EIN: 470666715
UEI: LBNNLRDE8793
Audited by: Lutz & Company, PC
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 May 22, 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 November 22, 2026 (83 days from today).
What is a management decision? →During the testing performed, it was noted that the Organization transferred payroll costs between programs, however, no time and effort certification or equivalent documentation was updated to reflect the changes. Additionally, the transfer of payroll costs between grants was not properly reflected within the accounting system records by grant. Cause: During the year the Organization had new grants, but the payroll system was not updated to reflect the changes. Effect: Allocation of payroll costs to the federal award program may be inaccurate or not properly documented. Questioned costs: n/a Context: The Organization did not maintain supporting documentation for payroll costs that were reallocated to a new grant. These costs were reallocated from the Health Center Program to the new award. Repeat Finding: Yes, 2024-004 Recommendation: The Organization should add the new grant to the payroll software for separate tracking and update their allocations within the general ledger to accurately reflect payroll costs incurred by grant. Additionally, the Organization should provide training to staff on grant tracking and documentation. Views of Responsible Officials: Management agrees with this finding. Due to the timing of when the prior year audit was completed and issues identified, this issue was in progress towards the end of the current year. Staff will be trained to ensure future changes in payroll costs are updated timely within the system and documentation maintained.
Show full finding ▾Hide full finding ▴Significant Deficiency in Internal Control for Allowable Costs/Cost Principles Health Center Program Cluster AL No. 93.224 and 93.527 U.S. Department of Health and Human Services Award No. H80CS00438 Criteria: Under 2 CFR 200.430, payroll expenses must be based on records that accurately reflect the work performed and supported by a system of internal control that provides reasonable assurance that charges are accurate, allowable, and properly allocated. Condition: During the testing performed, it was noted that the Organization transferred payroll costs between programs, however, no time and effort certification or equivalent documentation was updated to reflect the changes. Additionally, the transfer of payroll costs between grants was not properly reflected within the accounting system records by grant. Cause: During the year the Organization had new grants, but the payroll system was not updated to reflect the changes. Effect: Allocation of payroll costs to the federal award program may be inaccurate or not properly documented. Questioned costs: n/a Context: The Organization did not maintain supporting documentation for payroll costs that were reallocated to a new grant. These costs were reallocated from the Health Center Program to the new award. Repeat Finding: Yes, 2024-004 Recommendation: The Organization should add the new grant to the payroll software for separate tracking and update their allocations within the general ledger to accurately reflect payroll costs incurred by grant. Additionally, the Organization should provide training to staff on grant tracking and documentation. Views of Responsible Officials: Management agrees with this finding. Due to the timing of when the prior year audit was completed and issues identified, this issue was in progress towards the end of the current year. Staff will be trained to ensure future changes in payroll costs are updated timely within the system and documentation maintained.
Allowable Costs/Cost Principles Finding Summary: During the testing performed, it was noted that the Organization transferred payroll costs between programs, however, no time and effort certification or equivalent documentation was updated to reflect the changes. Additionally, the transfer of payroll costs between grants was not properly reflected within the accounting system records by grant. Responsible Individuals: Andre Stringfellow, Chief Financial Officer Corrective Action Plan: Procedures were in progress towards the end of the current year. Staff will be trained to ensure future changes in payroll costs are updated timely within the system and documentation maintained. Staff will be trained to ensure future changes in payroll costs are updated timely within the system and documentation maintained. Anticipated Completion Date: August 2026
2024-004
FAC accepted this audit on June 2, 2025 — management decision was due December 2, 2025.
One of three SF-425 reports reviewed were not submitted timely. The SF-425 report for Award No. H80CS00438 was due on 4/30/24 and was submitted on 5/2/2024. Of ten inputs selected for testing on the UDS report, four exceptions were noted. The Organization did not maintain support for data on Table 8A Line 17 Column C, Table 8A Line 1 Column C, and Table 8A Line 3 Column C. Additionally, the data on Table 5 Line 10a Column B was determined to be calculated incorrectly and should have been reported as 10,842. Cause: The Organization has designed internal controls over these areas; however, the controls did not operate as designed. Effect: Late submission of reports could result in a delay in future federal funding drawdowns. Additionally, potential errors were made on the annual UDS report. Questioned costs: n/a Context: Three SF-425 reports and the annual UDS report submitted during the year were selected for testing. Repeat Finding: Yes, 2023-002 Recommendation: The Organization should review and evaluate grant reporting deadlines for their federal awards and update internal control procedures for reporting. Additionally, the Organization should revise policies and procedures over reporting to ensure reports are prepared using accurate information and documentation is maintained. Views of Responsible Officials: Management agrees with this finding. Management has contracted with an outside vendor/ CPA firm to assist in the regular tracking and reporting of grant-related expenditures. Also, the Organization is in the process of creating the administrative infrastructure which includes new staff, new workflow and processes that are designed to report grant activity monthly which includes the timely submission of all grant related reports.
