EIN: 561852922
UEI: QLHBMF3MB1M8
Audited by: Terry Horne, CPA
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 July 21, 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 January 21, 2027 (143 days from today).
What is a management decision? →Health Centers receiving funding under the Health Center Program Cluster must prepare and apply a sliding fee discount so that the amounts owed for health center services by eligible patients are discounted based on the patient’s ability to pay. During testing, it was noted that a manual process within the billing process resulted in failure to appropriately provide a discount to a qualifying patient. In addition, two patients were given discounts when applications were incomplete or unavailable Cause: There were deficiencies in internal controls designed to ensure that proper sliding fee discounts were applied to patient accounts in accordance with the Organization’s sliding fee scale. Effect: Discounts were not properly applied to patient accounts. Questioned Costs: None reported. Context/Sampling: Errors in documentation or discounts were noted for 3 of 48 self-pay patients selected for testing. This sample was not, and was not intended to be, a statistically valid sample. The finding appears to be a systemic issue. Repeat Finding from Prior Year: No Recommendation: It is recommended that staff be trained to review sliding fee discounts applied to ensure they are accurate and that proper documentation is maintained. In addition, it is recommended that supervisory level personnel select and review a sample of sliding fee applications and discounts to ensure that staff are properly applying the discounts. Views of Responsible Officials: Management concurs. Efforts will be made to implement corrective actions as recommended above. Contact Person: Anita Case, CEO Anticipated Date of Completion: August 31, 2026
Show full finding ▾Hide full finding ▴Significant Deficiency Finding: 2025-001 Sliding Fee Discounts Federal Programs: Department of Health and Human Services Health Center Program Cluster Assistance Listing No. 93.224 and 93.527 Criteria: Uniform Guidance, Special Tests & Provisions, Sliding Fee Discounts, 42 CFR, 56.303 Condition: Health Centers receiving funding under the Health Center Program Cluster must prepare and apply a sliding fee discount so that the amounts owed for health center services by eligible patients are discounted based on the patient’s ability to pay. During testing, it was noted that a manual process within the billing process resulted in failure to appropriately provide a discount to a qualifying patient. In addition, two patients were given discounts when applications were incomplete or unavailable Cause: There were deficiencies in internal controls designed to ensure that proper sliding fee discounts were applied to patient accounts in accordance with the Organization’s sliding fee scale. Effect: Discounts were not properly applied to patient accounts. Questioned Costs: None reported. Context/Sampling: Errors in documentation or discounts were noted for 3 of 48 self-pay patients selected for testing. This sample was not, and was not intended to be, a statistically valid sample. The finding appears to be a systemic issue. Repeat Finding from Prior Year: No Recommendation: It is recommended that staff be trained to review sliding fee discounts applied to ensure they are accurate and that proper documentation is maintained. In addition, it is recommended that supervisory level personnel select and review a sample of sliding fee applications and discounts to ensure that staff are properly applying the discounts. Views of Responsible Officials: Management concurs. Efforts will be made to implement corrective actions as recommended above. Contact Person: Anita Case, CEO Anticipated Date of Completion: August 31, 2026
In Finding 2025-001, it was reported that the Organization did not properly apply the sliding fee discounts for certain patients with visits to the Organization during the year ended December 31, 2025. Management recognizes the importance of complying with sliding fee guidelines and the Organization’s sliding fee policy. In response to Finding 2025-001, proper training will be given to employees, and sliding fee discounts will be reviewed by a supervisor on a periodic basis to ensure compliance with the sliding fee policy.
FAC accepted this audit on July 31, 2025 — management decision was due January 31, 2026.
FAC accepted this audit on June 17, 2024 — management decision was due December 17, 2024.
