Hunter Health Clinic, Inc.Local Government

Sliding Fee Discount Supporting Documentation - Significant Deficiency 2025-001 Federal Program Identification: U.S. Department of Health and Human Services Health Centers Cluster - Health Center Program and Affordable Care Act - Grants for Expanded Service, AL 93.224 and 93.527 Grant Number: H80CS00622 Condition/Criteria: Community Health Centers are required to offer sliding fee discounts to patients with annual incomes at or below 200% of the federal poverty guidelines. While the Center has established policies to administer these discounts, opportunities exist to strengthen controls, particularly in documentation practices. Support documentation used to determine sliding fee discounts is not consistently maintained in every patient file. Cause: Turnover in certain key positions has placed a strain on operational resources. As a result, procedures related to the maintenance of required documentation for sliding fee determinations have not been fully implemented or consistently followed in accordance with the Center's established policies. Effect: Without proper documentation, there is a risk that patients may receive incorrect sliding fee discounts, potentially resulting in overpayment for services. Recommendation: We recommend the Center enhance its procedures to ensure that all required documentation used in the determination of sliding fee discounts is consistently collected and retained in each patient's file. View of Responsible Officials and Planned Corrective Action See corrective action plan.

Sliding Fee Discount Supporting Documentation - Significant Deficiency 2024-004 Federal Program Identification: U.S. Department of Health and Human Services Health Centers Cluster - Health Center Program and Affordable Care Act - Grants for Expanded Service, AL 93.224 and 93.527 Grant Number: H80CS00622 Condition/Criteria: Community Health Centers are required to offer sliding fee discounts to patients with annual incomes at or below 200% of the federal poverty guidelines. While the Center has established policies to administer these discounts, opportunities exist to strengthen controls, particularly in documentation practices. Support documentation used to determine sliding fee discounts is not consistently maintained in every patient file. Cause: Turnover in certain key positions has placed a strain on operational resources. As a result, procedures related to the maintenance of required documentation for sliding fee determinations have not been fully implemented or consistently followed in accordance with the Center's established policies. Effect: Without proper documentation, there is a risk that patients may receive incorrect sliding fee discounts, potentially resulting in overpayment for services. Recommendation: We recommend the Center enhance its procedures to ensure that all required documentation used in the determination of sliding fee discounts is consistently collected and retained in each patient's file. View of Responsible Officials and Planned Corrective Action See corrective action plan.

Type of Finding: Significant Deficiency Federal program information: Funding agency: U.S. Department of Health and Human Services Title: Urban Indian Health Centers Assistance listing number: 93.193 Criteria: Proper internal controls over eligibility requirements that govern Native American Organizations should involve documentation that patients receiving services were eligible Urban Indians residing in the urban centers in which the organization is located. Condition: Controls currently in place to ensure that all eligibility requirements are met are not adequate. As a result, for two of twenty-five individuals selected for testing who received services through the Urban Indian Health Centers program, the Center was initially unable to provide sufficient evidence to justify that the participants were eligible to receive services. Documentation was obtained after patients were sampled as a result of Single Audit testwork. Questioned Costs: N/A Context: Evidence of Tribal affiliation was not initially retained; however, management was familiar with patients and was able to obtain the required documentation after patients were sampled for eligibility testwork as part of the Single Audit. Cause: Program management has not designed a proper system of documentation to ensure that patients serviced meet program eligibility requirements and are properly supported as required by OMB Uniform Guidance. Center personnel may be familiar with patients and their Tribal affiliation in tight-knit community and are not diligent about requesting and retaining evidence of Tribal eligibility. Effect: Providing services to potentially unqualified applicants may result in lack of funding from the federal government. Auditor’s Recommendations: Program management should design and implement an internal control system that adequately documents patient eligibility to ensure that patients and applicants are eligible. Management’s Response: Hunter Health has revised its Native American Beneficiary Program Policy (CH-004) and corresponding procedure to correct this finding. In March of 2024 the revised policy was approved by Hunter’s Policy Review Team. This policy defines eligibility for the Native American Beneficiary Program, its scope of services, and outlines the documentation required. The correlating procedure, “Enrolling Native American Beneficiaries” goes further into detail with regards to eligibility and what specific documentation is collected. Specifically, Hunter Health has removed the requirement that a birth certificate be provided when a child is under 18 to prove that they belong to the Native American parent/guardian. Instead, as stated in the revised procedure, and in addition to the document requirements of the parent/guardian, Hunter now accepts “an attestation form signed by an eligible beneficiary parent/stepparent/legal guardian of a minor declaring the relationship and the minor’s eligibility for benefits.” An additional update to the policy has been made to allow a Native American father of a non-native American pregnant woman to attest in writing that he is the father of the Native American child and is not required to provide a marriage certificate.

