EIN: 561991438
UEI: UHH5JSWCGEP5
Audited by: Forvis Mazars, LLP
Oversight agency: 93 [Department of Health and Human Services]
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Data as of August 31, 2026
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on March 31, 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 October 1, 2026 (29 days from today).
What is a management decision? →Health Center Program Cluster Assistance Listing Nos. 93.224 and 93.527 U.S Department of Health and Human Services Award No. 6 C16CS50415-01-02 Criteria or Specific Requirement – Procurement, Suspension, & Debarment – 2 CFR 200.320 and 2 CFR 180 Condition – The Organization did not follow its policy governing procurement requirements for the purchase of goods and services charged to federal awards. Cause – The Organization did not comply with federal procurement requirements. Effect or Potential Effect – Purchases were made that did not adhere to the Organization’s procurement policy. Questioned Costs – Unknown Context – A sample of one purchase was tested out of a population of five purchases subject to procurement totaling $386,515. The sampling methodology was not, and was not intended to be, statistically valid. The one purchase tested in the amount of $179,232 was not completed in accordance with the Organization’s procurement policy for vendor selection. In addition, the Organization’s procurement policy does not specify the micro-purchase limit and ongoing monitoring procedures of suspended and debarred vendors is not defined. Lastly, a sample of one vendor was tested out of a population of two vendors with contracts exceeding $25,000. The Organization did not retain documentation to support initial verification of vendor against the exclusions list. Identification as a repeat finding, if applicable – Repeat of finding. 2024-003 Recommendation – The Organization should review its procurement policy and ensure proper staff education on the policy is established. In addition, the Organization should review the policy on an annual basis to ensure it is consistent with Uniform Guidance.
Show full finding ▾Hide full finding ▴Health Center Program Cluster Assistance Listing Nos. 93.224 and 93.527 U.S Department of Health and Human Services Award No. 6 C16CS50415-01-02 Criteria or Specific Requirement – Procurement, Suspension, & Debarment – 2 CFR 200.320 and 2 CFR 180 Condition – The Organization did not follow its policy governing procurement requirements for the purchase of goods and services charged to federal awards. Cause – The Organization did not comply with federal procurement requirements. Effect or Potential Effect – Purchases were made that did not adhere to the Organization’s procurement policy. Questioned Costs – Unknown Context – A sample of one purchase was tested out of a population of five purchases subject to procurement totaling $386,515. The sampling methodology was not, and was not intended to be, statistically valid. The one purchase tested in the amount of $179,232 was not completed in accordance with the Organization’s procurement policy for vendor selection. In addition, the Organization’s procurement policy does not specify the micro-purchase limit and ongoing monitoring procedures of suspended and debarred vendors is not defined. Lastly, a sample of one vendor was tested out of a population of two vendors with contracts exceeding $25,000. The Organization did not retain documentation to support initial verification of vendor against the exclusions list. Identification as a repeat finding, if applicable – Repeat of finding. 2024-003 Recommendation – The Organization should review its procurement policy and ensure proper staff education on the policy is established. In addition, the Organization should review the policy on an annual basis to ensure it is consistent with Uniform Guidance.
Management agrees with the finding. During 2024-2025, the Organization procured preferred pricing for the construction and equipment related to the dental facility. This was due to an affiliation agreement with High Point University. Due to this affiliation and the discounts, a formal Request for Proposal (RFP) process was not conducted for this procurement. While this decision was made in the best interest of ensuring low costs, the absence of an RFP process represents an area where the Organization’s procurement practices could be improved to align with best practices for vendor selection and documentation. Going forward, we will follow the established procurement procedures even when an affiliation agreement is in place for preferred pricing. We will update the current finance manual to reflect these procedures. This will be the responsibility of the Finance Director and CFO and will begin in April 2026 and be complete by June 30, 2026.
2024-003
Health Center Program Cluster Assistance Listing Nos. 93.224 and 93.527 U.S Department of Health and Human Services Award No. 5 H80CS26514-12-00 Criteria or Specific Requirement – Special Tests and Provisions: Sliding Fee Discounts – 42 CFR 245(k)(3)(g); 42 CFR section 51c.303(g) and 42 CFR section 56.303(f). Condition – Patients who were eligible for sliding fee discounts under the Organization’s policy were not given sliding fee discounts or received sliding fee discounts inconsistent with the policy. Cause – The Organization did not comply with their sliding fee discount policy. Effect or Potential Effect– Improper sliding fee discounts were given and appropriate documentation was not maintained for all sliding fee discounts given. Context – A sample of 25 encounters were tested out of the total population of 34,306 encounters. The sampling methodology used was not, and was not intended to be, statistically valid. Of the 25 transactions tested, eight were determined to include errors in the application of the sliding fee discount program and policy. Questioned Costs – None Identification as a repeat finding, if applicable – Not a repeat finding. Recommendation – The Organization should 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. Patient files should include documentation of eligibility to receive sliding fee scale discounts.