Health Centers receiving funding under the Health Center Program Cluster must prepare and apply a sliding fee discount so that the amounts owed for health center services by eligible patients are discounted based on the patient’s ability to pay. During compliance testing, it was determined that the Organization did not properly apply the sliding fee discount for four sliding fee patients tested. Cause: There were deficiencies in the internal controls that ensure proper documentation is obtained and that proper sliding fee discounts are applied to patient accounts in accordance with the Organization’s sliding fee policy and sliding fee scale. Effect: Sliding fee discounts were not properly applied to certain patient accounts. Questioned Costs: None reported. Context/Sampling: For 4 of 20 sliding fee patients selected for testing, the account had an incorrect discount applied. This sample was not, and was not intended to be, a statistically valid sample. The finding appears to be a systemic issue. Repeat Finding from Prior Year: No Recommendation: It is recommended that proper training be given to employees and that the sliding fee discounts be reviewed by a supervisor on a periodic basis to ensure compliance with the sliding fee scale. Views of Responsible Officials: Management concurs. Efforts will be made to implement corrective actions as recommended above. Contact Person: Kim Wagenaar, CEO Anticipated Date of Completion: July 31, 2024
Show full finding ▾Hide full finding ▴Finding: 2023-001 Sliding Fee Discounts Federal Programs: Department of Health and Human Services Health Center Program Cluster Assistance Listing No. 93.224 and 93.527 Criteria: Uniform Guidance, Special Tests & Provisions, Sliding Fee Discounts, 42 CFR, 56.303 Condition: Health Centers receiving funding under the Health Center Program Cluster must prepare and apply a sliding fee discount so that the amounts owed for health center services by eligible patients are discounted based on the patient’s ability to pay. During compliance testing, it was determined that the Organization did not properly apply the sliding fee discount for four sliding fee patients tested. Cause: There were deficiencies in the internal controls that ensure proper documentation is obtained and that proper sliding fee discounts are applied to patient accounts in accordance with the Organization’s sliding fee policy and sliding fee scale. Effect: Sliding fee discounts were not properly applied to certain patient accounts. Questioned Costs: None reported. Context/Sampling: For 4 of 20 sliding fee patients selected for testing, the account had an incorrect discount applied. This sample was not, and was not intended to be, a statistically valid sample. The finding appears to be a systemic issue. Repeat Finding from Prior Year: No Recommendation: It is recommended that proper training be given to employees and that the sliding fee discounts be reviewed by a supervisor on a periodic basis to ensure compliance with the sliding fee scale. Views of Responsible Officials: Management concurs. Efforts will be made to implement corrective actions as recommended above. Contact Person: Kim Wagenaar, CEO Anticipated Date of Completion: July 31, 2024
In Finding 2023-001, it was reported that the Organization did not properly apply the sliding fee discount for four sliding fee patients tested. Management recognizes the importance of complying with sliding fee guidelines. In response to Finding 2023-001, proper training will be given to employees and sliding fee applications and discounts will be reviewed by a supervisor on a periodic basis to ensure compliance with the sliding fee scale.
FAC accepted this audit on May 18, 2023 — management decision was due November 18, 2023.
FAC accepted this audit on May 8, 2022 — management decision was due November 8, 2022.
The Uniform Data System report submitted to DHHS for the year ended December 31, 2021 contained incorrect data for patient revenue and expenses. The charges and adjustments were not correctly reported on Table 9D of the UDS report. The charges were understated by approximately $395,000 and adjustments were understated by approximately $948,000. Also, the expenses were not correctly reported on Table 8A of the UDS report. The expenses were understated by approximately $1,000,000. Criteria: Uniform Guidance, Special Reporting ? Uniform Data System Cause: The above exception resulted from errors in preparing Table 8A and Table 9D of the Uniform Data System report. Effect: The Department of Health and Human Services reviews the UDS data for financial analysis for grant recipients. Errors in this data causes incorrect financial analysis results and distorted performance indicators. Questioned Costs: None reported Context/Sampling: The UDS contained incorrect data for patient revenue and expenses. Repeat Finding from Prior Year: Yes Recommendation: It is recommended that a system should be developed to ensure actual charges and adjustments from all sources are reported and reconciled to the UDS report. HRSA should be informed of the error and the 2021 Table 8A and Table 9D should be revised and resubmitted if requested. Auditee?s Response and Corrective Action Plan: Management concurs. Efforts will be made to ensure that the revenue and expenses recorded is reconciled to the revenue and expenses on the UDS report. HRSA has been notified and the 2021 Table 8A and Table 9D have been revised. Contact Person: Cody McKinney, CFO Anticipated Date of Completion: June 30, 2022
