EIN: 462155118
UEI: HRAATANFJ7C3
Data as of August 26, 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 (97 days from today).
What is a management decision? →Pursuant to the reporting requirement set forth by the Department of Health and Human Services, the Clinic is required to file the quarterly Federal Financial Report (FFR) within 30 days of the end of the quarter and submit the single audit to the Federal Audit Clearinghouse within the sooner of 30 days of the issuance of the audit report or nine months after the end of the Clinic’s fiscal year. During our reporting period, we were unable to determine the submission of the quarterly reports and noted also that the audit was not completed and filed timely. Cause: Turnover in the Clinic’s management. Effect: The delay in submitting the required reports may lead to the granting agency to impose temporary restrictions on the drawdown of grant funds process. Questioned Cost: None Recommendation: The Clinic should establish reporting deadlines so that reports are filed accurately and on a timely basis. Views of Responsible Officials and Corrective Action Plan: See corrective action plan.
Show full finding ▾Hide full finding ▴Finding 2024 - 001 Reporting (L) Significant Deficiency in Internal Controls over Compliance Identification of the Federal Program: U.S. Department of Health and Human Services; Health Clinic Program Cluster; CFDA 93.224: 18H80CS31240. Criteria or Specific Requirement: Recipients of federal awards must establish internal controls over reports that are prepared and submitted. Finding/Condition: Pursuant to the reporting requirement set forth by the Department of Health and Human Services, the Clinic is required to file the quarterly Federal Financial Report (FFR) within 30 days of the end of the quarter and submit the single audit to the Federal Audit Clearinghouse within the sooner of 30 days of the issuance of the audit report or nine months after the end of the Clinic’s fiscal year. During our reporting period, we were unable to determine the submission of the quarterly reports and noted also that the audit was not completed and filed timely. Cause: Turnover in the Clinic’s management. Effect: The delay in submitting the required reports may lead to the granting agency to impose temporary restrictions on the drawdown of grant funds process. Questioned Cost: None Recommendation: The Clinic should establish reporting deadlines so that reports are filed accurately and on a timely basis. Views of Responsible Officials and Corrective Action Plan: See corrective action plan.
Parties responsible for all action items: CEO First Person Care Clinic – Harsh Chhawchharia, harsh@firstpersonclinic.org, phone 702-572-3500 Controller First Person Care Clinic – Demetrio Ordas, dordas@firstpersonclinic.org, phone 702-572-3500 Finding 2024- 001 Reporting (L) Significant Deficiency in Internal Controls over Compliance. Throughout 2024, our organization struggled to overcome ongoing obstacles due to a lack of personnel. Despite our efforts to hire additional administrative support, the process proved arduous, and we encountered difficulties in finding suitable candidates. In our quest for solutions, we proactively engaged with other FQHCs and NV PCA, exploring the potential for collaborative personnel arrangements. Moreover, our existing staff members underwent periods of illness, as did their families, further straining our capacity to fulfill our responsibilities effectively. As a result, the burden on our small team, consisting of just one additional staff member alongside myself and the CFO, became overwhelming. Juggling multiple roles and responsibilities amid personal and familial health challenges made it exceedingly difficult to keep up with the demanding workload. These circumstances underscored the urgent need for additional support and highlighted the critical importance of finding viable solutions to address our staffing limitations. CEO and CFO Timeframe: 2-4 months a. Staff Augmentation: We are actively working on hiring dedicated administrative support staff who will be responsible for assisting with routine tasks. This strategic addition to our team will allow the CEO and CFO to focus more effectively on their core responsibilities. b. Streamlined Processes: We are in the process of reviewing and optimizing our internal processes. This critical step will help enhance the overall efficiency of managing tasks related to federal reporting and grants management. c. Task Delegation: With the inclusion of additional staff members, we will delegate specific responsibilities to ensure that FFR quarterly reports are not only prepared but also submitted promptly. d. Reporting Calendar: We will be implementing a comprehensive reporting calendar that clearly outlines deadlines and assigns responsibilities. This organized approach will assist us in staying on track and meeting our reporting obligations consistently. e. Training and Development: Our team is committed to continuous improvement. To this end, we will be providing training and development opportunities for our staff to enhance their skills and knowledge in grants management and federal reporting. This investment in their professional development will result in greater accuracy and efficiency. In addition to these measures, we are exploring the possibility of engaging a third-party company if we encounter challenges in hiring employees directly. We are actively in discussions with other hiring companies and Locum tenants companies as needed to ensure that we have all the resources required to address this issue effectively. By implementing these measures, we aim to overcome historical challenges related to understaffing and limited access to essential resources. The collaborative efforts of the FPCC finance team, combined with streamlined processes and improved technology, will position us to submit FFR quarterly reports and the annual submission to the federal clearinghouse promptly and efficiently.
