Greene County Health Care, Incorporated d/b/a Contentnea Health

Health Center Program Cluster Assistance Listing Numbers 93.224 and 93.527 U.S. Department of Health and Human Services Criteria or Specific Requirement: Special Tests and Provision Sliding Fee Discounts (42 USC 254(k)(3)(g); 42 CFR sections 51c.303(g); and 42 CFRsections 56.303(f). Condition: Sliding fee discounts applied to patient charges were inconsistent with the Organization’s sliding fee discount 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 cost: None Context: A sample of 60 encounters were tested out of the total population of 56,150 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 based on their income documentation. Identification as a repeat finding: Not a repeat finding Recommendation: It is recommended that 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: The Organization agrees with this finding.

Individuals Responsible for Corrective Action Plan Daphne Betts-Hemby, MBA, CMPE Chief Finance Officer (252) 747-8162 dhemby@contentnea.org Corrective Action Plan: Sliding fee discounts applied to patient charges were inconsistent with the Organization’s sliding fee discount policy. The miscalculations seem to be the leading cause of the errors noted by the auditors. Ongoing training/internal audits needs to be more robust to ensure staff understand and accurately calculate which discount the patient qualifies for. Management shall review the slide audits to determine which employees are making errors and provide re-training or corrective action as applicable and document/monitor for improvement. Anticipated Completion Date: June 30, 2026

Finding 2021-002 Noncompliance: Special Tests and Provisions SIGNIFICANT DEFICIENCY Criteria: 2 CFR part 200 of the Compliance Supplement requires that health centers must directly allocate costs charges to federal funds and maintain documents to support amounts recorded. Condition: 3 out of 51 samples tested were not properly documented or contained errors in calculating the sliding scale fee adjustment. Effect: Not meeting expectation of reliance over internal controls over special tests and provisions. Cause: The exceptions were mainly due to lack of enforcement of the designed controls and manual adjustments. Identification of repeat finding: Yes Recommendation: We recommend the Organization retain all patient sliding fee discount applications and design and implement controls such that miscalculations in the sliding scale fee adjustment are prevented or detected and corrected in a timely manner. Views of responsible officials and planned corrective actions: Management agrees with this finding. Please refer to the Corrective Action Plan. Questioned Costs: $16,025

Finding 2021-00 - Noncompliance: Special Tests and Provisions Name of contact person: Stephanie Fields Corrective Action : A new process for financial counselors has been implemented to ensure the collection and calculation of sliding fee documents for patients are current. Counselors follow up with patients within 72 hours prior to their visit to ensure all documents are updated and complete. Proposed Completion date: June 2022 for all actions above with ongoing monitoring and compliance.

2020-003

Finding 2020-001 Payroll Review ? Activities Allowed, Allowable Costs SIGNIFICANT DEFICIENCY Criteria: Duties should be segregated and formally documented to provide reasonable assurance that transactions are handled appropriately. Condition: 25 out of 51 samples did not show there was formal documentation that a review took place over payroll prior to the payment. Effect: Lack of a formal review over payroll could result in incorrect charging of costs to grants. Cause: The exceptions were mainly due to lack of a formal process to review the payroll report. Identification of repeat finding: Yes Recommendation: We recommend that the Organization create a formal approval process over payroll for each pay period. Views of responsible officials and planned corrective actions: Management agrees with this finding. Please refer to the Corrective Action Plan. Questioned Costs: None

Finding 2020-001 - Payroll Review - Activities Allowed, Allowable Costs Name of contact person Daniel Perritt Corrective Action: A formal process was put in place to support the approval of payroll by the Accounting Manager prior to final submission. Management has identified to our software vendor that this process needs to be audited to their audit trail documentation as well. Proposed Completion Date: November 2019

2019-004

Finding 2020-003 Noncompliance: Special Tests and Provisions SIGNIFICANT DEFICIENCY Criteria: 2 CFR part 200 of the Compliance Supplement requires that health centers must directly allocate costs charges to federal funds and maintain documents to support amounts recorded. Condition: Five out of 51 samples tested were unable to produce the sliding fee discount application for each patient in order to determine whether the patient meets the requirements for obtaining the discount. An additional two patients were incorrectly categorized by the manual process, resulting in incorrectly applied discounts. Effect: Not meeting expectation of reliance over internal controls over special tests and provisions and incorrect application of discounts. Cause: The file management system is a very manual process, and as a result the Organization was unable to locate applications for patients that received sliding fee discounts and had incorrectly categorized two patients. The Organization was unable to provide an explanation for the missing applications. Identification of repeat finding: Yes Recommendation: We recommend the Organization retain all patient sliding fee discount applications. Views of responsible officials and planned corrective actions: Management agrees with this finding. Please refer to the Corrective Action Plan. Questioned Costs: $7,475