Show full finding ▾Hide full finding ▴Finding: 2021-003 Uniform Data System Report Federal Programs: Department of Health and Human Services Health Center Program Cluster CFDA 93.224 and 93.527 Condition: The Uniform Data System report submitted to DHHS for the year ended December 31, 2021 contained incorrect data for patient revenue and expenses. The charges and adjustments were not correctly reported on Table 9D of the UDS report. The charges were understated by approximately $395,000 and adjustments were understated by approximately $948,000. Also, the expenses were not correctly reported on Table 8A of the UDS report. The expenses were understated by approximately $1,000,000. Criteria: Uniform Guidance, Special Reporting ? Uniform Data System Cause: The above exception resulted from errors in preparing Table 8A and Table 9D of the Uniform Data System report. Effect: The Department of Health and Human Services reviews the UDS data for financial analysis for grant recipients. Errors in this data causes incorrect financial analysis results and distorted performance indicators. Questioned Costs: None reported Context/Sampling: The UDS contained incorrect data for patient revenue and expenses. Repeat Finding from Prior Year: Yes Recommendation: It is recommended that a system should be developed to ensure actual charges and adjustments from all sources are reported and reconciled to the UDS report. HRSA should be informed of the error and the 2021 Table 8A and Table 9D should be revised and resubmitted if requested. Auditee?s Response and Corrective Action Plan: Management concurs. Efforts will be made to ensure that the revenue and expenses recorded is reconciled to the revenue and expenses on the UDS report. HRSA has been notified and the 2021 Table 8A and Table 9D have been revised. Contact Person: Cody McKinney, CFO Anticipated Date of Completion: June 30, 2022
In Finding 2021-003, it was reported that the Uniform Data System report submitted to DHHS for the year ended December 31, 2021 contained incorrect data for patient revenue. The charges and adjustments were not correctly reported on Table 9D of the UDS report. The charges were understated by approximately $395,000 and adjustments were understated by approximately $948,000. Also, the expenses not correctly reported on Table 8A of the UDS report. The expenses were understated by approximately $1,000,000. Management recognizes the importance of complying with federal reporting guidelines. In response to Finding 2021-003, efforts will be made to ensure that the revenue and expenses recorded is reconciled to the revenue and expenses on the UDS report. HRSA has been notified, and the 2021 Table 8A and Table 9D have been revised. This will be implemented by the Chief Financial Officer by August June 30, 2022.
2020-004
FAC accepted this audit on August 4, 2021 — management decision was due February 4, 2022.
The Uniform Data System report submitted to DHHS for the year ended December 31, 2020 contained incorrect data for patient revenue. The charges and adjustments were not correctly reported on Table 9D of the UDS report. The charges and adjustments were understated by approximately $900,000. Criteria: Uniform Guidance, Special Reporting ? Uniform Data System Cause: The above exception resulted from errors in preparing Table 9D of the Uniform Data System report. Effect: The Department of Health and Human Services reviews the UDS data for financial analysis for grant recipients. Errors in this data causes incorrect financial analysis results and distorted performance indicators. Questioned Costs: None reported Context/Sampling: The finding appears to be a systemic issue. Repeat Finding from Prior Year: NoRecommendation: It is recommended that a system should be developed to ensure actual charges and adjustments from all sources are reported and reconciled to the UDS report. HRSA should be informed of the error and the 2020 Table 9D should be revised and resubmitted if requested. Auditee?s Response and Corrective Action Plan: Management concurs. Efforts will be made to ensure that the revenue and expenses recorded is reconciled to the revenue and expenses on the UDS report. Contact Person: Cody McKinney, CFO Anticipated Date of Completion: August 31, 2021
Show full finding ▾Hide full finding ▴Finding: 2020-004 Uniform Data System Report Federal Programs: Department of Health and Human Services Health Center Program Cluster CFDA 93.224 and 93.527 Condition: The Uniform Data System report submitted to DHHS for the year ended December 31, 2020 contained incorrect data for patient revenue. The charges and adjustments were not correctly reported on Table 9D of the UDS report. The charges and adjustments were understated by approximately $900,000. Criteria: Uniform Guidance, Special Reporting ? Uniform Data System Cause: The above exception resulted from errors in preparing Table 9D of the Uniform Data System report. Effect: The Department of Health and Human Services reviews the UDS data for financial analysis for grant recipients. Errors in this data causes incorrect financial analysis results and distorted performance indicators. Questioned Costs: None reported Context/Sampling: The finding appears to be a systemic issue. Repeat Finding from Prior Year: NoRecommendation: It is recommended that a system should be developed to ensure actual charges and adjustments from all sources are reported and reconciled to the UDS report. HRSA should be informed of the error and the 2020 Table 9D should be revised and resubmitted if requested. Auditee?s Response and Corrective Action Plan: Management concurs. Efforts will be made to ensure that the revenue and expenses recorded is reconciled to the revenue and expenses on the UDS report. Contact Person: Cody McKinney, CFO Anticipated Date of Completion: August 31, 2021
In Finding 2020-004, it was reported that the Uniform Data System report submitted to DHHS for the year ended December 31, 2020 contained incorrect data for patient revenue. The charges and adjustments were not correctly reported on Table 9D of the UDS report. The charges and adjustments were understated by approximately $900,000. Management recognizes the importance of complying with federal reporting guidelines. In response to Finding 2020-004, efforts will be made to ensure that the revenue and expenses recorded is reconciled to the revenue and expenses on the UDS report. This will be implemented by the Chief Financial Officer by August 31, 2021.