2023-001
FAC accepted this audit on June 6, 2024 — management decision was due December 6, 2024.
Pursuant to the reporting requirement set forth by the Department of Health and Human Services, the Clinic is required to file the quarterly Federal Financial Report (FFR) within 30 days of the end of the quarter and submit the single audit to the Federal Audit Clearinghouse within the sooner of 30 days of the issuance of the audit report or nine months after the end of the Clinic’s fiscal year. During our reporting period, we were unable to determine the submission of the quarterly reports and noted also that the audit was not completed and filed timely. Cause: Turnover in the Clinic’s management. Effect: The delay in submitting the required reports may lead to the granting agency to impose temporary restrictions on the drawdown of grant funds process. Questioned Cost: None Recommendation: The Clinic should establish reporting deadlines so that reports are filed accurately and on a timely basis. Views of Responsible Officials and Corrective Action Plan: See corrective action plan.
Show full finding ▾Hide full finding ▴Finding 2022 - 001 Reporting (L) Significant Deficiency in Internal Controls over Compliance Identification of the Federal Program: U.S. Department of Health and Human Services; Health Clinic Program Cluster; CFDA 93.224: 18H80CS31240. Criteria or Specific Requirement: Recipients of federal awards must establish internal controls over reports that are prepared and submitted. Finding/Condition: Pursuant to the reporting requirement set forth by the Department of Health and Human Services, the Clinic is required to file the quarterly Federal Financial Report (FFR) within 30 days of the end of the quarter and submit the single audit to the Federal Audit Clearinghouse within the sooner of 30 days of the issuance of the audit report or nine months after the end of the Clinic’s fiscal year. During our reporting period, we were unable to determine the submission of the quarterly reports and noted also that the audit was not completed and filed timely. Cause: Turnover in the Clinic’s management. Effect: The delay in submitting the required reports may lead to the granting agency to impose temporary restrictions on the drawdown of grant funds process. Questioned Cost: None Recommendation: The Clinic should establish reporting deadlines so that reports are filed accurately and on a timely basis. Views of Responsible Officials and Corrective Action Plan: See corrective action plan.
Finding 2022- 001 Reporting (L) Significant Deficiency in Internal Controls over Compliance. The challenges we faced in meeting reporting deadlines were significantly compounded by the COVID-19 pandemic. Throughout 2022, our organization struggled to overcome ongoing obstacles due to a lack of personnel. Despite our efforts to hire additional administrative support, the process proved arduous, and we encountered difficulties in finding suitable candidates. In our quest for solutions, we proactively engaged with other FQHCs and NV PCA, exploring the potential for collaborative personnel arrangements. Moreover, our existing staff members underwent periods of illness, as did their families, further straining our capacity to fulfill our responsibilities effectively. As a result, the burden on our small team, consisting of just one additional staff member alongside myself and the CFO, became overwhelming. Juggling multiple roles and responsibilities amid personal and familial health challenges made it exceedingly difficult to keep up with the demanding workload. These circumstances underscored the urgent need for additional support and highlighted the critical importance of finding viable solutions to address our staffing limitations. CEO and CFO Timeframe: 2-4 months a. Staff Augmentation: We are actively working on hiring dedicated administrative support staff who will be responsible for assisting with routine tasks. This strategic addition to our team will allow the CEO and CFO to focus more effectively on their core responsibilities. b. Streamlined Processes: We are in the process of reviewing and optimizing our internal processes. This critical step will help enhance the overall efficiency of managing tasks related to federal reporting and grants management. c. Task Delegation: With the inclusion of additional staff members, we will delegate specific responsibilities to ensure that FFR quarterly reports are not only prepared but also submitted promptly. d. Reporting Calendar: We will be implementing a comprehensive reporting calendar that clearly outlines deadlines and assigns responsibilities. This organized approach will assist us in staying on track and meeting our reporting obligations consistently. e. Training and Development: Our team is committed to continuous improvement. To this end, we will be providing training and development opportunities for our staff to enhance their skills and knowledge in grants management and federal reporting. This investment in their professional development will result in greater accuracy and efficiency. In addition to these measures, we are exploring the possibility of engaging a third-party company if we encounter challenges in hiring employees directly. We are actively in discussions with other hiring companies and Locum tenants companies as needed to ensure that we have all the resources required to address this issue effectively. By implementing these measures, we aim to overcome historical challenges related to understaffing and limited access to essential resources. The collaborative efforts of the FPCC finance team, combined with streamlined processes and improved technology, will position us to submit FFR quarterly reports and the annual submission to the federal clearinghouse promptly and efficiently.