Show full finding ▾Hide full finding ▴Health Center Program Cluster AL No. 93.224 and 93.527 U.S. Department of Health and Human Services Award No. H80CS00438, H8FCS40427, H8GCS47600 Criteria: The Organization is required to submit federal financial reports (SF-425) and the annual Uniform Data System (UDS) report in accordance with established requirements and deadlines. These reports are to be prepared using accurate financial data. Condition: One of three SF-425 reports reviewed were not submitted timely. The SF-425 report for Award No. H80CS00438 was due on 4/30/24 and was submitted on 5/2/2024. Of ten inputs selected for testing on the UDS report, four exceptions were noted. The Organization did not maintain support for data on Table 8A Line 17 Column C, Table 8A Line 1 Column C, and Table 8A Line 3 Column C. Additionally, the data on Table 5 Line 10a Column B was determined to be calculated incorrectly and should have been reported as 10,842. Cause: The Organization has designed internal controls over these areas; however, the controls did not operate as designed. Effect: Late submission of reports could result in a delay in future federal funding drawdowns. Additionally, potential errors were made on the annual UDS report. Questioned costs: n/a Context: Three SF-425 reports and the annual UDS report submitted during the year were selected for testing. Repeat Finding: Yes, 2023-002 Recommendation: The Organization should review and evaluate grant reporting deadlines for their federal awards and update internal control procedures for reporting. Additionally, the Organization should revise policies and procedures over reporting to ensure reports are prepared using accurate information and documentation is maintained. Views of Responsible Officials: Management agrees with this finding. Management has contracted with an outside vendor/ CPA firm to assist in the regular tracking and reporting of grant-related expenditures. Also, the Organization is in the process of creating the administrative infrastructure which includes new staff, new workflow and processes that are designed to report grant activity monthly which includes the timely submission of all grant related reports.
Finding Summary: One of three SF-425 reports reviewed were not submitted timely. The SF-425 report for Award No. H80CS00438 was due on 4/30/24 and was submitted on 5/2/2024. Of ten inputs selected for testing on the UDS report, four exceptions were noted. The Organization did not maintain support for data on Table 8A Line 17 Column C, Table 8A Line 1 Column C, and Table 8A Line 3 Column C. Additionally, the data on Table 5 Line 10a Column B was determined to be calculated incorrectly and should have been reported as 10,842. Responsible Individuals: Andre Stringfellow, Chief Financial Officer Corrective Action Plan: Management has contracted with an outside vendor/ CPA firm to assist in the regular tracking and reporting of grant-related expenditures. Also, the Organization is in the process of creating the administrative infrastructure which includes new staff, new workflow and processes that are designed to report grant activity monthly which includes the timely submission of all grant related reports. Anticipated Completion Date: August 2025
2023-002
During the testing performed, it was determined that documentation to support quotes, estimates, or closed bids was not maintained prior to entering into contracts. Additionally, documentation was not maintained to support that the vendors were not suspended or debarred. Cause: The Organization has designed internal controls over these areas; however, the controls did not operate as designed. Effect: Purchases were made that did not adhere to the Organization’s procurement, suspension and debarment policy. Questioned costs: n/a Context: The Organization did not maintain supporting documentation that management obtained price or rate quotes for purchases above the micro-purchase threshold. In addition, the Health Center did not maintain documentation to support that the vendors were not suspended or debarred, however subsequent testing verified that none of the vendors selected for review were suspended or debarred. Repeat Finding: Yes, 2023-003 Recommendation: The Organization should review and update the procurement and suspension and debarment policies. Additionally, the Organization should provide training to staff on transactions that are covered by the procurement, suspension and debarment policies. Views of Responsible Officials: Management agrees with this finding. Staff will be trained to ensure future procurement, suspension and debarment transactions are identified and documentation is maintained to support the evaluation.
Show full finding ▾Hide full finding ▴Health Center Program Cluster AL No. 93.224 and 93.527 U.S. Department of Health and Human Services Award No. H80CS00438, H8FCS40427, H8GCS47600 Healthy Start Initiative AL No. 93.926 Us. Department of Health and Human Services Award No. H49MC00156 Criteria: The Organization is required to create a written procurement, suspension and debarment policy that complies with applicable federal requirements as indicated in 2 CFR 200.318 -200.326 and to follow this policy when procuring goods and services.Condition: During the testing performed, it was determined that documentation to support quotes, estimates, or closed bids was not maintained prior to entering into contracts. Additionally, documentation was not maintained to support that the vendors were not suspended or debarred. Cause: The Organization has designed internal controls over these areas; however, the controls did not operate as designed. Effect: Purchases were made that did not adhere to the Organization’s procurement, suspension and debarment policy. Questioned costs: n/a Context: The Organization did not maintain supporting documentation that management obtained price or rate quotes for purchases above the micro-purchase threshold. In addition, the Health Center did not maintain documentation to support that the vendors were not suspended or debarred, however subsequent testing verified that none of the vendors selected for review were suspended or debarred. Repeat Finding: Yes, 2023-003 Recommendation: The Organization should review and update the procurement and suspension and debarment policies. Additionally, the Organization should provide training to staff on transactions that are covered by the procurement, suspension and debarment policies. Views of Responsible Officials: Management agrees with this finding. Staff will be trained to ensure future procurement, suspension and debarment transactions are identified and documentation is maintained to support the evaluation.