? Procurement policies were not updated to conform to applicable standards under the Uniform Guidance. ? The Organization did not verify that vendors were not suspended, debarred, or otherwise excluded from participating in federal programs before entering into transactions with them. Cause: ? The Organization did not have proper procedures in place to ensure its procurement policies were updated to conform to the requirements identified in the Uniform Guidance. ? The Organization did not follow its policy regarding debarment searches. Effect: ? The Organization?s procurement policy did not conform to applicable standards under the Uniform Guidance?s procurement limits for micro, small, and simplified purchases. ? There were several vendors for which the Organization did not verify that they were not suspended, debarred, or otherwise excluded from participating in Federal programs before entering into transactions with them. Questioned Costs: None reported Context/Sampling: The finding appears to be a systemic issue. Repeat Finding from Prior Year: No Recommendation: We recommend that the Organization update its procurement policies to conform to the requirements identified in Uniform Guidance, and that employees be trained to follow the established debarment policy. Views of Responsible Officials: Management concurs. Policies and procedures will be updated to reflect the Uniform Guidance procurement limits for micro, small, and simplified purchases and to ensure debarment searches are completed annually to verify that employees and vendors are not suspended, debarred, or otherwise excluded from participating in Federal programs before entering into transactions with them. Contact Person: Cody McKinney, CFO Anticipated Date of Completion: August 31, 2021
Show full finding ▾Hide full finding ▴Finding: 2020-005 Procurement, Suspension and Debarment Federal Programs: Department of Health and Human Services Health Center Program Cluster CFDA 93.224 and 93.527 Criteria: Procurement 45 CFR 75.329 and 45 CFR 75.213 Condition: ? Procurement policies were not updated to conform to applicable standards under the Uniform Guidance. ? The Organization did not verify that vendors were not suspended, debarred, or otherwise excluded from participating in federal programs before entering into transactions with them. Cause: ? The Organization did not have proper procedures in place to ensure its procurement policies were updated to conform to the requirements identified in the Uniform Guidance. ? The Organization did not follow its policy regarding debarment searches. Effect: ? The Organization?s procurement policy did not conform to applicable standards under the Uniform Guidance?s procurement limits for micro, small, and simplified purchases. ? There were several vendors for which the Organization did not verify that they were not suspended, debarred, or otherwise excluded from participating in Federal programs before entering into transactions with them. Questioned Costs: None reported Context/Sampling: The finding appears to be a systemic issue. Repeat Finding from Prior Year: No Recommendation: We recommend that the Organization update its procurement policies to conform to the requirements identified in Uniform Guidance, and that employees be trained to follow the established debarment policy. Views of Responsible Officials: Management concurs. Policies and procedures will be updated to reflect the Uniform Guidance procurement limits for micro, small, and simplified purchases and to ensure debarment searches are completed annually to verify that employees and vendors are not suspended, debarred, or otherwise excluded from participating in Federal programs before entering into transactions with them. Contact Person: Cody McKinney, CFO Anticipated Date of Completion: August 31, 2021
In Finding 2020-005, a finding reported that the Organization did not follow its policy governing procurement requirements for the purchase of goods or services. Management recognizes the importance of complying with procurement, debarment, and suspension guidelines. In response to Finding 2020-005, policies and controls that were previously designed will be implemented to verify that vendors are not suspended or debarred or otherwise excluded from participating in Federal programs before entering into transactions with the vendor. The procurement policy will also be updated to comply with the Uniform Guidance procurement procedures This review and update will be performed by the Chief Financial Officer and completed by August 31, 2021.
FAC accepted this audit on November 19, 2020 — management decision was due May 19, 2021.
The Organization made a draw of federal funds that were not disbursed for program expenses. The Organization is required to minimize the time elapsing between the transfer of funds to the Organization and the issuance of payments for program purposes by the Organization. Context: $154,730 out of a draw of $374,521 was determined to be an advance draw for one out of three sampled draws. Cause: The Organization did not identify qualifying expenditures prior to drawing down grant funds. Effect: Grant funds were drawn in advance of qualifying expenditures. The draw included $47,577 in supplementary funds that were not earned as of the end of the grant period and are reflected as deferred revenue. The funds are eligible for carry forward based on the grant terms. Recommendation: Management should make additional efforts to ensure that advance draws of federal funds do not occur. Views of Responsible Officials and Planned Corrective Actions: Management of the Organization agrees with this finding and will adhere to the Corrective Action Plan.