2021-001
FAC accepted this audit on April 3, 2024 — management decision was due October 3, 2024.
Pursuant to the reporting requirement set forth by the Department of Health and Human Services, the Clinic is required to file the quarterly Federal Financial Report (FFR) within 30 days of the end of the quarter and submit the single audit to the Federal Audit Clearinghouse within the sooner of 30 days of the issuance of the audit report or nine months after the end of the Clinic’s fiscal year. During our reporting period, we were unable to determine the submission of the quarterly reports and noted also that the audit was not completed and filed timely. Cause: Turnover in the Clinic’s management. Effect: The delay in submitting the required reports may lead to the granting agency to impose temporary restrictions on the drawdown of grant funds process. Questioned Cost: None Recommendation: The Clinic should establish reporting deadlines so that reports are filed accurately and on a timely basis. Views of Responsible Officials and Corrective Action Plan: See corrective action plan.
Show full finding ▾Hide full finding ▴Finding 2021 - 001 Reporting (L) Significant Deficiency in Internal Controls over Compliance Identification of the Federal Program: U.S. Department of Health and Human Services; Health Clinic Program Cluster; CFDA 93.224: 18H80CS31240. Criteria or Specific Requirement: Recipients of federal awards must establish internal controls over reports that are prepared and submitted. Finding/Condition: Pursuant to the reporting requirement set forth by the Department of Health and Human Services, the Clinic is required to file the quarterly Federal Financial Report (FFR) within 30 days of the end of the quarter and submit the single audit to the Federal Audit Clearinghouse within the sooner of 30 days of the issuance of the audit report or nine months after the end of the Clinic’s fiscal year. During our reporting period, we were unable to determine the submission of the quarterly reports and noted also that the audit was not completed and filed timely. Cause: Turnover in the Clinic’s management. Effect: The delay in submitting the required reports may lead to the granting agency to impose temporary restrictions on the drawdown of grant funds process. Questioned Cost: None Recommendation: The Clinic should establish reporting deadlines so that reports are filed accurately and on a timely basis. Views of Responsible Officials and Corrective Action Plan: See corrective action plan.
Finding 2021- 001 Reporting (L) Significant Deficiency in Internal Controls over Compliance. The challenges we faced in meeting reporting deadlines were significantly compounded by the COVID-19 pandemic. Throughout 2021, our organization struggled to overcome ongoing obstacles due to a lack of personnel. Despite our efforts to hire additional administrative support, the process proved arduous, and we encountered difficulties in finding suitable candidates. In our quest for solutions, we proactively engaged with other FQHCs and NV PCA, exploring the potential for collaborative personnel arrangements. Moreover, our existing staff members underwent periods of illness, as did their families, further straining our capacity to fulfill our responsibilities effectively. As a result, the burden on our small team, consisting of just one additional staff member alongside myself and the CFO, became overwhelming. Juggling multiple roles and responsibilities amid personal and familial health challenges made it exceedingly difficult to keep up with the demanding workload. These circumstances underscored the urgent need for additional support and highlighted the critical importance of finding viable solutions to address our staffing limitations. CEO and CFO Timeframe: 2-4 months a. Staff Augmentation: We are actively working on hiring dedicated administrative support staff who will be responsible for assisting with routine tasks. This strategic addition to our team will allow the CEO and CFO to focus more effectively on their core responsibilities. b. Streamlined Processes: We are in the process of reviewing and optimizing our internal processes. This critical step will help enhance the overall efficiency of managing tasks related to federal reporting and grants management. c. Task Delegation: With the inclusion of additional staff members, we will delegate specific responsibilities to ensure that FFR quarterly reports are not only prepared but also submitted promptly. d. Reporting Calendar: We will be implementing a comprehensive reporting calendar that clearly outlines deadlines and assigns responsibilities. This organized approach will assist us in staying on track and meeting our reporting obligations consistently. e. Training and Development: Our team is committed to continuous improvement. To this end, we will be providing training and development opportunities for our staff to enhance their skills and knowledge in grants management and federal reporting. This investment in their professional development will result in greater accuracy and efficiency. In addition to these measures, we are exploring the possibility of engaging a third-party company if we encounter challenges in hiring employees directly. We are actively in discussions with other hiring companies and Locum tenants companies as needed to ensure that we have all the resources required to address this issue effectively. By implementing these measures, we aim to overcome historical challenges related to understaffing and limited access to essential resources. The collaborative efforts of the FPCC finance team, combined with streamlined processes and improved technology, will position us to submit FFR quarterly reports and the annual submission to the federal clearinghouse promptly and efficiently.