Show full finding ▾Hide full finding ▴Health Center Program Cluster Assistance Listing Nos. 93.224 and 93.527 U.S Department of Health and Human Services Award No. 5 H80CS26514-12-00 Criteria or Specific Requirement – Special Tests and Provisions: Sliding Fee Discounts – 42 CFR 245(k)(3)(g); 42 CFR section 51c.303(g) and 42 CFR section 56.303(f). Condition – Patients who were eligible for sliding fee discounts under the Organization’s policy were not given sliding fee discounts or received sliding fee discounts inconsistent with the policy. Cause – The Organization did not comply with their sliding fee discount policy. Effect or Potential Effect– Improper sliding fee discounts were given and appropriate documentation was not maintained for all sliding fee discounts given. Context – A sample of 25 encounters were tested out of the total population of 34,306 encounters. The sampling methodology used was not, and was not intended to be, statistically valid. Of the 25 transactions tested, eight were determined to include errors in the application of the sliding fee discount program and policy. Questioned Costs – None Identification as a repeat finding, if applicable – Not a repeat finding. Recommendation – The Organization should 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. Patient files should include documentation of eligibility to receive sliding fee scale discounts.
Management agrees with the finding. The sliding fee applications are processed by the staff at each site and unfortunately, there were errors by some staff in the calculations for income and family size. Of the eight findings, four were actual errors in calculations by staff. The remaining four were correctly calculated; however, they were charged a flat $10 nurse only fee that is an established TAPM policy that was not documented in the sliding fee policy. Management will conduct trainings with all patient services staff to review the sliding fee discount program and the application documentation. This will be the responsibility of the COO and will begin in April 2026 and be ongoing. The documentation of the flat $10 nurse only visit was approved by the Board of Directors and added to the policy effective January 21, 2026.
FAC accepted this audit on March 29, 2025 — management decision was due September 29, 2025.
Health Center Program Cluster Assistance Listing Nos. 93.224 and 93.527 U.S Department of Health and Human Services Award Nos. 6 H80CS26514-10-02, 3 H8FCS40655-01-01, 4 H8GCS47538-01-01, 1 H8LCS50783-01-00 Criteria or Specific Requirement – Procurement – 45 CFR 75.329 Condition – The Organization did not follow its policy governing procurement requirements for the purchase of goods and services charged to federal awards. Questioned Costs – Unknown Context – A sample of one procurement was tested out of a population of six procurements totaling $605,943. The sample was not, and is not intended to be, statistically valid. The one procurement tested in the amount of $18,277 was not completed in accordance with the Organization’s procurement policy for vendor selection. The Organization’s procurement policy does not specify the micro-purchase limit and ongoing monitoring procedures of suspended and debarred vendors is not defined. Lastly, a sample of one vendor was tested out of a population of four vendors with contracts exceeding $25,000. The Organization did not retain documentation to support initial verification of vendor against the exclusions list. Effect – Purchases were made that did not adhere to the Organization’s procurement policy. Cause – The Organization did not comply with their federal procurement policy. Identification as a repeat finding, if applicable – Not a repeat finding. Recommendation – The Organization should review its procurement policy and ensure proper staff education on the policy is established. In addition, the Organization should review the policy on an annual basis to ensure it is consistent with Uniform Guidance.
Show full finding ▾Hide full finding ▴Health Center Program Cluster Assistance Listing Nos. 93.224 and 93.527 U.S Department of Health and Human Services Award Nos. 6 H80CS26514-10-02, 3 H8FCS40655-01-01, 4 H8GCS47538-01-01, 1 H8LCS50783-01-00 Criteria or Specific Requirement – Procurement – 45 CFR 75.329 Condition – The Organization did not follow its policy governing procurement requirements for the purchase of goods and services charged to federal awards. Questioned Costs – Unknown Context – A sample of one procurement was tested out of a population of six procurements totaling $605,943. The sample was not, and is not intended to be, statistically valid. The one procurement tested in the amount of $18,277 was not completed in accordance with the Organization’s procurement policy for vendor selection. The Organization’s procurement policy does not specify the micro-purchase limit and ongoing monitoring procedures of suspended and debarred vendors is not defined. Lastly, a sample of one vendor was tested out of a population of four vendors with contracts exceeding $25,000. The Organization did not retain documentation to support initial verification of vendor against the exclusions list. Effect – Purchases were made that did not adhere to the Organization’s procurement policy. Cause – The Organization did not comply with their federal procurement policy. Identification as a repeat finding, if applicable – Not a repeat finding. Recommendation – The Organization should review its procurement policy and ensure proper staff education on the policy is established. In addition, the Organization should review the policy on an annual basis to ensure it is consistent with Uniform Guidance.