Finding Summary: During the testing performed, it was determined that documentation to support quotes, estimates, or closed bids were not maintained prior to entering into contracts. Additionally, documentation was not maintained to support that the vendors were not suspended or debarred. Responsible Individuals: Andre Stringfellow, Chief Financial Officer Corrective Action Plan: Procedures will be developed and staff will be trained to ensure future procurement, suspension and debarment transactions are identified and documentation is maintained to support the evaluation. Anticipated Completion Date: August 2025
2023-003
During the testing performed, it was noted that the Organization transferred payroll costs between programs, however, no time and effort certification or equivalent documentation was updated to reflect the changes. Additionally, the transfer of payroll costs between grants was not properly reflected within the accounting system records by grant. These transfers between grants were completed after the end of the fiscal year. Cause: During the year the Organization had new grants, but the payroll system was not updated to reflect the changes. Effect: Allocation of payroll costs to the federal award program may be inaccurate or not properly documented. Questioned costs: n/a Context: The Organization did not maintain supporting documentation for payroll costs that were reallocated to a new grant. These costs were reallocated from the Health Center Program and from the Healthy Start Initiative funding to the new award. Repeat Finding: No Recommendation: The Organization should review and update the policies and procedures regarding payroll costs. Additionally, the Organization should provide training to staff on grant tracking and documentation. Views of Responsible Officials: Management agrees with this finding. Staff will be trained to ensure future changes in payroll costs are updated timely within the system and documentation maintained.
Show full finding ▾Hide full finding ▴Health Center Program Cluster AL No. 93.224 and 93.527 U.S. Department of Health and Human Services Award No. H80CS00438, H8FCS40427, H8GCS47600 Healthy Start Initiative AL No. 93.926 Us. Department of Health and Human Services Award No. H49MC00156 Criteria: Under 2 CFR 200.430, payroll expenses must be based on records that accurately reflect the work performed and supported by a system of internal control that provides reasonable assurance that charges are accurate, allowable, and properly allocated. Condition: During the testing performed, it was noted that the Organization transferred payroll costs between programs, however, no time and effort certification or equivalent documentation was updated to reflect the changes. Additionally, the transfer of payroll costs between grants was not properly reflected within the accounting system records by grant. These transfers between grants were completed after the end of the fiscal year. Cause: During the year the Organization had new grants, but the payroll system was not updated to reflect the changes. Effect: Allocation of payroll costs to the federal award program may be inaccurate or not properly documented. Questioned costs: n/a Context: The Organization did not maintain supporting documentation for payroll costs that were reallocated to a new grant. These costs were reallocated from the Health Center Program and from the Healthy Start Initiative funding to the new award. Repeat Finding: No Recommendation: The Organization should review and update the policies and procedures regarding payroll costs. Additionally, the Organization should provide training to staff on grant tracking and documentation. Views of Responsible Officials: Management agrees with this finding. Staff will be trained to ensure future changes in payroll costs are updated timely within the system and documentation maintained.
Finding Summary: During the testing performed, it was noted that the Organization transferred payroll costs between programs, however, no time and effort certification or equivalent documentation was updated to reflect the changes. Additionally, the transfer of payroll costs between grants was not properly reflected within the accounting system records by grant. These transfers between grants were completed after the end of the fiscal year. Responsible Individuals: Andre Stringfellow, Chief Financial Officer Corrective Action Plan: Management agrees with this finding. Staff will be trained to ensure future changes in payroll costs are updated timely within the system and documentation maintained.. Anticipated Completion Date: August 2025
FAC accepted this audit on May 31, 2024 — management decision was due December 1, 2024.