2020-001
FAC accepted this audit on February 29, 2024 — management decision was due August 29, 2024.
Pursuant to the reporting requirement set forth by the Department of Health and Human Services, the Clinic is required to file the quarterly Federal Financial Report (FFR) within 30 days of the end of the quarter and submit the single audit to the Federal Audit Clearinghouse within the sooner of 30 days of the issuance of the audit report or nine months after the end of the Clinic’s fiscal year. During our reporting period, we were unable to determine the submission of the quarterly reports and noted also that the audit was not completed and filed timely. Cause: Turnover in the Clinic’s management. Effect: The delay in submitting the required reports may lead to the granting agency to impose temporary restrictions on the drawdown of grant funds process. Questioned Cost: None Recommendation: The Clinic should establish reporting deadlines so that reports are filed accurately and on a timely basis. Views of Responsible Officials and Corrective Action Plan: See corrective action plan.
Show full finding ▾Hide full finding ▴Finding 2020 - 001 Reporting (L) Significant Deficiency in Internal Controls over Compliance Identification of the Federal Program: U.S. Department of Health and Human Services; Health Clinic Program Cluster; CFDA 93.224: 18H80CS31240. Criteria or Specific Requirement: Recipients of federal awards must establish internal controls over reports that are prepared and submitted. Finding/Condition: Pursuant to the reporting requirement set forth by the Department of Health and Human Services, the Clinic is required to file the quarterly Federal Financial Report (FFR) within 30 days of the end of the quarter and submit the single audit to the Federal Audit Clearinghouse within the sooner of 30 days of the issuance of the audit report or nine months after the end of the Clinic’s fiscal year. During our reporting period, we were unable to determine the submission of the quarterly reports and noted also that the audit was not completed and filed timely. Cause: Turnover in the Clinic’s management. Effect: The delay in submitting the required reports may lead to the granting agency to impose temporary restrictions on the drawdown of grant funds process. Questioned Cost: None Recommendation: The Clinic should establish reporting deadlines so that reports are filed accurately and on a timely basis. Views of Responsible Officials and Corrective Action Plan: See corrective action plan.