Show full finding ▾Hide full finding ▴Finding 2019-001 - Cash Management Federal Programs: Health Center Program (CFDA #93.224) Grants for New and Expanded Services Under the Health Center Program (CFDA #93.527) U.S. Department of Health and Human Services SIGNIFICANT DEFICIENCY NONCOMPLIANCE Cash Management Criteria: The Organization must pay for program costs prior to request for reimbursement by the Federal Government when grant funding is on a reimbursement basis. Condition: The Organization made a draw of federal funds that were not disbursed for program expenses. The Organization is required to minimize the time elapsing between the transfer of funds to the Organization and the issuance of payments for program purposes by the Organization. Context: $154,730 out of a draw of $374,521 was determined to be an advance draw for one out of three sampled draws. Cause: The Organization did not identify qualifying expenditures prior to drawing down grant funds. Effect: Grant funds were drawn in advance of qualifying expenditures. The draw included $47,577 in supplementary funds that were not earned as of the end of the grant period and are reflected as deferred revenue. The funds are eligible for carry forward based on the grant terms. Recommendation: Management should make additional efforts to ensure that advance draws of federal funds do not occur. Views of Responsible Officials and Planned Corrective Actions: Management of the Organization agrees with this finding and will adhere to the Corrective Action Plan.
Finding 2019-001 - Cash Management Federal Programs: Health Center Program (CFDA #93.224) Grants for New and Expanded Services Under the Health Center Program (CFDA #93.527) U.S. Department of Health and Human Services SIGNIFICANT DEFICIENCY NONCOMPLIANCE Cash Management Name of Contact Persons: Cody McKinney, CFO Corrective Action: Management implemented a new accounting software/system in January 2020 to more effectively and accurately track expenses that will then be requested for reimbursement from the Payment Management System. The new management team is also fully aware of the importance of spending federal funds for the purposes outlined for approved budgetary items. Completion Date: January 1, 2020
The annual report was not filed in a timely manner. Cause: Reporting deadlines were not met due to a system not being in place to track due dates and status of those filings. Context: We tested the required annual report filing for the major program. Effect: Delays in reporting could subject the Organization to suspension of grant funding. Recommendation: We recommend the Organization implement a system for tracking due dates of report filings and maintain calendar reminders to ensure deadlines are met. Views of Responsible Officials and Planned Corrective Actions: Management of the Organization agrees with this finding and will adhere to the Corrective Action Plan.
Show full finding ▾Hide full finding ▴Finding 2019-002 - Reporting Federal Programs: Health Center Program (CFDA #93.224) Grants for New and Expanded Services Under the Health Center Program (CFDA #93.527) U.S. Department of Health and Human Services NONCOMPLIANCE Reporting Criteria: The federal award requires the Organization to file an annual report by April 30. Condition: The annual report was not filed in a timely manner. Cause: Reporting deadlines were not met due to a system not being in place to track due dates and status of those filings. Context: We tested the required annual report filing for the major program. Effect: Delays in reporting could subject the Organization to suspension of grant funding. Recommendation: We recommend the Organization implement a system for tracking due dates of report filings and maintain calendar reminders to ensure deadlines are met. Views of Responsible Officials and Planned Corrective Actions: Management of the Organization agrees with this finding and will adhere to the Corrective Action Plan.
Finding 2019-002 - Reporting Federal Programs: Health Center Program (CFDA #93.224) Grants for New and Expanded Services Under the Health Center Program (CFDA #93.527) U.S. Department of Health and Human Services NONCOMPLIANCE Reporting Name of Contact Persons: Cody McKinney, CFO Corrective Action: Management will implement a tracking system to monitor filing deadlines. This deadline was missed as COVID delayed completion of the audit, and we wanted to match our amounts to the final adjusted audit figures. Now that we are aware of an edit option in the EHB, we can file timely and adjust as needed. Completion Date: September 1, 2020
FAC accepted this audit on July 20, 2019 — management decision was due January 20, 2020.
GSA_MIGRATION
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GSA_MIGRATION
2017-002
GSA_MIGRATION
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GSA_MIGRATION
FAC accepted this audit on September 27, 2018 — management decision was due March 27, 2019.
GSA_MIGRATION
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GSA_MIGRATION
FAC accepted this audit on September 28, 2017 — management decision was due March 28, 2018.
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