Two of five reports reviewed were not submitted timely. The SF‐425 report for Award No. H80CS00438 was due on 4/30/23 and was submitted on 6/15/23. The SF‐425 report for Award No. H8FCS40427 was due on 4/30/23 and was submitted on 7/31/2023. Cause: During the year, there was turnover in the accounting department. Effect: Late submission of reports could result in a delay in future federal funding drawdowns. Questioned costs: n/a Context: Five reports submitted during the year were selected for testing. Repeat Finding: 2022‐001 Recommendation: The Organization should review and evaluate grant reporting deadlines for their federal awards and update internal control procedures for reporting. Views of Responsible Officials: Management agrees with this finding. Management has contracted with an outside vendor/ CPA firm to assist in the regular tracking and reporting of grant‐related expenditures. Also, the Organization is in the process of creating the administrative infrastructure which includes new staff, new workflow and processes that are designed to report grant activity monthly which includes the timely submission of all grant related reports
Show full finding ▾Hide full finding ▴Noncompliance and Significant Deficiency in Internal Control over Compliance for Reporting Health Center Program Cluster CFDA No. 93.224 and 93.527 U.S. Department of Health and Human Services Award No. H80CS00438 and H8FCS40427 Criteria: The Organization is required to submit federal financial reports (SF‐425), the UDS Report, and Budget Progress Reports (BPR) in accordance with established requirements and deadlines. Condition: Two of five reports reviewed were not submitted timely. The SF‐425 report for Award No. H80CS00438 was due on 4/30/23 and was submitted on 6/15/23. The SF‐425 report for Award No. H8FCS40427 was due on 4/30/23 and was submitted on 7/31/2023. Cause: During the year, there was turnover in the accounting department. Effect: Late submission of reports could result in a delay in future federal funding drawdowns. Questioned costs: n/a Context: Five reports submitted during the year were selected for testing. Repeat Finding: 2022‐001 Recommendation: The Organization should review and evaluate grant reporting deadlines for their federal awards and update internal control procedures for reporting. Views of Responsible Officials: Management agrees with this finding. Management has contracted with an outside vendor/ CPA firm to assist in the regular tracking and reporting of grant‐related expenditures. Also, the Organization is in the process of creating the administrative infrastructure which includes new staff, new workflow and processes that are designed to report grant activity monthly which includes the timely submission of all grant related reports
Finding Summary: Two of five reports reviewed were not submitted timely. The SF‐425 report for Award No. H80CS00438 was due on 4/30/23 and was submitted on 6/15/23. The SF‐425 report for Award No. H8FCS40427 was due on 4/30/23 and was submitted on 7/31/2023. Responsible Individuals: Andre Stringfellow, CFO Corrective Action Plan: Management has contracted with an outside vendor/ CPA firm to assist in the regular tracking and reporting of grant‐related expenditures. Also, the Organization is in the process of creating the administrative infrastructure which includes new staff, new workflow and processes that are designed to report grant activity monthly which includes the timely submission of all grant related reports Anticipated Completion Date: August 2024
2022-001
During the testing performed, it was determined that documentation to support quotes, estimates, or closed bids were not maintained prior to entering into contracts. Additionally, documentation was not maintained to support that the vendors were not suspended or debarred. Cause: The Organization has designed internal controls over these areas; however, the controls did not operate as designed. Effect: Purchases were made that did not adhere to the Health Organization’s procurement, suspension and debarment policy. Questioned costs: n/a Context: The Organization did not maintain supporting documentation that management obtained price or rate quotes for purchases above the micro‐purchase threshold. In addition, the Health Center did not maintain documentation to support that the vendors were not suspended or debarred, however subsequent testing verified that none of the vendors selected for review were suspended or debarred. Views of Responsible Officials: Management agrees with this finding. Procedures will be developed and staff will be trained to ensure future procurement, suspension and debarment transactions are identified and documentation is maintained to support the evaluation. Repeat Finding: n/a Recommendation: The Organization should review and update the procurement and suspension and debarment policies. Additionally, the Organization should provide training to staff on transactions that are covered by the procurement, suspension and debarment policies. Views of Responsible Officials: Management agrees with this finding. Procedures will be developed and staff will be trained to ensure future procurement, suspension and debarment transactions are identified and documentation is maintained to support the evaluation.
Show full finding ▾Hide full finding ▴Noncompliance and Material Weakness in Internal Control for Procurement, Suspension and Debarment Health Center Program Cluster CFDA No. 93.224 and 93.527 U.S. Department of Health and Human Services Award No. H80CS00438 and H8FCS40427 Criteria: The Organization is required to create a written procurement, suspension and debarment policy that complies with applicable federal requirements as indicated in 2 CFR 200.318 ‐200.326 and to follow this policy when procuring goods and services. Condition: During the testing performed, it was determined that documentation to support quotes, estimates, or closed bids were not maintained prior to entering into contracts. Additionally, documentation was not maintained to support that the vendors were not suspended or debarred. Cause: The Organization has designed internal controls over these areas; however, the controls did not operate as designed. Effect: Purchases were made that did not adhere to the Health Organization’s procurement, suspension and debarment policy. Questioned costs: n/a Context: The Organization did not maintain supporting documentation that management obtained price or rate quotes for purchases above the micro‐purchase threshold. In addition, the Health Center did not maintain documentation to support that the vendors were not suspended or debarred, however subsequent testing verified that none of the vendors selected for review were suspended or debarred. Views of Responsible Officials: Management agrees with this finding. Procedures will be developed and staff will be trained to ensure future procurement, suspension and debarment transactions are identified and documentation is maintained to support the evaluation. Repeat Finding: n/a Recommendation: The Organization should review and update the procurement and suspension and debarment policies. Additionally, the Organization should provide training to staff on transactions that are covered by the procurement, suspension and debarment policies. Views of Responsible Officials: Management agrees with this finding. Procedures will be developed and staff will be trained to ensure future procurement, suspension and debarment transactions are identified and documentation is maintained to support the evaluation.
