EIN: 550581968
UEI: YA54TMKN58P5
Audit also covers 2 related EINs: 334379599, 852403278 · unlinked EINs have no separate FAC filing
Audited by: Forvis Mazars, LLP
Oversight agency: 93 [Department of Health and Human Services]
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Data as of September 7, 2026
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on December 23, 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 23, 2026 (81 days ago).
What is a management decision? →Health Center Program Cluster – ALN Nos. 93.224 and 93.527 U.S. Department of Health and Human Services Award No. 6 H80CS00075, April 1, 2025 - March 31, 2026 Award No. 6 H80CS00075, April 1, 2024 - March 31, 2025 Criteria or Specific Requirement – Reporting (45 CFR 75.342) Condition – The Organization incorrectly classified certain adjustments for pharmacy purchases as sliding fee discounts on the Uniform Data System (UDS) report. Additionally, the Organization double counted certain facility and non-clinical support services costs on the UDS Report. Cause – The Organization’s pharmacy practice management software was incorrectly set up to classify certain adjustments as sliding fee discounts and a manual correction was not made during the preparation of the UDS report. In addition, the Organization’s supporting schedules had formula errors that causes certain costs to be duplicated. Effect or potential effect– The Organization overstated sliding fee discounts and overstated the total costs for facility and non-clinical support services. Questioned costs – None Context – A sample of 2 reports were tested out of the total population of 6 reports. The sampling methodology used is not and is not intended to be statistically valid. Certain amounts on the UDS Report were not accurately reported. Identification as a repeat finding, if applicable – 2024-002 Recommendation – Management should review the required reports for accuracy prior to submission to ensure the documentation supports the amounts in the report. View of Responsible Officials and Planned Corrective Actions – Management agrees with the auditors’ recommendations. In the upcoming year it is expected that new accounting leadership and Grant Management will work together to ensure the accuracy of the UDS Report. Organization’s contact persons responsible for corrective action: Michele Sarrett, Chief Financial Officer Anticipated completion date: 2/15/2026
Show full finding ▾Hide full finding ▴Health Center Program Cluster – ALN Nos. 93.224 and 93.527 U.S. Department of Health and Human Services Award No. 6 H80CS00075, April 1, 2025 - March 31, 2026 Award No. 6 H80CS00075, April 1, 2024 - March 31, 2025 Criteria or Specific Requirement – Reporting (45 CFR 75.342) Condition – The Organization incorrectly classified certain adjustments for pharmacy purchases as sliding fee discounts on the Uniform Data System (UDS) report. Additionally, the Organization double counted certain facility and non-clinical support services costs on the UDS Report. Cause – The Organization’s pharmacy practice management software was incorrectly set up to classify certain adjustments as sliding fee discounts and a manual correction was not made during the preparation of the UDS report. In addition, the Organization’s supporting schedules had formula errors that causes certain costs to be duplicated. Effect or potential effect– The Organization overstated sliding fee discounts and overstated the total costs for facility and non-clinical support services. Questioned costs – None Context – A sample of 2 reports were tested out of the total population of 6 reports. The sampling methodology used is not and is not intended to be statistically valid. Certain amounts on the UDS Report were not accurately reported. Identification as a repeat finding, if applicable – 2024-002 Recommendation – Management should review the required reports for accuracy prior to submission to ensure the documentation supports the amounts in the report. View of Responsible Officials and Planned Corrective Actions – Management agrees with the auditors’ recommendations. In the upcoming year it is expected that new accounting leadership and Grant Management will work together to ensure the accuracy of the UDS Report. Organization’s contact persons responsible for corrective action: Michele Sarrett, Chief Financial Officer Anticipated completion date: 2/15/2026
Management agrees with the auditors' recommendations. In the upcoming year it is expected that new accounting leadership and Grant Management will work together to ensure the accuracy of the UDS Report. Organization contact persons responsible for corrective action: Michele Sarrett, Chief Financial Officer. Anticipated completion date: 2/15/26
2024-002
FAC accepted this audit on March 31, 2025 — management decision was due October 1, 2025.
