EIN: 560952737
UEI: KZEZD5KKFAA3
Audited by: Forvis Mazars, LLP
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 August 6, 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 February 6, 2027 (160 days from today).
What is a management decision? →Health Center Program Cluster Assistance Listing Numbers 93.224 and 93.527 U.S. Department of Health and Human Services Award No. 6 H80CS00086-24-10 Program Year 25 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 discount policy. Questioned costs – None Context – A sample of 25 patients were tested out of the total population of 132,315 encounters. The sampling methodology used is not and is not intended to be statistically valid. Three patients received a sliding fee adjustment that was inconsistent with the approved policy based on their income determination. Identification as a repeat finding – Not a repeat finding Recommendation - We recommend management continue to ensure all personnel understand the sliding fee scale policy and adhere to the requirements and guidelines set forth in the policy. Procedures should be implemented to ensure that eligible patients receive discounts in accordance with the sliding fee scale and the Health Center Program Compliance Manual.
Show full finding ▾Hide full finding ▴Health Center Program Cluster Assistance Listing Numbers 93.224 and 93.527 U.S. Department of Health and Human Services Award No. 6 H80CS00086-24-10 Program Year 25 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 discount policy. Questioned costs – None Context – A sample of 25 patients were tested out of the total population of 132,315 encounters. The sampling methodology used is not and is not intended to be statistically valid. Three patients received a sliding fee adjustment that was inconsistent with the approved policy based on their income determination. Identification as a repeat finding – Not a repeat finding Recommendation - We recommend management continue to ensure all personnel understand the sliding fee scale policy and adhere to the requirements and guidelines set forth in the policy. Procedures should be implemented to ensure that eligible patients receive discounts in accordance with the sliding fee scale and the Health Center Program Compliance Manual.
Views of Responsible Officials and Planned Corrective Actions – Management agrees that the Sliding scale has been incorrectly applied on patient accounts and intends to do the following: A root cause analysis should determine whether the errors resulted from: • Staff calculation errors when annualizing income. • Failure to properly verify income documentation. • Incorrect data entry in the practice management system. • Inadequate training on sliding fee eligibility determination procedures. • Lack of secondary review or quality assurance monitoring by the revenue cycle team. In addition to the root cause analysis Piedmont Health Services will do the following: 1. Correct the three identified patient accounts and process any necessary refunds, adjustments, or account corrections. 2. Conduct a targeted review of a broader sample of recent sliding fee determinations to identify any additional errors and implement corrective action where necessary. 3. Retrain registration, eligibility, and financial counseling staff on income verification requirements, family-size determination, documentation standards, and sliding fee calculation procedures. 4. Implement secondary review procedures for sliding fee determinations until system enhancements are in place. 5. Continue monthly quality assurance audits of sliding fee eligibility determinations and monitor error rates. 6. Transition to OCHIN Epic in August 2026. The new EMR platform is expected to significantly strengthen internal controls through enhanced workflow automation, improved documentation, standardized eligibility processes, and expanded reporting capabilities. These features will provide greater visibility into sliding fee eligibility determinations, improve management's ability to monitor compliance, and reduce the risk of manual calculation and data-entry errors. 7. Following Epic implementation, management will conduct post-go-live validation testing to confirm that sliding fee determinations are functioning as designed and that eligibility calculations are accurate and compliant with HRSA requirements. Expected Outcome The combination of staff retraining, enhanced monitoring, and migration to OCHIN Epic is expected to improve the accuracy of sliding fee eligibility determinations, strengthen compliance oversight, and reduce the risk of future errors. The Director of Revenue and the CFO will monitor error rates through periodic audits and leverage Epic reporting tools to support ongoing compliance and quality assurance efforts. Individuals Responsible Beth Moseley, Chief Financial Officer and Daniella Jaimes-Colina, Chief Executive Officer
FAC accepted this audit on July 7, 2025 — management decision was due January 7, 2026.
FAC accepted this audit on June 3, 2024 — management decision was due December 3, 2024.
FAC accepted this audit on June 28, 2023 — management decision was due December 28, 2023.
FAC accepted this audit on May 25, 2022 — management decision was due November 25, 2022.
Provider Relief Funds Assistance Listing No. 93.498 U.S. Department of Health and Human Services Criteria or Specific Requirement ? Reporting (45 CFR 75.342) and Activities Allowed/Unallowed and Cost Principles (45 CFR 75.403) Condition ? The Organization is required to prepare and submit period one provider relief fund reporting. This report is to be prepared using accurate financial information and submitted by the deadline established. Questioned costs ? Unknown Context - The period one Provider Relief Fund report was tested. The Organization initially selected option one to report lost revenues based on quarterly actuals. A material error in patient service revenue for the quarters reported was identified. This included a change to revenues that were included in the component values reported impacting the quarterly lost revenues reported. Management requested to amend the original calculation to use option three. The Organization has not been authorized by HRSA to open the portal in order to submit the amended report. Effect ? Errors were made in reporting quarterly Total Revenue/Net Charges from Patient Care. Lost revenues were not accurately reported. Cause ? The Organization did not identify certain material patient service revenue adjustments in their calculation. The Organization selected option one and did not identify the components that were to be included in patient service revenue. Identification as a repeat finding ? Not a repeat finding Recommendation ? Policies and procedures over federal grant reporting should be modified to ensure reports are prepared using complete and accurate information.