Finding Summary: During the testing performed, it was determined that documentation to support quotes, estimates, or closed bids were not maintained prior to entering into contracts. Additionally, documentation was not maintained to support that the vendors were not suspended or debarred. Responsible Individuals: Andre Stringfellow, CFO Corrective Action Plan: Procedures will be developed and staff will be trained to ensure future procurement, suspension and debarment transactions are identified and documentation is maintained to support the evaluation. Anticipated Completion Date: August 2024
FAC accepted this audit on May 30, 2023 — management decision was due November 30, 2023.
The Health Center must timely file its SF-425 Federal Financial Reports for each of its awards. Questioned costs: n/a Context: The auditor found that some of the Health Center?s Forms SF-425 were filed after their respective due dates. Effect or Potential Effect: Information about the awards is not communicated timely to the awarding agency. Cause: The Health Center had inadequate controls that would prevent them from missing reporting due dates. Recommendation: The Health Center should adopt an internal control procedure that allows them to consistently file its reports on a timely basis. Repeat Finding: n/a Views of Responsible Officials: See page 12.
Show full finding ▾Hide full finding ▴Health Center Program Cluster Assistance Listing Number(s) 93.224 and 93.527 U.S. Department of Health and Human Services Criteria or Specific Requirement: Reporting Type of Finding: Significant Deficiency in Internal Control Over Compliance Condition: The Health Center must timely file its SF-425 Federal Financial Reports for each of its awards. Questioned costs: n/a Context: The auditor found that some of the Health Center?s Forms SF-425 were filed after their respective due dates. Effect or Potential Effect: Information about the awards is not communicated timely to the awarding agency. Cause: The Health Center had inadequate controls that would prevent them from missing reporting due dates. Recommendation: The Health Center should adopt an internal control procedure that allows them to consistently file its reports on a timely basis. Repeat Finding: n/a Views of Responsible Officials: See page 12.
CORRECTIVE ACTION PLAN Management will adopt an internal control process that will alert the Health Center when reporting due dates are approaching.
The Health Center must prepare and apply a sliding fee discount schedule (SFDS) so that the amounts owed for health center services by eligible participants are adjusted based on the patient?s ability to pay. Questioned costs: n/a Context: The auditor selected a sample of 60 encounters. After the auditor tested selection #49, enough errors had been identified that the auditor stopped testing because the sample results could not support a low assessed level of control risk. The errors were a result of the misapplication of the sliding fee discount. The sliding fee discounts are based on the slide level code. In these instances, the sliding fee discount that was applied was not in accordance with the SFDS. Effect or Potential Effect: Either the Health Center or the patients may be paying more than required under the contract. Cause: The Health Center applied its SFDS inconsistently to the patients selected for testing. Recommendation: The Health Center should adopt an internal control procedure that allows them to consistently apply its SFDS to all eligible patients. Repeat Finding: 2021-001 Views of Responsible Officials: See page 12.
Show full finding ▾Hide full finding ▴Health Center Program Cluster Assistance Listing Number(s) 93.224 and 93.527 U.S. Department of Health and Human Services Award No. H80CS00438 Criteria or Specific Requirement: Special Tests and Provisions Type of Finding: Significant Deficiency in Internal Control Over Compliance Condition: The Health Center must prepare and apply a sliding fee discount schedule (SFDS) so that the amounts owed for health center services by eligible participants are adjusted based on the patient?s ability to pay. Questioned costs: n/a Context: The auditor selected a sample of 60 encounters. After the auditor tested selection #49, enough errors had been identified that the auditor stopped testing because the sample results could not support a low assessed level of control risk. The errors were a result of the misapplication of the sliding fee discount. The sliding fee discounts are based on the slide level code. In these instances, the sliding fee discount that was applied was not in accordance with the SFDS. Effect or Potential Effect: Either the Health Center or the patients may be paying more than required under the contract. Cause: The Health Center applied its SFDS inconsistently to the patients selected for testing. Recommendation: The Health Center should adopt an internal control procedure that allows them to consistently apply its SFDS to all eligible patients. Repeat Finding: 2021-001 Views of Responsible Officials: See page 12.
CORRECTIVE ACTION PLAN Management has developed the following for consistent adjustments to patient accounts according to the SFDS: 1. Management will work with the electronic payment system contractors to update system parameters for automatic system generated discounts in accordance with the sliding discount schedule. This process began February 28, 2023. 2. Management will implement a monthly audit of a statistically relevant sample of all encounters subjected to the sliding fee adjustment process to test the consistency of the adjustment with the SFDS. This process began February 28, 2023. 3. Management will implement a process to ensure that all reviews and audit corrections are performed by a person other than the person performing the review and all adjustments to patient accounts are reviewed subsequent to processing. Anticipated completion date is June 30, 2023.
2021-001
FAC accepted this audit on September 21, 2022 — management decision was due March 21, 2023.
