Advance Community Health Inc.

Criteria or Specific Requirement – Reporting – 45 CFR 75.342 Condition – The Organization is required to prepare and submit an annual Federal Financial Report (FFR) for each grant year for each separate awards in the cluster. Questioned cost – None Context – The FFR was selected for testing with specific data from the line items selected. The sampling methodology used is not and is not intended to be statistically valid. Exceptions were noted related to the annual FFR report. Effect – Potential errors were made on the annual FFR report. Cause – The Organization was unable to provide supporting documentation that agreed to the line items tested on the report. Identification as a Repeat Finding – Not a repeat finding. Recommendation – The Organization should revise policies and procedures over federal reporting to ensure reports are prepared using complete information and supporting documentation for federal grant reports should be maintained.

Provider Relief Fund and American Rescue Plan Act (ARP) Rural Distribution Federal 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 Allowable Costs/Cost Principles (Pub. L. No. 116?136, 134 Stat. 563 and Pub. L. No. 116?139, 134 Stat. 622 and 623) Condition ? The Organization is required to prepare and submit phase one Provider Relief Funding 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 Program and American Rescue Plan (ARP) Rural Distribution (collectively the ?Provider Relief Fund?) report was tested. The Organization selected option three to report lost revenues, using a calculation that excluded certain patient service revenue categories but did not disclose the categories in sufficient detail in the required narrative that would allow the Health Resources Services Administration (HRSA) to be able to clearly understand the categories that have been excluded from the option three calculation. Effect ? The report provided to HRSA included adjustments that were not adequately described and disclosed through the Provider Relief Fund phase one report. Cause ? The narrative did not fully and clearly describe the exclusions from patient service revenue in the narrative of the method for calculating lost revenue, as required by the Provider Relief Fund terms and conditions. Identification As a Repeat Finding ? Not a repeat finding. Recommendation ? Policies and procedures over federal grant reporting should be modified to ensure reports and supporting documentation provided to regulatory agencies are clear, accurate, and easily understood. Views of Responsible Officials and Planned Corrective Actions ? Advance Community Health was inundated with HRSA reporting due to the multiple funding we received in response to the Covid-19 Pandemic. In an effort to help health centers deal expeditiously with the Covid crisis some of the funding was given in advance with reporting requirements to follow. The rush to get funding out to address the Covid-19 pandemic crisis resulted in reporting requirements that were developed and implemented very quickly, and the reporting requirements were confusing to many health centers. The Provider Relief Funding was one of the instances in which funding was given in advance with reporting requirements to follow. As a result of the confusion surrounding these last-minute reporting requirements, we believe that the former CFO inadvertently omitted certain revenue that perhaps should have been included in the Provider Relief Funding (PRF) report and there was no clear explanation in the narrative section as to why these revenues were omitted. We attempted to recall and amend the PRF report but were told by the PRF reporting team that we are unable to amend the report at this time. However, should the opportunity to amend the PRF Report occur, we will make the appropriate amendment to the PRF report with a reconciliation and narrative that will support the earning of the PRF funding. To prevent future occurrences of where it is not clear why revenue items are being omitted or included on a federal provider relief report, a reconciliation will be prepared that ties the revenue section of the PRF report with the revenue section of the internal financial statements. The reconciliation will clearly outline what is included in and what is omitted from the report and establish clear documentation to strongly support the amounts on the PRF report. A narrative documenting why certain revenue is omitted should be attached, which will clearly and concisely explain how the revenue amounts on the PRF report were derived. The reconciliation will be prepared by our senior accountant and reviewed by the CFO. Tiffany Robertson, the interim CFO and Rhonda Payne, our Chief Compliance Officer will be responsible for and will continue to assess our internal reporting processes. We will continue to conduct staff training as deemed necessary to ensure compliance with federal reporting requirements for PRF funding. The training and procedure should be implemented by December 2022.

Health Center Program Cluster ? CFDA Nos. 93.224 and 93.527 U.S. Department of Health and Human Services Award No. 6 H80CS00087-19-04 Program Year 2021 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. Questioned cost ? None Context ? A sample of 40 patients were tested out of the total population of 74,749 encounters. The sampling methodology used is not and is not intended to be statistically valid. Thirteen 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. Identification as a repeat finding, if applicable ? Is a repeat of finding 2020-001. 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 ? Advance Community Health began auditing its sliding fee process in May, 2018 and continues to perform targeted audits on the slide process. In response to prior year audit findings, the management team at Advance studied the patient sliding fee process and determined that the process needed to be streamlined and simplified. Advance has made several modifications to its sliding fee program with the goal of minimizing errors. These modifications include the following: ? In February 2020 Advance digitized the sliding fee application document, enabling the documents to be automatically indexed to the patients record within the EHR. ? Advance is building a process for digital intake within Epic EHR and hopes to have this in full effect by the beginning of 2022. There were two findings this year, each requiring a different response. 1. In August, 2021 Advance automated the sliding fee waiver for Homeless patients to adjust the balance of a patient experiencing homeless to $0 using an adjustment code that specifically notes ?Homeless Waiver?, as opposed to ?Sliding Fee Adjustment?. 2. On May 18, 2020, in response to the COVID pandemic the Board approved sliding all Telehealth visits to a flat $6 fee. The Board made this decision to ensure patients were able to continue to get their clinical needs met during the pandemic. Advance was notified during their HRSA site visit that sliding a Telehealth visit was not allowed and rescinded the $6 Telehealth slide visit in May, 2021. Steve Shelton, Chief Finance Officer and Jamal Jones, Chief Operating and Strategy Officer will continue to assess our internal audit process and modify it as we streamline and simplify the sliding fee application process. We will continue to conduct staff training as deemed necessary to ensure compliance with the board approved policies and procedures relating to adjustments provided to patients as part of the sliding fee program.