Type of Finding: Significant Deficiency and Noncompliance Federal program information: Funding agency: U.S. Department of Health and Human Services Title: Provider Relief Fund, Consolidated Health Centers Assistance listing number: 93.498, 93.224 Criteria: The Provider Relief Fund (PRF) indicates the providers who received funds exceeding $10,000 in the aggregate are required to report on their use of funds. The Consolidated Health Centers program is required to submit the financial information to the funding agency using standard financial reporting forms. These reports are to be submitted by the required due date and be accurately completed and supported by the underlying accounting records. Condition: During testing, the PRF report was filed late in 2023 for the Period 2 funding. We were unable to agree the Consolidated Health Center?s Federal Financial Report (FFR) to supporting documentation or to amounts reported in prior periods. Additionally, the report was submitted late. Questioned Costs: N/A Context: One of the reports was unavailable to test for completion. The other FFR report tested was inaccurate and did not agree with the prior period amount or supporting documentation. Cause: Internal controls were not adequate to ensure timely and accurate filing of required financial reports. Effect: The Center did not comply with reporting requirements for both programs. Auditor?s Recommendations: Ensure financial reports are properly completed and submitted to the granting agency by the required due dates by implementing monitoring and other appropriate internal control procedures. Documentation substantiating compliance with reporting requirements should be maintained. Management?s Response: In March of 2022, both the CFO and Accounting Manager terminated employment with Hunter Health. During the latter half of the fiscal year, Hunter Health contracted with a temporary CFO and Controller, both of whom had FQHC experience, for three months. The current CFO and Controller were onboarded late Q3/early Q4. During this time of transition, there was not a transfer of knowledge of the PRF funding ($20,340.39) or the portal access. The portal was accessed by the current accounting team and the appropriate documentation was filed timely but not during the testing period. PRF funding has ended, and no future action is needed. The timely filing of the FFR report and maintenance of reporting is also attributable to this unusual turnover situation in the Finance department. The current CFO began June 26th and the referenced FFR was due June 30th. The FFR was filed July 28th due to knowledge transfer timing. FFR reports are now being tracked and saved in an accessible and secure location based on internal control procedures.

Type of Finding: Significant Deficiency and Noncompliance Federal program information: Funding agency: U.S. Department of Health and Human Services Title: Consolidated Health Centers Assistance listing number: 93.224 Criteria: Requirements for procurement are contained in the OMB Uniform Guidance, federal awarding agency regulations, and terms of the award. Procurement transactions should be conducted in a manner providing full and open competition in according with the Center?s procurement policy. The Center?s procurement policy requires three quotes or more of any purchases over $10,000. Condition: The program made purchases in excess of $10,000 without obtaining three quotes. Questioned Costs: None. Context: Five out of twenty-five transactions tested. Cause and effect: Controls over procurement as documented in the Center?s procurement policy have not been followed. The Center was not in compliance with the procurement requirements. Auditor?s Recommendations: Enforce policies and procedures that will promote adequate monitoring of the procurement and bidding process. Management?s Response: In March of 2022, both the CFO and Accounting Manager terminated employment with Hunter Health. During the latter half of the fiscal year, Hunter Health contracted with a temporary CFO and Controller, both of whom had FQHC experience, for three months. The current CFO and Controller were onboarded late Q3/early Q4. During this time of transition, the procurement procedures were not maintained at the normal standard. With the new finance team in place, the Finance team has reviewed the procedures and retrained the leadership team to ensure compliance. Submittal of purchasing requests has been centralized within the Finance Department to ensure an extra level of oversight.

Federal program information: Funding agency: U.S. Department of Health and Human Services Title: Provider Relief Fund Assistance listing number: 93.498 Criteria: The 2021 Compliance Supplement for the Provider Relief Fund (PRF) indicates the amounts reported in the Health Resources and Services Administration (HRSA) PRF submission must be audited back to the written narrative regarding how lost revenues were calculated and the underlying supporting documentation. Condition: The Center did not save the system generated reports in their calculation of lost revenues used for Provider Relief Fund special reporting requirements. Instead, the information was transcribed to an Excel based document. Questioned Costs: N/A Context: Amounts agreed to Excel based documentation only. Cause: The billing system runs as a point-in-time system, so unless the reports generated at specific dates are saved on those dates, there is no way to reproduce the report with the same result in future periods. Effect: The Provider Relief Fund lost revenue calculations cannot be substantiated by system generated reports. Auditor?s Recommendations: Management should save all system generated reports used in the development of their Excel based tools to ensure balances are supported by a system generated document. Management?s Response: Effective immediately, the Center will begin memorializing Excel based reporting documents in a non-updatable and date-stamped format. Additionally, the Center will institute a hard close process within our operating and financial reporting systems to ensure consistent historical reporting data can be retrieved from the system source of record in future periods. This is anticipated to be in place for February 2022 month end.

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