Health Center Program Cluster – ALN Nos. 93.224 and 93.527 U.S. Department of Health and Human Services Award No. 6 H80CS00075, April 1, 2024 - March 31, 2025 Award No. 2 H80CS00075, April 1, 2023 - March 31, 2024 Award No. 4 H8FCS41116, April 1, 2021 - March 31, 2024 Award No. 4 H8GCS48805, December 1, 2022 – June 30, 2024 Award No. 1 H8LCS51581, September 1, 2023 – December 31, 2024 Criteria or Specific Requirement – Reporting (45 CFR 75.342) Condition – The Organization incorrectly classified certain adjustments for pharmacy purchases as sliding fee discounts on the Uniform Data System (UDS) report. Additionally, the Organization double counted certain facility and non-clinical support services costs on the UDS Report. Cause – The Organization’s pharmacy practice management software was incorrectly set up to classify certain adjustments as sliding fee discounts and a manual correction was not made during the preparation of the UDS report. In addition, the Organization’s supporting schedules had formula errors that causes certain costs to be duplicated. Effect or potential effect– The Organization overstated sliding fee discounts and overstated the total costs for facility and non-clinical support services. Questioned costs – None Context – A sample of 2 reports were tested out of the total population of 3 reports. The sampling methodology used is not and is not intended to be statistically valid. Certain amounts on the UDS Report were not accurately reported. Identification as a repeat finding, if applicable – N/A Recommendation – Management should review the required reports for accuracy prior to submission to ensure the documentation supports the amounts in the report. View of Responsible Officials and Planned Corrective Actions – Management agrees with the auditors’ recommendations. The UDS formulas were updated and the issues corrected for the 2024 UDS report. In the upcoming year it is expected that new accounting leadership and Grant Management will work together to ensure the accuracy of the UDS Report. Organization’s contact persons responsible for corrective action: Michele Sarrett Anticipated completion date: 12/31/2025
Show full finding ▾Hide full finding ▴Health Center Program Cluster – ALN Nos. 93.224 and 93.527 U.S. Department of Health and Human Services Award No. 6 H80CS00075, April 1, 2024 - March 31, 2025 Award No. 2 H80CS00075, April 1, 2023 - March 31, 2024 Award No. 4 H8FCS41116, April 1, 2021 - March 31, 2024 Award No. 4 H8GCS48805, December 1, 2022 – June 30, 2024 Award No. 1 H8LCS51581, September 1, 2023 – December 31, 2024 Criteria or Specific Requirement – Reporting (45 CFR 75.342) Condition – The Organization incorrectly classified certain adjustments for pharmacy purchases as sliding fee discounts on the Uniform Data System (UDS) report. Additionally, the Organization double counted certain facility and non-clinical support services costs on the UDS Report. Cause – The Organization’s pharmacy practice management software was incorrectly set up to classify certain adjustments as sliding fee discounts and a manual correction was not made during the preparation of the UDS report. In addition, the Organization’s supporting schedules had formula errors that causes certain costs to be duplicated. Effect or potential effect– The Organization overstated sliding fee discounts and overstated the total costs for facility and non-clinical support services. Questioned costs – None Context – A sample of 2 reports were tested out of the total population of 3 reports. The sampling methodology used is not and is not intended to be statistically valid. Certain amounts on the UDS Report were not accurately reported. Identification as a repeat finding, if applicable – N/A Recommendation – Management should review the required reports for accuracy prior to submission to ensure the documentation supports the amounts in the report. View of Responsible Officials and Planned Corrective Actions – Management agrees with the auditors’ recommendations. The UDS formulas were updated and the issues corrected for the 2024 UDS report. In the upcoming year it is expected that new accounting leadership and Grant Management will work together to ensure the accuracy of the UDS Report. Organization’s contact persons responsible for corrective action: Michele Sarrett Anticipated completion date: 12/31/2025
Management agrees with the auditors' recommendations. The UDS formulas were updated and the issues corrected for the 2024 UDS report. In the upcoming year it is expected that new accounting leadership and Grant Management will work together to ensure the accuracy of the UDS Report. Organization contact persons responsible for corrective action: Michele Sarrett Anticipated completion date: 12/31/2025