The Health Center must prepare and apply a sliding fee discount schedule (SFDS) so that the amounts owed for health center services by eligible participants are adjusted based on the patient?s ability to pay. Questioned costs: n/a Context: The auditor selected a sample of 60 encounters. After the auditor tested selection #20, two errors had been identified. The auditor stopped testing at this point because the sample results could not support a low assessed level of control risk. Both errors were a result of the misapplication of the sliding fee discount. The sliding fee discounts are based on the slide level code. In these two instances, the sliding fee discount that was applied to the encounter was not in accordance with the patient?s slide level. Effect or Potential Effect: Either the Health Center or the patients may be paying more than required under the contract. Cause: The Health Center applied its SFDS inconsistently to two of the patients selected for testing. Recommendation: The Health Center should adopt an internal control procedure that allows them to consistently apply its SFDS to all eligible patients. Repeat Finding: 2020-001 Views of Responsible Officials: FINDING Reference Number: 2021-001 VIEWS OF RESPONSIBLE OFFICIALS Management acknowledges that the adjustments to patient account were not consistent with the SFDS. PERSONS RESPONSIBLE FOR CORRECTIVE ACTION Tarsha Jackson, CFO Cathy Bojanski, Revenue Cycle Director
Show full finding ▾Hide full finding ▴Health Center Program Cluster CFDA No. 93.224 and 93.527 U.S. Department of Health and Human Services Award No. H80CS00438 Criteria or Specific Requirement: Special Tests and Provisions Type of Finding: Significant Deficiency in Internal Control Over Compliance Condition: The Health Center must prepare and apply a sliding fee discount schedule (SFDS) so that the amounts owed for health center services by eligible participants are adjusted based on the patient?s ability to pay. Questioned costs: n/a Context: The auditor selected a sample of 60 encounters. After the auditor tested selection #20, two errors had been identified. The auditor stopped testing at this point because the sample results could not support a low assessed level of control risk. Both errors were a result of the misapplication of the sliding fee discount. The sliding fee discounts are based on the slide level code. In these two instances, the sliding fee discount that was applied to the encounter was not in accordance with the patient?s slide level. Effect or Potential Effect: Either the Health Center or the patients may be paying more than required under the contract. Cause: The Health Center applied its SFDS inconsistently to two of the patients selected for testing. Recommendation: The Health Center should adopt an internal control procedure that allows them to consistently apply its SFDS to all eligible patients. Repeat Finding: 2020-001 Views of Responsible Officials: FINDING Reference Number: 2021-001 VIEWS OF RESPONSIBLE OFFICIALS Management acknowledges that the adjustments to patient account were not consistent with the SFDS. PERSONS RESPONSIBLE FOR CORRECTIVE ACTION Tarsha Jackson, CFO Cathy Bojanski, Revenue Cycle Director
CORRECTIVE ACTION PLAN Management has developed the following for consistent adjustments to patient accounts according to the SFDS: 1. Management will work with the electronic payment system contractors to update system parameters for automatic system generated discounts in accordance with the sliding discount schedule. Anticipated completion date is January 31, 2023. 2. Management will implement a monthly audit of a statistically relevant sample of all encounters subjected to the sliding fee adjustment process to test the consistency of the adjustment with the SFDS. Anticipated completion date is February 28, 2023. ANTICIPATED COMPLETION DATE February 28, 2023
2020-001
FAC accepted this audit on October 18, 2021 — management decision was due April 18, 2022.
The Health Center must prepare and apply a sliding fee discount schedule (SFDS) so that the amounts owed for health center services by eligible participants are adjusted based on the patient?s ability to pay. Questioned costs: n/a Context: The auditor selected a sample of 60 encounters. After the auditor tested selection #32, two errors had been identified. The auditor stopped testing at this point because the sample results could not support a low assessed level of control risk. Both errors were a result of the misapplication of the nominal fee. The nominal fees are based on the slide level code. In these two instances, the nominal fee that was applied to the encounter was not in accordance with the patient?s slide level. The first error came as a result the billing department applying a $35 nominal fee when it should have been a $50 nominal fee. The second error came as a result the billing department applying a $50 nominal fee when it should have been a $55 nominal fee. Effect or Potential Effect: Either the Health Center or the patients may be paying more than required under the contract. Cause: The Health Center applied its SFDS inconsistently to two of the patients selected for testing. Recommendation: The Health Center should adopt an internal control procedure that allows them to consistently apply its SFDS to all eligible patients. Repeat Finding: 2019-001 Views of Responsible Officials: See page 35.
Show full finding ▾Hide full finding ▴Health Center Program Cluster CFDA No. 93.224 and 93.527 U.S. Department of Health and Human Services Award No. H80CS00438-18 Criteria or Specific Requirement: Special Tests and Provisions Type of Finding: Significant Deficiency in Internal Control Over Compliance Condition: The Health Center must prepare and apply a sliding fee discount schedule (SFDS) so that the amounts owed for health center services by eligible participants are adjusted based on the patient?s ability to pay. Questioned costs: n/a Context: The auditor selected a sample of 60 encounters. After the auditor tested selection #32, two errors had been identified. The auditor stopped testing at this point because the sample results could not support a low assessed level of control risk. Both errors were a result of the misapplication of the nominal fee. The nominal fees are based on the slide level code. In these two instances, the nominal fee that was applied to the encounter was not in accordance with the patient?s slide level. The first error came as a result the billing department applying a $35 nominal fee when it should have been a $50 nominal fee. The second error came as a result the billing department applying a $50 nominal fee when it should have been a $55 nominal fee. Effect or Potential Effect: Either the Health Center or the patients may be paying more than required under the contract. Cause: The Health Center applied its SFDS inconsistently to two of the patients selected for testing. Recommendation: The Health Center should adopt an internal control procedure that allows them to consistently apply its SFDS to all eligible patients. Repeat Finding: 2019-001 Views of Responsible Officials: See page 35.