During 2023, the Company procured temporary staffing for Certified Nursing Assistants (CNAs) to meet operational needs. The Human Resources (HR) department reached out to multiple staffing agencies to secure qualified personnel. However, many agencies did not have available staff at the time of the request, and as a result, the Company ultimately selected the staffing firm that could meet its immediate needs in terms of staffing availability. It is important to note that a formal Request for Proposal (RFP) process was not conducted for this procurement. Additionally, HR did not formally document the details of the outreach made to the agencies that were unable to provide staffing. While this decision was made in the best interest of ensuring that operational needs were met without delay, the lack of formal documentation and the absence of an RFP process represent areas where the Company’s procurement practices could be improved to align with best practices for vendor selection and documentation. Going forward, will implement enhanced procedures for procurement processes, including the documentation of agency outreach and the consideration of more formalized vendor selection methods, such as RFPs, to ensure transparency and strengthen internal controls. This will be the responsibility of the Finance Director and CFO and will begin in April 2024 and will be complete by June 30, 2025.
Health Center Program Cluster Assistance Listing Nos. 93.224 and 93.527 U.S Department of Health and Human Services Award Nos. 6 H80CS26514-10-02, 3 H8FCS40655-01-01, 4 H8GCS47538-01-01, 1 H8LCS50783-01-00 Criteria or Specific Requirement – Reporting – 45 CFR 75.342 Condition – The Organization is required to prepare and submit an annual Uniform Data System (UDS) report for each calendar year and an annual Federal Financial Report (FFR) for each award and each grant year. These reports are to be prepared using accurate financial information. Questioned Costs – None Context – One report for each report type listed above was selected for testing with specific data from each report selected for testing. The sampling methodology used is not and is not intended to be statistically valid. Of the twenty-four inputs tested, sixteen exceptions were noted related to the UDS report and one exception was noted related to the annual FFR. Effect – Potential errors were made on the annual UDS and annual FFR reports. Cause – The Organization’s policies and procedures did not identify certain errors that were noted on required reports. Multiple exceptions noted on the UDS related to the Organization’s use of an estimate calculation to report patient totals in Table 4 and encounter totals in Table 5 for the 15 attributes selected for testing between the two tables. The Organization was unable to provide documentation to explain a $13,000 variance for one of the attributes selected for testing in Table 8A. The final UDS error was related to the overreporting of slide discounts and underreporting of other adjustments associated with nurse only visits coded in the practice management system. Program income was not reported on the annual FFR and therefore did not reflect the Organization’s patient service revenue from activities within scope of the health center program. Identification as a repeat finding, if applicable – Not a repeat finding. Recommendation – The Organization should revise policies and procedures over federal reporting to ensure reports are prepared using accurate information and supporting documentation for federal grant reports should be maintained.
Show full finding ▾Hide full finding ▴Health Center Program Cluster Assistance Listing Nos. 93.224 and 93.527 U.S Department of Health and Human Services Award Nos. 6 H80CS26514-10-02, 3 H8FCS40655-01-01, 4 H8GCS47538-01-01, 1 H8LCS50783-01-00 Criteria or Specific Requirement – Reporting – 45 CFR 75.342 Condition – The Organization is required to prepare and submit an annual Uniform Data System (UDS) report for each calendar year and an annual Federal Financial Report (FFR) for each award and each grant year. These reports are to be prepared using accurate financial information. Questioned Costs – None Context – One report for each report type listed above was selected for testing with specific data from each report selected for testing. The sampling methodology used is not and is not intended to be statistically valid. Of the twenty-four inputs tested, sixteen exceptions were noted related to the UDS report and one exception was noted related to the annual FFR. Effect – Potential errors were made on the annual UDS and annual FFR reports. Cause – The Organization’s policies and procedures did not identify certain errors that were noted on required reports. Multiple exceptions noted on the UDS related to the Organization’s use of an estimate calculation to report patient totals in Table 4 and encounter totals in Table 5 for the 15 attributes selected for testing between the two tables. The Organization was unable to provide documentation to explain a $13,000 variance for one of the attributes selected for testing in Table 8A. The final UDS error was related to the overreporting of slide discounts and underreporting of other adjustments associated with nurse only visits coded in the practice management system. Program income was not reported on the annual FFR and therefore did not reflect the Organization’s patient service revenue from activities within scope of the health center program. Identification as a repeat finding, if applicable – Not a repeat finding. Recommendation – The Organization should revise policies and procedures over federal reporting to ensure reports are prepared using accurate information and supporting documentation for federal grant reports should be maintained.