Show full finding ▾Hide full finding ▴Provider Relief Funds Assistance Listing No. 93.498 U.S. Department of Health and Human Services Criteria or Specific Requirement ? Reporting (45 CFR 75.342) and Activities Allowed/Unallowed and Cost Principles (45 CFR 75.403) Condition ? The Organization is required to prepare and submit period one provider relief fund reporting. This report is to be prepared using accurate financial information and submitted by the deadline established. Questioned costs ? Unknown Context - The period one Provider Relief Fund report was tested. The Organization initially selected option one to report lost revenues based on quarterly actuals. A material error in patient service revenue for the quarters reported was identified. This included a change to revenues that were included in the component values reported impacting the quarterly lost revenues reported. Management requested to amend the original calculation to use option three. The Organization has not been authorized by HRSA to open the portal in order to submit the amended report. Effect ? Errors were made in reporting quarterly Total Revenue/Net Charges from Patient Care. Lost revenues were not accurately reported. Cause ? The Organization did not identify certain material patient service revenue adjustments in their calculation. The Organization selected option one and did not identify the components that were to be included in patient service revenue. Identification as a repeat finding ? Not a repeat finding Recommendation ? Policies and procedures over federal grant reporting should be modified to ensure reports are prepared using complete and accurate information.
Management Response and Planned Corrective Actions - Management agrees with the condition. The audit revealed that material Patient Revenue was omitted from the Lost Revenue report. The following Corrective Actions are taking place: ? Lydia Mason, CFO will work to reopen the Period one report. ? Once the report is reopened, Lydia Mason, CFO will revise the methodology and the Net Charge amounts changing from option one to the option three methodology. The option three methodology used will compare 2020 actuals to the board approved 2020 budget and actual values in quarters one and two of 2021 to the actual results for the same quarters within 2019. This supports the full use of the Provider Relief Funds. ? As new reports are required, Lydia Mason, CFO will review the latest filing requirements prior to completing the online reporting.
FAC accepted this audit on September 23, 2021 — management decision was due March 23, 2022.
FAC accepted this audit on July 12, 2020 — management decision was due January 12, 2021.
Health Center Program Cluster CFDA Nos. 93.224 and 93.527 U.S. Department of Health and Human Services Award Nos. 6 H80CS00086-18 Program Year 2019 Criteria or Specific Requirement ? Special Tests and Provisions: Sliding Fee Discounts (42 USC 254(k)(3)(g); 42 CFR section 51c.303(g) and 42 CFR section 56.303(f)). Identification as a Repeat Finding ? Not applicable. Condition ? Patients received a sliding fee discount that was inconsistent with the stated sliding fee discount categories under the Organization?s policy. Questioned cost ? None Context ? A sample of 25 patients were tested out of the total population of 151,424 encounters. The sampling methodology used is not and is not intended to be statistically valid. Five patients received a sliding fee adjustment that was inconsistent with the approved policy for the proper sliding fee adjustments based on their income documentation. Effect ? Sliding fee discounts were given to patients that were inconsistent with the Organization?s sliding fee discount policy. Cause ? The Organization did not comply with their sliding fee policy. Recommendation ? We recommend management continue to ensure all personnel understand the sliding fee scale policy and adhere to the requirements and guidelines set forth in the policy. Procedures should be implemented to ensure that eligible patients receive discounts in accordance with the sliding fee scale and the Health Center Program Compliance Manual.
Show full finding ▾Hide full finding ▴Health Center Program Cluster CFDA Nos. 93.224 and 93.527 U.S. Department of Health and Human Services Award Nos. 6 H80CS00086-18 Program Year 2019 Criteria or Specific Requirement ? Special Tests and Provisions: Sliding Fee Discounts (42 USC 254(k)(3)(g); 42 CFR section 51c.303(g) and 42 CFR section 56.303(f)). Identification as a Repeat Finding ? Not applicable. Condition ? Patients received a sliding fee discount that was inconsistent with the stated sliding fee discount categories under the Organization?s policy. Questioned cost ? None Context ? A sample of 25 patients were tested out of the total population of 151,424 encounters. The sampling methodology used is not and is not intended to be statistically valid. Five patients received a sliding fee adjustment that was inconsistent with the approved policy for the proper sliding fee adjustments based on their income documentation. Effect ? Sliding fee discounts were given to patients that were inconsistent with the Organization?s sliding fee discount policy. Cause ? The Organization did not comply with their sliding fee policy. Recommendation ? We recommend management continue to ensure all personnel understand the sliding fee scale policy and adhere to the requirements and guidelines set forth in the policy. Procedures should be implemented to ensure that eligible patients receive discounts in accordance with the sliding fee scale and the Health Center Program Compliance Manual.
Management Response and Planned Corrective Actions - Management agrees with the condition. The audit sampling revealed that 4 out of the10 dental patient accounts selected had sliding fee errors. The following Corrective Actions are taking place: ? The COO for the Community Health Center had the Registration Audit schedule updated to list the medical and dental sites individually to insure both departments are audited. This was completed in April. ? The COO had the dental locations audited for the 1st Quarter of 2020 because they were omitted. ? Based on the registration audit findings, retraining and education materials are offered to staff by the Manager of Patient Engagement.
FAC accepted this audit on August 6, 2019 — management decision was due February 6, 2020.
FAC accepted this audit on April 29, 2018 — management decision was due October 29, 2018.
FAC accepted this audit on July 25, 2017 — management decision was due January 25, 2018.
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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