Finding 2020- 001 Reporting (L) Significant Deficiency in Internal Controls over Compliance. The challenges we faced in meeting reporting deadlines were significantly compounded by the COVID-19 pandemic. Throughout 2020, our organization struggled to overcome ongoing obstacles due to a lack of personnel. Despite our efforts to hire additional administrative support, the process proved arduous, and we encountered difficulties in finding suitable candidates. In our quest for solutions, we proactively engaged with other FQHCs and NV PCA, exploring the potential for collaborative personnel arrangements. Moreover, our existing staff members underwent periods of illness, as did their families, further straining our capacity to fulfill our responsibilities effectively. As a result, the burden on our small team, consisting of just one additional staff member alongside myself and the CFO, became overwhelming. Juggling multiple roles and responsibilities amid personal and familial health challenges made it exceedingly difficult to keep up with the demanding workload. These circumstances underscored the urgent need for additional support and highlighted the critical importance of finding viable solutions to address our staffing limitations. CEO and CFO Timeframe: 2-4 months a. Staff Augmentation: We are actively working on hiring dedicated administrative support staff who will be responsible for assisting with routine tasks. This strategic addition to our team will allow the CEO and CFO to focus more effectively on their core responsibilities. b. Streamlined Processes: We are in the process of reviewing and optimizing our internal processes. This critical step will help enhance the overall efficiency of managing tasks related to federal reporting and grants management. c. Task Delegation: With the inclusion of additional staff members, we will delegate specific responsibilities to ensure that FFR quarterly reports are not only prepared but also submitted promptly. d. Reporting Calendar: We will be implementing a comprehensive reporting calendar that clearly outlines deadlines and assigns responsibilities. This organized approach will assist us in staying on track and meeting our reporting obligations consistently. e. Training and Development: Our team is committed to continuous improvement. To this end, we will be providing training and development opportunities for our staff to enhance their skills and knowledge in grants management and federal reporting. This investment in their professional development will result in greater accuracy and efficiency. In addition to these measures, we are exploring the possibility of engaging a third-party company if we encounter challenges in hiring employees directly. We are actively in discussions with other hiring companies and Locum tenants companies as needed to ensure that we have all the resources required to address this issue effectively. By implementing these measures, we aim to overcome historical challenges related to understaffing and limited access to essential resources. The collaborative efforts of the FPCC finance team, combined with streamlined processes and improved technology, will position us to submit FFR quarterly reports and the annual submission to the federal clearinghouse promptly and efficiently.
2019-001
FAC accepted this audit on January 8, 2024 — management decision was due July 8, 2024.
Pursuant to the reporting requirement set forth by the Department of Health and Human Services, the Clinic is required to file the quarterly Federal Financial Report (FFR) within 30 days of the end of the quarter and submit the single audit to the Federal Audit Clearinghouse within the sooner of 30 days of the issuance of the audit report or nine months after the end of the Clinic’s fiscal year. During our reporting period, we were unable to determine the submission of the quarterly reports and noted also that the audit was not completed and filed timely. Cause: Turnover in the Clinic’s management. Effect: The delay in submitting the required reports may lead to the granting agency to impose temporary restrictions on the drawdown of grant funds process. Questioned Cost: None Recommendation: The Clinic should establish reporting deadlines so that reports are filed accurately and on a timely basis. Views of Responsible Officials and Corrective Action Plan: See corrective action plan.
Show full finding ▾Hide full finding ▴Finding 2019 - 001 Reporting (L) Significant Deficiency in Internal Controls over Compliance Identification of the Federal Program: U.S. Department of Health and Human Services; Health Clinic Program Cluster; CFDA 93.224: 18H80CS31240. Criteria or Specific Requirement: Recipients of federal awards must establish internal controls over reports that are prepared and submitted. Finding/Condition: Pursuant to the reporting requirement set forth by the Department of Health and Human Services, the Clinic is required to file the quarterly Federal Financial Report (FFR) within 30 days of the end of the quarter and submit the single audit to the Federal Audit Clearinghouse within the sooner of 30 days of the issuance of the audit report or nine months after the end of the Clinic’s fiscal year. During our reporting period, we were unable to determine the submission of the quarterly reports and noted also that the audit was not completed and filed timely. Cause: Turnover in the Clinic’s management. Effect: The delay in submitting the required reports may lead to the granting agency to impose temporary restrictions on the drawdown of grant funds process. Questioned Cost: None Recommendation: The Clinic should establish reporting deadlines so that reports are filed accurately and on a timely basis. Views of Responsible Officials and Corrective Action Plan: See corrective action plan.
