate supervisor and ensure that they agree to the payroll register. Views of Responsible Officials and Planned Corrective Actions Management agrees with the audit finding and will implement additional controls to ensure payroll expenditures are being formally reviewed and approved.

Finding 2024.005: Reporting - Significant Deficiency Grantor: U.S. Department of Health and Human Services Federal Program Names: Health Center Program Cluster, COVID-19 Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care), Grants for New and Expanded Services under the Health Center Program, COVID-19 Grants for New and Expanded Services under the Health Center Program. Federal Assistance Listing Numbers: 93.224 and 93.527 Federal Award Identification Number and Year: H80CS00132-2022 and 2023 Criteria Health centers are required to have documentation that supports the amounts reported within the tables on the Health Resources and Services Administration Uniform Data Systems ("UDS") submission in accordance with the Office of Management and Budget Control No. 0915-0193. The Organization should be implementing and monitoring procedures to properly determine, calculate and review the amounts that are reported on the UDS submission. Condition The Organization did not have the proper documentation readily available to ensure that the calculations within the UDS reports were correct and accurate. Cause The Organization did not have adequate internal controls in place to effectively ensure that all calculations within the UDS report were correct and accurate. Effect or Potential Effect The Organization did not comply with the appropriate rules and regulations as per the Uniform Guidance. Questioned Costs None. Context A review of the UDS submission was performed and the Organization was unable to provide documentation to support the tables within the report. Identification as a Repeat Finding Not a repeat finding. Recommendation The Organization should establish a system of internal controls to ensure that all UDS related calculations are properly documented and maintained. Views of Responsible Officials and Planned Corrective Actions Management agrees with the audit finding and will strengthen internal controls and accountability to correct the deficiency.

Finding 2023.001: Special Tests and Provisions Grantor: U.S. Department of Health and Human Services Federal Program Names: Health Center Program Cluster, Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care), COVID-19 Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care), Grants for New and Expanded Services under the Health Center Program, COVID-19 Grants for New and Expanded Services under the Health Center Program. Federal Assistance Listing Numbers: 93.224 and 93.527 Criteria Health centers are required to have a corresponding schedule of discounts applied and adjusted on the basis of patients' ability to pay and their eligibility. A patient's eligibility to pay is determined on the basis of the official poverty guideline, as revised by DHHS (42 CFR Sections 51c, 107(b)(5), 56.108(b)(5) and 56.303(f)). The Organization should be implementing and monitoring procedures to properly determine, calculate and review sliding fee discounts issued to patients in accordance with the Organization's sliding fee scale. Condition The Organization did not always appropriately apply the sliding fee discount based on income levels. Cause The Organization did not have adequate internal controls in place to effectively ensure that patients receive the correct sliding fee discount. Effect The Organization did not comply with the appropriate rules and regulations as per the Uniform Guidance. Questioned Costs None. Context A test of 40 slide fee discount transactions was performed and resulted in six instances of sliding fee discounts not being properly calculated based on the respective patient family size and income or was not in agreement with the supporting documentation. Our sample was a statistically valid sample. Identification as Repeat Finding Yes - Finding 2022.001. Recommendation The Organization should strengthen internal controls in place to effectively ensure that patients receive the correct sliding fee discount. Views of Responsible Officials and Planned Corrective Actions Management agrees with the audit finding and will strengthen internal controls and accountability to correct the deficiency.

Finding 2023.002: Activities Allowed or Unallowed Grantor: U.S. Department of Health and Human Services Federal Program Names: Health Center Program Cluster, Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care), COVID-19 Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care), Grants for New and Expanded Services under the Health Center Program, COVID-19 Grants for New and Expanded Services under the Health Center Program. Federal Assistance Listing Numbers: 93.224 and 93.527 Criteria According to 2 CFR, Part 200.430(i)(1) charges to Federal awards for salaries and wages must be based on records that accurately reflect the actual work performed, which must, among other things: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) and reasonably reflect the total activity for which the employee is compensated by the non-Federal entity. Condition There was no evidence that management reviewed and approved the payroll cost charged to the major program to ensure it was an allowable cost under the Uniform Guidance, as evidenced by a reviewer's signature on the labor report. Cause The Center's internal controls over payroll were not consistently followed. Effect Unallowable expenses could be charged to the grant. Questioned Costs None. Context Out of the 25 payroll transactions selected for testing, none of them illustrated documentation of formal approval. Identification as Repeat Finding Not a repeat finding. Recommendation We recommend that the Organization consistently enforce its internal controls over payroll to ensure that all labor reports are reviewed and show formal approval before payroll is submitted. Views of Responsible Officials and Planned Corrective Actions Management agrees with the audit finding and will implement additional controls to ensure payroll expenditures are being formally reviewed and approved.

Finding 2022-001: Activities Allowed or Unallowed Grantor: U.S. Department of Health and Human Services Federal Program Names: Health Center Program Cluster, Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care), Health Center Program Cluster, COVID-19 Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care), Grants for New and Expanded Services under the Health Center Program. Federal Assistance Listing Numbers: 93.224 and 93.527 Criteria Health centers are required to have a corresponding schedule of discounts applied and adjusted on the basis of patients' ability to pay and their eligibility. A patient's eligibility to pay is determined on the basis of the official poverty guideline, as revised by DHHS (42 CFR Sections 51c, 107(b)(5), 56.108(b)(5) and 56.303(f)). The Organization should be implementing and monitoring procedures to properly determine, calculate and review sliding fee discounts issued to patients in accordance with the Organization's sliding fee scale. Condition The Organization did not always appropriately apply the sliding fee discount based on income levels. Context A test of 71 discount transactions was performed and resulted in two instances in which the incorrect sliding fee discount was provided to a patient. Our sample was a statistically valid sample. Questioned Costs None. Cause The Organization did not have adequate internal controls in place to effectively ensure that patients receive the correct sliding fee discount. Effect The Organization did not comply with the appropriate rules and regulations as per the Uniform Guidance. Identification as Repeat Finding Yes - Finding 2021-001. Recommendation The Organization should ensure that internal controls are in place to effectively ensure that patients receive the correct sliding fee discount. Views of Responsible Officials and Planned Corrective Actions Management agrees with the audit finding and will strengthen internal controls and accountability to correct the deficiency.