Finding 2020-003 - Noncompliance: Special Tests and Provisions Name of contact person: Daniel Perritt Corrective Action: These are the actions current in process: 1. In January, a new financial counselor position was created for each site location, excluding Student Health Services, which includes the responsibility of assisting patients with sliding fees, including uploading into the system. Front desk receptionist will also be reminded of the importance of ensuring that a current sliding fee application is on file at registration. 2. A central call center is also in process of implementation (one site implemented with a rollout of all sites by the end of 2021) who will schedule all patients and ensure that sliding fees are kept current upon scheduling. 3. A new position, Director-Revenue integrity, has been created and filled as of April 2021. One responsibility is to perform quarterly audits to ensure that sliding fee applications are on file, accurate and up{o-date. Quarterly reports will be sent to management of all audit findings 4. Automatic calculations for sliding fee discounts are in place in our practice management system, however, old insurance plans which are manual were still being used ln some instances. All old insurance plans have been disabled and warns registration that this insurance plan is invalid. Updates to the dental sliding fee scale is in process to ensure that calculations for all procedures are accurate and correct. Proposed Completion Date: June 2022 for all actions above with ongoing monitoring and compliance

2019-006

Finding 2019-003 Omitted Nonmajor Federal Program SIGNIFICANT DEFICIENCY Criteria: 2 CFR Section 200.510(b)(2) requires federal awards received as a subrecipient, the name of the pass-through entity and identifying number assigned by the pass-through entity to be included on the schedule of expenditures of federal awards. Condition: An award under CFDA #93.226 passed through from Wake Forest University Health Sciences for $60,204 was excluded from the Schedule of Expenditures of Federal and State Awards for the year ended June 30, 2018. Effect: A federal program was omitted from the report for the year ended June 30, 2018. Cause: The Organization was unaware of the requirement for subrecipients to report pass-through federal awards. Identification of repeat finding: No Recommendation: We recommend the Organization implement an annual grant review procedure to ensure the grant revenues and program grant expenditures are appropriately identified and reported. Views of responsible officials and planned corrective actions: Management agrees with this finding. Please refer to the Corrective Action Plan. Questioned Costs: None

Finding 2019-003 - Omitted Nonmajor Federal Program Name of contact person: Daniel Perrift Corrective Action: All Federal awards are reviewed monthly and reconciled. Any sub-recipient awards will be included in this review (there are no current sub-recipients in either fiscal year). Proposed Completion Date: May 2021

Finding 2019-004 Payroll Review ? Activities Allowed, Allowable Costs SIGNIFICANT DEFICIENCY Criteria: Duties should be segregated and formally documented to provide reasonable assurance that transactions are handled appropriately. Condition: Two out of 51 samples tested did not show there was formal documentation that employee timesheets were being formally reviewed to support payroll costs incurred and charged to the Health Center Program Cluster were allowable and accurate. 51 out of 51 samples did not show there was formal documentation that a review took place over payroll prior to the payment. Effect: Lack of a formal review over timesheets and overall payroll could result in incorrect charging of costs to grants. Cause: The exceptions were mainly due to lack of a formal process to review employee?s timesheets and the payroll. Identification of repeat finding: No Recommendation: We recommend that the Organization create a formal approval process over payroll for each pay period. We also recommend that timesheets are approved prior to payout of payroll to ensure each employee's payroll amounts are accurate. Views of responsible officials and planned corrective actions: Management agrees with this finding. Please refer to the Corrective Action Plan. Questioned Costs: None

Name of contact person Corrective Action: Daniel Perritt Managers and supervisors have been reminded of the requirement to approve all timesheets for their direct reports. The accounting department will send out a bi-weekly report to management after payroll close of any timesheets that were not approved. A formal process was put in place in November 2019 to support the approval of payroll by the Accounting Manager prior to final submission. Management has identified to our software vendor that this process needs to be audited to their audit trail documentation as well. Proposed Completion Date: May 2021

Finding 2019-006 Noncompliance: Special Tests and Provisions SIGNIFICANT DEFICIENCY Criteria: 2 CFR part 200 of the Compliance Supplement requires that health centers must directly allocate costs charges to federal funds and maintain documents to support amounts recorded. Condition: Ten out of 51 samples tested were unable to produce the sliding fee discount application for each patient in order to determine whether the patient meets the requirements for obtaining the discount. Effect: Not meeting expectation of reliance over internal controls over special tests and provisions. Cause: The Organization was unable to locate applications for patients that received sliding fee discounts. The Organization was unable to provide an explanation for these missing applications. Identification of repeat finding: No Recommendation: We recommend the Organization retain all patient sliding fee discount applications. Views of responsible officials and planned corrective actions: Management agrees with this finding. Please refer to the Corrective Action Plan. Questioned Costs: None

Finding 2019-006 - Noncompliance: Special Tests and Provisions Name of contact person: Daniel Perritt Corrective Action: These are the actions currently in process: 1. ln January 2021, a new financial counselor position was created for each site location, excluding Student Health Services, which includes the responsibility of assisting patients with sliding fees, including uploading into the system. Front desk receptionist will also be reminded of the importance of ensuring that a current sliding fee application is on file at registration. 2. A central call center is also in process of implementation (one site implemented with a rollout of all sites by the end of 2021) who will schedule all patients and ensure that sliding fees are kept current upon scheduling. 3. A new position, Director-Revenue integrity, has been created and filled as of April 2021. One responsibility is to perform quarterly audits to ensure that sliding fee applications are on file, accurate and up-to-date. Quarterly reports will be sent to management of all audit findings. Pro posed Completion Date: June 2022 for all actions above with ongoing monitoring noncompliance