Finding 2019- 001 Reporting (L) Significant Deficiency in Internal Controls over Compliance. In 2019, our organization grappled with ongoing challenges when it came to meeting reporting deadlines. These hurdles were primarily a result of our small team, which consisted of only one additional staff member alongside the CEO and CFO. Despite our best endeavors, we encountered significant obstacles in our attempts to hire additional administrative support personnel. In our quest for solutions, we proactively engaged with other FQHCs and NV PCA, exploring the potential for collaborative personnel arrangements. The absence of additional support placed a considerable burden on both the CEO and CFO. They found themselves juggling a multitude of responsibilities, encompassing tasks such as mail management, deposit preparation, supply procurement, receipt matching, approval document handling, drawdown completion, federal funding expense tracking, committee and board meeting preparation, day-to-day operational oversight, and critical grants management duties. Consequently, occasional delays occurred in the submission of FFR quarterly reports, and there was limited time available for following up with State and local institutions to obtain the necessary documentation required for the audit. Additionally, accessing the Medicare Portal, which still bore the name of the previous CEO, presented challenges. All of these factors collectively impacted the timing of the Federal Audit. CEO and CFO Timeframe: 2-4 months a. Staff Augmentation: We are actively working on hiring dedicated administrative support staff who will be responsible for assisting with routine tasks. This strategic addition to our team will allow the CEO and CFO to focus more effectively on their core responsibilities. b. Streamlined Processes: We are in the process of reviewing and optimizing our internal processes. This critical step will help enhance the overall efficiency of managing tasks related to federal reporting and grants management. c. Task Delegation: With the inclusion of additional staff members, we will delegate specific responsibilities to ensure that FFR quarterly reports are not only prepared but also submitted promptly. d. Reporting Calendar: We will be implementing a comprehensive reporting calendar that clearly outlines deadlines and assigns responsibilities. This organized approach will assist us in staying on track and meeting our reporting obligations consistently. e. Training and Development: Our team is committed to continuous improvement. To this end, we will be providing training and development opportunities for our staff to enhance their skills and knowledge in grants management and federal reporting. This investment in their professional development will result in greater accuracy and efficiency. In addition to these measures, we are exploring the possibility of engaging a third-party company if we encounter challenges in hiring employees directly. We are actively in discussions with other hiring companies and Locum tenants companies as needed to ensure that we have all the resources required to address this issue effectively. By implementing these measures, we aim to overcome historical challenges related to understaffing and limited access to essential resources. The collaborative efforts of the FPCC finance team, combined with streamlined processes and improved technology, will position us to submit FFR quarterly reports and the annual submission to the federal clearinghouse promptly and efficiently.
2018-002
FAC accepted this audit on December 15, 2023 — management decision was due June 15, 2024.
The procurement policies and procedures were found lacking as to the bidding and retaining process. We could not locate certain files indicating that the procurement requirements had been followed. In addition, we could not locate certain files indicating the debarment procedures had been properly followed per the requirements. Cause: Management lack of time to establishing a policy and procedure regarding this requirement. Effect: The lack of policies and procedures in this area may cause the Clinic to be out of compliance with this procurement, suspension and debarment requirement. A lack of competitive bidding may overstate allowable costs and a lack of debarment procedures may allow debarred vendors in providing material, supplies and services. Questioned Cost: None Recommendation: The Clinic should establish sound policies and procedures which conform to federal requirements for procurement, suspension and debarment. Views of Responsible Officials and Corrective Action Plan: See corrective action plan.
Show full finding ▾Hide full finding ▴Finding 2018 - 001 Procurement, Suspension & Debarment (I) Significant Deficiency in Internal Controls over Compliance Identification of the Federal Program: U.S. Department of Health and Human Services; Health Clinic Program Cluster; CFDA 93.224: 18H80CS31240. Criteria or Specific Requirement: Non-federal entities must follow the procurement standards set out at 2 CFR Sections 200.318 through 200.326. They must use their own documented procedures, which reflect applicable state and local laws and regulations, provided that the procurements conform to applicable federal statues and the procurement requirements identified in 2 CFR Part 200 as described above. Finding/Condition: The procurement policies and procedures were found lacking as to the bidding and retaining process. We could not locate certain files indicating that the procurement requirements had been followed. In addition, we could not locate certain files indicating the debarment procedures had been properly followed per the requirements. Cause: Management lack of time to establishing a policy and procedure regarding this requirement. Effect: The lack of policies and procedures in this area may cause the Clinic to be out of compliance with this procurement, suspension and debarment requirement. A lack of competitive bidding may overstate allowable costs and a lack of debarment procedures may allow debarred vendors in providing material, supplies and services. Questioned Cost: None Recommendation: The Clinic should establish sound policies and procedures which conform to federal requirements for procurement, suspension and debarment. Views of Responsible Officials and Corrective Action Plan: See corrective action plan.