Finding 2021.001: Activities Allowed or Unallowed Grantor: U.S. Department of Health and Human Services Federal Program Names: Health Center Program Cluster, Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care), Health Center Program Cluster, COVID-19 Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care), Grants for New and Expanded Services under the Health Center Program. Federal Assistance Listing Numbers: 93.224 and 93.527 Criteria In accordance with the Uniform Guidance, health centers must prepare and apply a sliding fee discount schedule so that the amounts owed for health center services by eligible patients are adjusted (discounted) based on a patient's poverty level, which is determined by the patient's income and family size. Condition The Center did not always appropriately apply the sliding fee discount based on income levels. Context A test of 40 discount transactions was performed and resulted in three instances in which the incorrect sliding fee discount was provided to a patient. Our sample was a statistically valid sample. Questioned Costs None. Cause The Center did not have adequate internal controls in place to effectively ensure that patients receive the correct sliding fee discount. Effect The Center did not comply with the appropriate rules and regulations as per the Uniform Guidance. Identification as Repeat Finding Yes - Finding 2020.002. Recommendation The Center should ensure that internal controls are in place to effectively ensure that patients receive the correct sliding fee discount. Views of Responsible Officials and Planned Corrective Actions Management agrees with the audit finding and will strengthen internal controls and accountability to correct the deficiency.

Finding 2020.002: Activities Allowed or Unallowed Grantor: U.S. Department of Health and Human Services Federal Program Names: Health Center Program Cluster, Health Center Program, Grants for New and Expanded Services under the Health Center Program. CFDA Numbers: 93.224 and 93.527 Criteria In accordance with the Uniform Guidance, health centers must prepare and apply a sliding fee discount schedule so that the amounts owed for health center services by eligible patients are adjusted (discounted) based on a patient's poverty level, which is determined by the patient's income and family size. Condition The Center did not always appropriately apply the sliding fee discount based on income levels. Context A test of 40 discount transactions was performed and resulted in three instances where the incorrect sliding fee discount was provided to a patient. Our sample was a statistically valid sample. Questioned Costs None. Cause The Center did not have adequate internal controls in place to effectively ensure that patients receive the correct sliding fee discount. Effect The Center did not comply with the appropriate rules and regulations as per the Uniform Guidance. Identification as Repeat Finding Yes ? Finding 2019-002. Recommendation The Center should ensure that internal controls are in place to effectively ensure that patients receive the correct sliding fee discount. Views of Responsible Officials and Planned Corrective Actions Management agrees with the audit finding and will strengthen internal controls and accountability to correct the deficiency.

Finding 2019.001: Activities Allowed or Unallowed Grantor: U.S. Department of Health and Human Services Federal Program Names: Health Center Program Cluster, Health Center Program, Grants for New and Expanded Services under the Health Center Program. CFDA Numbers: 93.224 and 93.527 Criteria The Uniform Guidance requires that charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must be supported by a system of internal controls that provides reasonable assurance that the charges are accurate, allowable and properly allocated. Condition The Center did not appropriately adjust an employee?s status within the payroll system from nonexempt to exempt. This resulted in the exempt employee being overpaid for paid time off hours in addition to their normal salaried amount for one payroll period. Questioned Costs None. Cause The Center did not have adequate controls in place to ensure accurate reporting of hours worked. Effect Certain personnel costs allocated to the grant exceeded the actual work performed. Identification as Repeat Finding No. Recommendation We recommend that management review the control system surrounding payroll changes to ensure that payroll records accurately reflect the work performed. Views of Responsible Officials and Planned Corrective Actions Management agrees with this finding and has established internal control procedures to ensure the accurate reporting of work performed.

Finding 2019.002: Sliding Fee Scale Documentation Grantor: U.S. Department of Health and Human Services Federal Program Names: Health Center Program Cluster, Health Center Program, Grants for New and Expanded Services under the Health Center Program. CFDA Numbers: 93.224 and 93.527 Criteria In accordance with the Uniform Guidance, health centers must prepare and apply a sliding fee discount schedule so that the amounts owed for health center services by eligible patients are adjusted (discounted) based on a patient's poverty level, which is determined by the patient's income and family size. Condition The Center did not always appropriately apply the sliding discount based on income levels. Context A test of 53 sliding fee discount transactions was performed and resulted in two instances where the sliding fee discount was either improperly provided to a patient who was not eligible to receive the discount or the supporting documentation was not able to be located. Our sample was a statistically valid sample. Questioned Costs None. Cause The Center did not have adequate internal controls in place to effectively ensure that only eligible patients receive the sliding fee discount and the supporting documentation is present. Effect The Center did not comply with the appropriate rules and regulations as per the Uniform Guidance. Identification of Repeat Finding No. Recommendation The Center should implement internal controls to effectively prevent ineligible patients from receiving a sliding fee discount and ensure supporting documentation is on file. Views of Responsible Officials and Planning Corrective Actions Management agrees with the audit finding and will strengthen internal controls and accountability to correct the deficiency.

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