VIEWS OF RESPONSIBLE OFFICIALS In connection with our audit and auditors? opinion by Lutz & Company, P.C. for the year ended August 31, 2020, the auditors cited audit findings required to be reported in accordance with 2 CFR 200.516(a). FINDING Reference Number: 2020-001 VIEWS OF RESPONSIBLE OFFICIALS Management acknowledges that the adjustments to patient account were not consistent with the SFDS. PERSONS RESPONSIBLE FOR CORRECTIVE ACTION Tarsha Jackson, CFO Cathy Bojanski, Revenue Cycle Director CORRECTIVE ACTION PLAN Management has developed the following for consistent adjustments to patient accounts according to the SFDS: 1. Management will work with the electronic payment system contractors to update system parameters for automatic system generated discounts in accordance with the sliding discount schedule. Anticipated completion date is January 31, 2022. 2. Management will implement a monthly audit of a statistically relevant sample of all encounters subjected to the sliding fee adjustment process to test the consistency of the adjustment with the SFDS. Anticipated completion date is February 28, 2022. ANTICIPATED COMPLETION DATE - February 28, 2022
2019-001
FAC accepted this audit on April 2, 2020 — management decision was due October 2, 2020.
The Organization must prepare and apply a sliding fee discount schedule (SFDS) so that the amounts owed for health center services by eligible participants are adjusted based on the patient?s ability to pay. Questioned costs: n/a Context: Two of the forty patient charges tested were found to be inappropriately adjusted based on the Organization?s SFDS. Effect or Potential Effect: Either the Organization or the patients may be paying more than required under the contract. Cause: The Organization applied its SFDS inconsistently to two of the patients selected for testing. Recommendation: The Organization should adopt an internal control procedure that allows them to consistently apply its SFDS to all eligible patients. Repeat Finding: n/a Responsible Official?s Response and Corrective Action Planned: See page 35. Planned Implementation Date of Corrective Action: May 1, 2020 Person Responsible for Corrective Action: Chief Financial Officer
Show full finding ▾Hide full finding ▴Health Center Program Cluster CFDA No. 93.224 and 93.527 U.S. Department of Health and Human Services Award No. H80CS00438-18 Criteria or Specific Requirement: Special Tests and Provisions Type of Finding: Significant Deficiency in Internal Control Over Compliance Condition: The Organization must prepare and apply a sliding fee discount schedule (SFDS) so that the amounts owed for health center services by eligible participants are adjusted based on the patient?s ability to pay. Questioned costs: n/a Context: Two of the forty patient charges tested were found to be inappropriately adjusted based on the Organization?s SFDS. Effect or Potential Effect: Either the Organization or the patients may be paying more than required under the contract. Cause: The Organization applied its SFDS inconsistently to two of the patients selected for testing. Recommendation: The Organization should adopt an internal control procedure that allows them to consistently apply its SFDS to all eligible patients. Repeat Finding: n/a Responsible Official?s Response and Corrective Action Planned: See page 35. Planned Implementation Date of Corrective Action: May 1, 2020 Person Responsible for Corrective Action: Chief Financial Officer
In connection with our audit and auditors opinion by Lutz & Company, PC. for the year ended August 31, 2019, the auditors cited audit findings required to be reported in accordance with 2 CFR 200.516(a). FINDING Reference Number: 2019-001 CONDITION The Organization must prepare and apply a sliding fee discount schedule (SFDS) so that the amounts owed for health center services by eligible participants are adjusted based on the patient?s ability to pay. CAUSE The Organization applied its SFDS inconsistently to two of the patients selected for testing. RECOMMENDATION The Organization should adopt an internal control procedure that allows them to consistently apply its SFDS to all eligible patients. MANAGEMENT RESPONSE Management acknowledges that the adjustments to patient account were not consistent with the SFDS. One instance was related to a program with outdated documented authorization allowing for further discounts beyond the SFDS and in accordance with the Health Center Program under the Bureau of Primary Health Care. The second instance was related to the misclassification of the patient?s poverty level inconsistent with provided documentation. CORRECTIVE ACTION PLAN Management has developed the following for consistent adjustments to patient accounts according to the SFDS: 1. Management will ensure an at least annual publication of approved discount programs beyond the SFDS and train impacted staff to administer appropriately. 2. Management will implement a monthly audit of a statistically relevant sample of all encounters subjected to the sliding fee adjustment process to test the consistency of the adjustment with the SFDS.