Action Plan to Address Policy Updates and Implementation (Finding 2018-001): a. Review and Update Policies: Begin by conducting a comprehensive review of existing policies, particularly those related to procurement, suspension, and debarment. Ensure these policies align with the latest HRSA requirements and federal regulations. b. Engage a Policy Consultant: Seek the expertise of a policy consultant or legal counsel well-versed in healthcare compliance and HRSA regulations to assist in policy revision. c. Policy Training: Develop a training program to educate staff, especially key personnel like the CEO and CFO, on the updated policies. This training should emphasize the significance of compliance and the potential consequences of non-compliance. d. Implementation Oversight: Appoint a Compliance Officer responsible for overseeing the implementation of updated policies and procedures. This officer should regularly audit and monitor adherence to these policies. e. Documentation and Reporting: Implement a robust documentation system to track policy adherence and any deviations. Ensure that timely and accurate reports are generated for review by internal committees and the board. f. Board and Committee Involvement: Enhance board and committee involvement in the oversight of policy compliance. Provide regular updates and reports to these entities to keep them informed and engaged in the compliance process. g. Continuous Monitoring: Establish a continuous monitoring process to identify any policy-related deficiencies promptly. Regularly assess the effectiveness of policies and make necessary adjustments. h. External Audit: Schedule an external audit ahead of time by an independent auditor or agency to ensure objectivity and compliance with HRSA standards. i. Communication: Promote a culture of compliance through effective communication channels. Encourage employees at all levels to report potential violations or concerns without fear of retaliation. j. Periodic Review: Commit to a periodic review of policies, at least annually, to ensure they remain current and aligned with any evolving HRSA regulations or federal mandates.
Pursuant to the reporting requirement set forth by the Department of Health and Human Services, the Clinic is required to file the quarterly Federal Financial Report (FFR) within 30 days of the end of the quarter and submit the single audit to the Federal Audit Clearinghouse within the sooner of 30 days of the issuance of the audit report or nine months after the end of the Clinic’s fiscal year. During our reporting period, we were unable to determine the submission of the quarterly reports and noted also that the audit was not completed and filed timely. Cause: Turnover in the Clinic’s management. Effect: The delay in submitting the required reports may lead to the granting agency to impose temporary restrictions on the drawdown of grant funds process. Questioned Cost: None Recommendation: The Clinic should establish reporting deadlines so that reports are filed accurately and on a timely basis. Views of Responsible Officials and Corrective Action Plan: See corrective action plan. Section III - Prior Year Findings and Questioned Costs No prior year findings or questioned costs.
Show full finding ▾Hide full finding ▴Finding 2018 - 002 Reporting (L) Significant Deficiency in Internal Controls over Compliance Identification of the Federal Program: U.S. Department of Health and Human Services; Health Clinic Program Cluster; CFDA 93.224: 18H80CS31240. Criteria or Specific Requirement: Recipients of federal awards must establish internal controls over reports that are prepared and submitted. Finding/Condition: Pursuant to the reporting requirement set forth by the Department of Health and Human Services, the Clinic is required to file the quarterly Federal Financial Report (FFR) within 30 days of the end of the quarter and submit the single audit to the Federal Audit Clearinghouse within the sooner of 30 days of the issuance of the audit report or nine months after the end of the Clinic’s fiscal year. During our reporting period, we were unable to determine the submission of the quarterly reports and noted also that the audit was not completed and filed timely. Cause: Turnover in the Clinic’s management. Effect: The delay in submitting the required reports may lead to the granting agency to impose temporary restrictions on the drawdown of grant funds process. Questioned Cost: None Recommendation: The Clinic should establish reporting deadlines so that reports are filed accurately and on a timely basis. Views of Responsible Officials and Corrective Action Plan: See corrective action plan. Section III - Prior Year Findings and Questioned Costs No prior year findings or questioned costs.
To address this issue and ensure timeliness in the future, we have devised the following action plan: a. Staff Augmentation: We plan to hire dedicated administrative support staff to assist with routine tasks, allowing the CEO and CFO to focus on their core responsibilities. b. Streamlined Processes: We will review and optimize our internal processes to ensure efficiency in handling tasks related to federal reporting and grants management. c. Task Delegation: With additional staff in place, we will delegate specific responsibilities to ensure that FFR quarterly reports are prepared and submitted promptly. d. Reporting Calendar: We will implement a reporting calendar that outlines deadlines and responsibilities, helping us stay organized and on track. e. Training and Development: Our team will undergo training to enhance their skills and knowledge in grants management and federal reporting, ensuring greater accuracy and efficiency.
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