Health Center Program Cluster – CFDA Nos. 93.224 and 93.527 Health Center Program Cluster – ALN Nos. 93.224 and 93.527 U.S. Department of Health and Human Services Award No. 6 H80CS00075, April 1, 2024 - March 31, 2025 Award No. 2 H80CS00075, April 1, 2023 - March 31, 2024 Award No. 4 H8FCS41116, April 1, 2021 - March 31, 2024 Award No. 4 H8GCS48805, December 1, 2022 – June 30, 2024 Award No. 1 H8LCS51581, September 1, 2023 – December 31, 2024 Criteria or Specific Requirement – Special Tests and Provisions: Sliding Fee Discounts (42 USC 254(k)(3)(g); 42 CFR sections 51c.303(g); and 42 CFR sections 56.303 (f)) Condition – Patients received a sliding fee discount that was inconsistent with the stated sliding fee discount categories under the Organization’s policy. Cause – The Organization did not comply with their sliding fee policy. Effect or potential effect– Sliding fee discounts were given to patients that were inconsistent with the Organization’s sliding fee policy. Questioned costs – None Context – A sample of 25 encounters were tested out of the total population of 290,121 encounters. The sampling methodology used is not and is not intended to be statistically valid. Two patients received a sliding fee adjustment that was inconsistent with the approved policy for the proper sliding fee adjustments based on their income documentation. Identification as a repeat finding, if applicable – N/A Recommendation – We recommend management continue to ensure all personnel understand the sliding fee policy and adhere to the guidelines set forth in the policy. Additionally, we recommend the client ensure the sliding fee scales within their systems are updated annually and in a timely manner. View of Responsible Officials and Planned Corrective Actions – Management will work with Athena to correct the workflow to ensure slide fees are adjusted at the correct updated Federal Poverty Level at the beginning of the new year. Organization’s contact persons responsible for corrective action: Michele Sarrett Anticipated completion date: 12/31/2025
Show full finding ▾Hide full finding ▴Health Center Program Cluster – CFDA Nos. 93.224 and 93.527 Health Center Program Cluster – ALN Nos. 93.224 and 93.527 U.S. Department of Health and Human Services Award No. 6 H80CS00075, April 1, 2024 - March 31, 2025 Award No. 2 H80CS00075, April 1, 2023 - March 31, 2024 Award No. 4 H8FCS41116, April 1, 2021 - March 31, 2024 Award No. 4 H8GCS48805, December 1, 2022 – June 30, 2024 Award No. 1 H8LCS51581, September 1, 2023 – December 31, 2024 Criteria or Specific Requirement – Special Tests and Provisions: Sliding Fee Discounts (42 USC 254(k)(3)(g); 42 CFR sections 51c.303(g); and 42 CFR sections 56.303 (f)) Condition – Patients received a sliding fee discount that was inconsistent with the stated sliding fee discount categories under the Organization’s policy. Cause – The Organization did not comply with their sliding fee policy. Effect or potential effect– Sliding fee discounts were given to patients that were inconsistent with the Organization’s sliding fee policy. Questioned costs – None Context – A sample of 25 encounters were tested out of the total population of 290,121 encounters. The sampling methodology used is not and is not intended to be statistically valid. Two patients received a sliding fee adjustment that was inconsistent with the approved policy for the proper sliding fee adjustments based on their income documentation. Identification as a repeat finding, if applicable – N/A Recommendation – We recommend management continue to ensure all personnel understand the sliding fee policy and adhere to the guidelines set forth in the policy. Additionally, we recommend the client ensure the sliding fee scales within their systems are updated annually and in a timely manner. View of Responsible Officials and Planned Corrective Actions – Management will work with Athena to correct the workflow to ensure slide fees are adjusted at the correct updated Federal Poverty Level at the beginning of the new year. Organization’s contact persons responsible for corrective action: Michele Sarrett Anticipated completion date: 12/31/2025
Management will work with Athena to correct the workflow to ensure slide fees are adjusted at the correct updated Federal Poverty Level at the beginning of the new year. Organization contact persons responsible for corrective action: Michele Sarrett Anticipated completion date: 12/31/2025
FAC accepted this audit on April 19, 2024 — management decision was due October 19, 2024.
FAC accepted this audit on March 30, 2023 — management decision was due September 30, 2023.
FAC accepted this audit on May 16, 2022 — management decision was due November 16, 2022.
FAC accepted this audit on February 10, 2021 — management decision was due August 10, 2021.
FAC accepted this audit on January 8, 2020 — management decision was due July 8, 2020.
FAC accepted this audit on December 11, 2018 — management decision was due June 11, 2019.
FAC accepted this audit on February 13, 2018 — management decision was due August 13, 2018.
FAC accepted this audit on January 23, 2017 — management decision was due July 23, 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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