The Organization must disburse funds for program purposes before requesting reimbursement from the pass-through entity. Questioned costs: n/a Context: Seven out of sixty expenses selected for testing were not paid prior to requesting reimbursement from the pass-through entity. These non-compliant requests for reimbursement amounted to $996, or 4.79% of the total dollars tested. When the error rate in our random sample was extrapolated across the population, the projected non-compliant transactions amounted to $20,399. All non-compliant transactions were paid prior to receiving reimbursement from the pass-through entity. Effect or Potential Effect: Grant funds were requested for reimbursement in advance of paying qualified expenditures. Cause: The Organization?s reimbursement requests were created using accrual-basis general ledger reports. All expenses that were requested for reimbursement had been incurred prior to the request date, however, some of those expenditures were not paid prior to the request date. Recommendation: The Organization should adopt an internal control procedure that allows them to identify paid qualifying expenditures prior to submitting a request for reimbursement. Repeat Finding: n/a Responsible Official?s Response and Corrective Action Planned: See page 36. Planned Implementation Date of Corrective Action: May 1, 2020 Person Responsible for Corrective Action: Chief Financial Officer
Show full finding ▾Hide full finding ▴Special Supplemental Nutrition Program for Women, Infants, and Children CFDA No. 10.557 U.S. Department of Agriculture Award No. 173NE706W1003 Criteria or Specific Requirement: Cash Management Type of Finding: Significant Deficiency in Internal Control Over Compliance Condition: The Organization must disburse funds for program purposes before requesting reimbursement from the pass-through entity. Questioned costs: n/a Context: Seven out of sixty expenses selected for testing were not paid prior to requesting reimbursement from the pass-through entity. These non-compliant requests for reimbursement amounted to $996, or 4.79% of the total dollars tested. When the error rate in our random sample was extrapolated across the population, the projected non-compliant transactions amounted to $20,399. All non-compliant transactions were paid prior to receiving reimbursement from the pass-through entity. Effect or Potential Effect: Grant funds were requested for reimbursement in advance of paying qualified expenditures. Cause: The Organization?s reimbursement requests were created using accrual-basis general ledger reports. All expenses that were requested for reimbursement had been incurred prior to the request date, however, some of those expenditures were not paid prior to the request date. Recommendation: The Organization should adopt an internal control procedure that allows them to identify paid qualifying expenditures prior to submitting a request for reimbursement. Repeat Finding: n/a Responsible Official?s Response and Corrective Action Planned: See page 36. Planned Implementation Date of Corrective Action: May 1, 2020 Person Responsible for Corrective Action: Chief Financial Officer
FINDING Reference Number: 2019-002 CONDITION The Organization must disburse funds for program purposes before requesting reimbursement from the pass-through entity. CAUSE The Organization?s reimbursement requests were created using accrual-basis general ledger reports. All expenses that were requested for reimbursement had been incurred prior to the request date, however, some of those expenditures were not paid prior to the request date. RECOMMENDATION The Organization should adopt an internal control procedure that allows them to identify paid qualifying expenditures prior to submitting a request for reimbursement. MANAGEMENT RESPONSE The Organization maintains policies and procedures in accordance with 2 CFR Part 200?Uniform Administrative Requirements, Cost Principles, And Audit Requirements for Federal Awards, Subpart D?Post Federal Award Requirements for managing federal award. 2 CFR section 200.305 states that ?payments methods must minimize the time elapsing between the transfer of funds from ? the pass-through entity and the disbursement by the [Organization]? for all federal funds. It is Management?s position that this is the appropriate payment method for the federal funds subject to this testing. The agreement with the pass-through entity states that ?The [pass-through entity] shall reimburse the [Organization] on a monthly basis for actual, allowable, allocable and reasonable direct costs in accordance with the approved budget??. As noted with the tested sample, while 4.79% of direct costs tested were incurred, but unpaid at the time of the request, no funds were received by the Organization prior to disbursement. The methodology used by Management to request payment is appropriate to ?minimize the time elapsing? between receipt of federal funds and disbursement by the Organization. The pass-through entity did not impose the additional Specific Award Condition of ?requiring payments as reimbursements rather than advance payments? under the ?Special Conditions? provisions at 2 CFR 200.207. This Condition requires the pass-through entity to notify Charles Drew of the nature of the additional requirement and meet the other elements listed in 200.207(c) and (d). Management will adopt a corrective action plan for the purpose of identifying the program costs that are incurred, but unpaid to provide to the pass-through entity. CORRECTIVE ACTION PLAN 1. Management has implemented a process to identify incurred, but unpaid direct program costs on a monthly basis. 2. Management will ensure that amounts identified as unpaid are excluded from the payment request to the pass-through agency. 3. Management will work with the pass-through entity to ensure that agreement language is in alignment with 2 CFR Part 200?Uniform Administrative Requirements, Cost Principles, And Audit Requirements for Federal Awards.
FAC accepted this audit on May 29, 2019 — management decision was due November 29, 2019.
FAC accepted this audit on May 30, 2018 — management decision was due November 30, 2018.
GSA_MIGRATION
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GSA_MIGRATION
2016-001
FAC accepted this audit on June 4, 2017 — management decision was due December 4, 2017.
GSA_MIGRATION
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