EIN: 510137745
UEI: MY33PMAQFBG9
Audited by: BDMP ASSURANCE, LLP
Oversight agency: 93 [Department of Health and Human Services]
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Data as of September 2, 2026
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on December 29, 2025. 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 June 29, 2026 (67 days ago).
What is a management decision? →FAC accepted this audit on November 18, 2024 — management decision was due May 18, 2025.
FAC accepted this audit on November 13, 2023 — management decision was due May 13, 2024.
FAC accepted this audit on November 6, 2022 — management decision was due May 6, 2023.
Finding Number: 2022-001 Finding Type: Compliance - Special Tests and Provisions Information on the Federal Program: Program Name: Health Center Program Cluster (AL numbers 93.224 and 93.527) Grant Award: 4 H80CS00554-20 from March 1, 2021 through February 28, 2022 and 6 H80CS00554-21 from March 1, 2022 through February 28, 2023 Agency: U.S. Department of Health and Human Services, Health Resources and Services Administration Pass-Through Entity: N/A Criteria: In accordance with Section 330(k)(3)(G) of the Public Health Service Act (42 U.S. Code ? 254b), as an FQHC, the Organization must have a sliding fee discount program in which the Organization?s fee schedule is discounted based on a patient?s ability to pay. Condition and Context:The Organization has not applied sliding fee discounts to patient charges consistent with its sliding fee discount program. Through testing a statistically valid sample of transactions for the appropriate application of the Organization's sliding fee discount program to 25 individual patient balances, noted one patient did not have a valid application in effect for the date of service tested. Cause and Effect: The Organization had a major Electronic Health Records (EHR) information system upgrade during the year and the process for verification of valid sliding fee discount applications within the EHR changed. The patient previously had a valid sliding fee discount application but discount expiration date was no longer easily identifiable in the EHR by the patient intake staff due to the upgrade and the patient visit noted as a sliding fee discount eligible visit. As a result, the patient was given a $124 discount without a valid sliding fee application. The Organization has implemented monthly monitoring procedures which include the review of sliding fee applications and sampling of discounts provided to patients to help ensure patients receive discounts in accordance with the Organization's sliding fee discount policy. The volume of discounts provided to patients annually does not allow for 100% review of all patient discounts and the inherent nature of sampling will not result in all errors will be identified and corrected. As a result, it is possible the Organization may not apply sliding fee discounts to patient charges consistent with its sliding fee discount program. Questioned Costs: None Repeat Finding: No Recommendation: We recommend management provide training to individuals involved in the patient intake and billing processes specific to the EHR process changes and to modify internal monitoring procedures to include an emphasis in the sampling on changes in processes or staffing. We further recommend specific procedures be development as part of the internal monitoring to verify discounts were not provided to patients with recently expired discounts. Views of a Responsible Official and Corrective Action Plan: Management agrees with the finding and has implemented additional training and will update monitoring procedures to increase compliance with program requirements.
Show full finding ▾Hide full finding ▴Finding Number: 2022-001 Finding Type: Compliance - Special Tests and Provisions Information on the Federal Program: Program Name: Health Center Program Cluster (AL numbers 93.224 and 93.527) Grant Award: 4 H80CS00554-20 from March 1, 2021 through February 28, 2022 and 6 H80CS00554-21 from March 1, 2022 through February 28, 2023 Agency: U.S. Department of Health and Human Services, Health Resources and Services Administration Pass-Through Entity: N/A Criteria: In accordance with Section 330(k)(3)(G) of the Public Health Service Act (42 U.S. Code ? 254b), as an FQHC, the Organization must have a sliding fee discount program in which the Organization?s fee schedule is discounted based on a patient?s ability to pay. Condition and Context:The Organization has not applied sliding fee discounts to patient charges consistent with its sliding fee discount program. Through testing a statistically valid sample of transactions for the appropriate application of the Organization's sliding fee discount program to 25 individual patient balances, noted one patient did not have a valid application in effect for the date of service tested. Cause and Effect: The Organization had a major Electronic Health Records (EHR) information system upgrade during the year and the process for verification of valid sliding fee discount applications within the EHR changed. The patient previously had a valid sliding fee discount application but discount expiration date was no longer easily identifiable in the EHR by the patient intake staff due to the upgrade and the patient visit noted as a sliding fee discount eligible visit. As a result, the patient was given a $124 discount without a valid sliding fee application. The Organization has implemented monthly monitoring procedures which include the review of sliding fee applications and sampling of discounts provided to patients to help ensure patients receive discounts in accordance with the Organization's sliding fee discount policy. The volume of discounts provided to patients annually does not allow for 100% review of all patient discounts and the inherent nature of sampling will not result in all errors will be identified and corrected. As a result, it is possible the Organization may not apply sliding fee discounts to patient charges consistent with its sliding fee discount program. Questioned Costs: None Repeat Finding: No Recommendation: We recommend management provide training to individuals involved in the patient intake and billing processes specific to the EHR process changes and to modify internal monitoring procedures to include an emphasis in the sampling on changes in processes or staffing. We further recommend specific procedures be development as part of the internal monitoring to verify discounts were not provided to patients with recently expired discounts. Views of a Responsible Official and Corrective Action Plan: Management agrees with the finding and has implemented additional training and will update monitoring procedures to increase compliance with program requirements.
Finding Number: 2022-001 Condition Found: The Organization has not applied sliding fee discounts to patient charges consistent with its sliding fee discount program. Individual(s) Responsible for Corrective Action: Tammy Talotta, CFO, Michelle Routhier, Billing Manager Corrective Action Planned: Staff Training on Community Health Enhancement and Billing Profiles in Visualutions. All new sliding fee applications are now sent to a manager to review and make sure the information has been entered into the system correctly, all dates match, and we have the correct supporting documentation. Monthly sliding fee reports to be run for all patients with active sliding fee and reviewed by the billing manager to review for accuracy of setup in the billing profile. Monthly sliding fee reports to be run for patients with an expiring sliding fee. The billing manager will review the report in the month following expiration to be sure a new sliding fee has been set up correctly. If it has not been set up, the patient is changed to self-pay, preventing a patient from getting a sliding fee without an active application on file. Any person in the billing department who applies a sliding fee as a secondary insurance will also verify that the sliding fee is active for the visit and the correct sliding fee is applied. Any person in the billing department coding charges will double check that the sliding fee is active for the date of service and the correct sliding fee is applied. Anticipated Completion Date: All of the above items have been implemented as of October 25, 2022.
FAC accepted this audit on November 1, 2021 — management decision was due May 1, 2022.
FAC accepted this audit on December 2, 2020 — management decision was due June 2, 2021.
FAC accepted this audit on October 1, 2019 — management decision was due April 1, 2020.
FAC accepted this audit on November 13, 2018 — management decision was due May 13, 2019.
FAC accepted this audit on November 2, 2017 — management decision was due May 2, 2018.
FAC accepted this audit on October 30, 2016 — management decision was due April 30, 2017.
Data source: This information comes from the Federal Audit Clearinghouse, the official repository of Single Audit data. All data is public domain. Verify this organization's audit history at fac.gov.
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