Health Center Program Cluster ? CFDA Nos. 93.224 and 93.527 U.S. Department of Health and Human Services Award No. 6 H80CS00087-18-10 Program Year 2020 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. Questioned cost ? None Context ? A sample of 40 patients were tested out of the total population of 61,581 encounters. The sampling methodology used is not and is not intended to be statistically valid. Four 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. Identification as a repeat finding, if applicable ? Is a repeat of finding 2019-001. 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 ? Advance Community Health began auditing its sliding fee process in May, 2018 and continues to perform targeted audits on the slide process. In response to prior year audit findings, the management team at Advance studied the patient sliding fee process and determined that the process needed to be streamlined and simplified. In February 2020 Advance digitized the sliding fee application document, enabling the documents to be automatically indexed to the patients record within the EHR. We have seen a positive effective to the digitization as we had no errors related to missing supporting documentation this year. In response to the COVID pandemic, on May 18, 2020 the Board approved a change to the Slide policy addressing the need to reduce barriers to caring for patients via telehealth. The Board approved change simplifies the slide application process by allowing patients to self-attest and complete the application process annually as opposed to semi-annually. We will study the effects of this simplification on finances with the hopes of being able to make this temporary change permanent. In the Fall of 2020, Advance will adopt digital intake. The effect of this is an overall reduction in paperwork needed at registration. We feel that this reduction in paperwork will allow our staff to devote more time to the documentation and attention to detail needed to apply the correct slide for our patients. The errors found this year differed from the errors found in prior years. The errors were adjustment and charge errors as opposed to documentation errors. We will take the audit feedback and modify our audit to include procedures that assess these types of errors. The Chief Operation and Strategy Officer will continue to assess our internal audit process and modify it as we streamline and simplify the sliding fee application process. We will continue to conduct staff training as deemed necessary to ensure compliance with the board approved policies and procedures relating to adjustments provided to patients as part of the sliding fee program.

Health Center Program Cluster ? CFDA Nos. 93.224 and 93.527 U.S. Department of Health and Human Services Award No. 6 H80CS00087-18-10 Program Year 2020 Criteria or Specific Requirement ? Cash Management (45 CFR 75.305) Condition ? The Organization?s internal controls over the cash draw down process were not operating effectively to minimize the time elapsing between the transfer of funds to the Organization from the U.S. Treasury and the issuance of payments for program purposes by the Organization. Questioned cost ? None Context ? The Organization did not follow their process of determining whether sufficient grant expenditures had been incurred prior to drawing down grant funds due to cash flow needs. Grant funds were drawn down prior to disbursements of expenditures within the grant period for four of twenty-four draws during the fiscal year ended March 31, 2020. Effect ? Grant funds were drawn down sooner than administrative necessary. The final threes draws included supplemental funds that were not earned as of the end of the grant period and are reflected as deferred grant revenue. These funds were eligible for carryforward and the carryforward was subsequently granted based on the grant terms. The deferred grant revenues were subsequently obligated and expended. Cause ? The Organization did not comply with their federal cash drawdown policy or federal grant cash management requirements due to cash flow needs of the Organization. Identification as a repeat finding, if applicable ? Is not a repeat finding. Recommendation ? The Organization should identify other cash flow solutions to avoid the need to advance draw federal grant funds prior to disbursement of allowable expenditures. Views of Responsible Officials and Planned Corrective Actions ? Advance Community Health concurs with the audit recommendation that we identify other cash flow solutions to avoid the need to advance draw federal grant funds. The funds that Advance overdrew were carryforward funds that have been subsequently approved for carryover. Per review and monitoring by the Chief Financial Officer, Advance Community Health was able to incur the expenses related to the overdrawn funds by June, 2020. Advance, through monitoring by the Chief Financial Officer, will ensure that this finding does not occur again in FY21 by determining cash availability one week prior to needing to draw funds. In addition, Advance was able to secure funding from the Paycheck Protection Program and has requested a tentative settlement of its FY20 Medicaid Cost Report settlement. These sources of cash will help to ensure cash is available so that federal grants funds aren?t used when expenses have not been incurred.

Health Center Program Cluster ? CFDA Nos. 93.224 and 93.527 U.S. Department of Health and Human Services Award No. 6 H80CS00087-17-05 Program Year 2019 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, or patients received a sliding fee discount when their application had expired per the Organization?s policy. Questioned cost ? None Context ? A sample of 40 patients were tested out of the total population of 46,976 encounters. The sampling methodology used is not and is not intended to be statistically valid. Fourteen 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. Identification as a repeat finding, if applicable ? Is 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 ? Advance Community Health began auditing its sliding fee process in May, 2018 and continues to do so. The audit exposed operational issues related to the complete collection of patient information, what is considered income and what sources prove that income, errors entering the data from applications into the EHR system and untimeliness uploading documents into the patient record. After a complete year of self-audits, we are finding we have not been able to reduce the operational errors down to an acceptable level. Currently Advance Community Health pairs its internal sliding fee application with additional charity programs available to patients at or below the federal poverty level. Advance Community Health believed it would be best to be proactive in collecting enough information to ensure that documentation requirements needed for additional programs, including specialty services and diagnostic testing, was collected at one time. Advance Community Health?s policy requires staff to collect data that far exceeds the minimum requirements set forth by HRSA. The Health Center feels that there is flexibility to simplify the data collection process and reduce the burden placed on patients and staff. The Chief Operating Officer of Advance Community Health has established a task force to review the HRSA program requirements for a sliding fee scale program and design a simpler, patient focused program that remains HRSA compliant. This task force met on September 16, 2019 and will deliver a compliant and streamlined process by December 1, 2019. The process will be measured for effectiveness and modified as needed.

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