For the 2023 Uniform Data System (UDS) report, the data was compiled using information from two different Electronic Medical Record (EMR) systems. Due to this system fragmentation, there were reporting shortfalls, and the organization relied on historical data estimates to ensure timely submission of the report. These estimates were used to comply with the UDS submission requirements, despite the data not being fully supported by direct system generated reports. For the 2024 UDS report, the organization transitioned to a single EMR system, which has significantly improved the accuracy and completeness of the data. All reported amounts for the 2024 UDS submission are now fully supported by backup data directly generated from the unified EMR system. It is important to note that the Health Resources and Services Administration (HRSA) has consistently approved the organization’s Federal Financial Report (FFR) submissions without including program income, and as such, the organization was not aware of a potential noncompliance issue related to this omission. Going forward, the organization’s Uniform Data System (UDS) reports will be consistent and based on data extracted from a single, unified Electronic Medical Record (EMR) system. This transition ensures greater accuracy and completeness in reporting, with all future UDS reports supported by direct system-generated data. Additionally, the organization will begin reporting program income on the Federal Financial Report (FFR) as part of ongoing improvements to ensure full compliance with reporting requirements. It is important to note that the current FFR report was approved by the Health Resources and Services Administration (HRSA) without program income listed, and this omission was not previously identified as a noncompliance issue. The organization is committed to maintaining transparent and accurate reporting in the future, and steps are being taken to ensure that all required data, including program income, is properly reflected in all relevant reports. This is the responsibility of the QI department and the CFO and will be complete following the next filing of the FFR and UDS.
Health Center Program Cluster Assistance Listing Nos. 93.224 and 93.527 U.S Department of Health and Human Services Award No. 6 H80CS26514-04-00 Criteria or Specific Requirement – Activities Allowed or Unallowed and Allowable Costs/Cost Principles - 45 CFR 75.403(g) and Period of Performance - 45 CFR 75.309. Condition – The Organization is required to maintain a system of internal control over compliance to ensure expenditures applied to federal awards are allowable, meet Federal cost principles, and fall within the period of performance. Context - The Organization was subject to a limited scope review by the U.S. Department of Health and Human Services, Health Resources and Services Administration, Division of Financial Integrity. This review examined the Organization's compliance with certain requirements related to the Access Increases in Mental Health and Substance Abuse Services Supplemental Funding (AIMS), which covered a period of from September 1, 2017 through February 28, 2019, following an approved carryover request. The review identified certain expenditures that fell outside the period of performance or were not supported by appropriate documentation. Questioned Costs - $55,112 Effect - The Organization was not in compliance with the requirements relating to activities allowed or unallowed, allowable costs/cost principles, and period of performance and were required to repay the questioned costs to the granting agency. Cause - The Organization's policies and procedures did not allow for proper cut-off of expenditures as it applied to the AIMS grant. In addition, the Organization's policies and procedures did not prevent certain costs from being applied to the AIMS grant twice. Identification as a repeat finding, if applicable - Not a repeat finding. Recommendation - The Organization should revise its policies and procedures over related to grant expenditures cut-off and tracking to ensure compliant grants management.
Show full finding ▾Hide full finding ▴Health Center Program Cluster Assistance Listing Nos. 93.224 and 93.527 U.S Department of Health and Human Services Award No. 6 H80CS26514-04-00 Criteria or Specific Requirement – Activities Allowed or Unallowed and Allowable Costs/Cost Principles - 45 CFR 75.403(g) and Period of Performance - 45 CFR 75.309. Condition – The Organization is required to maintain a system of internal control over compliance to ensure expenditures applied to federal awards are allowable, meet Federal cost principles, and fall within the period of performance. Context - The Organization was subject to a limited scope review by the U.S. Department of Health and Human Services, Health Resources and Services Administration, Division of Financial Integrity. This review examined the Organization's compliance with certain requirements related to the Access Increases in Mental Health and Substance Abuse Services Supplemental Funding (AIMS), which covered a period of from September 1, 2017 through February 28, 2019, following an approved carryover request. The review identified certain expenditures that fell outside the period of performance or were not supported by appropriate documentation. Questioned Costs - $55,112 Effect - The Organization was not in compliance with the requirements relating to activities allowed or unallowed, allowable costs/cost principles, and period of performance and were required to repay the questioned costs to the granting agency. Cause - The Organization's policies and procedures did not allow for proper cut-off of expenditures as it applied to the AIMS grant. In addition, the Organization's policies and procedures did not prevent certain costs from being applied to the AIMS grant twice. Identification as a repeat finding, if applicable - Not a repeat finding. Recommendation - The Organization should revise its policies and procedures over related to grant expenditures cut-off and tracking to ensure compliant grants management.
Management agrees with this finding. Triad Adult and Pediatric Medicine has updated its Grant Policy and Procedure to address how the organization can reasonably ensure that costs claimed against future federal awards will be allowable federal costs that are incurred within the approved period of performance and meet federal cost principles. This action was the responsibility of the Chief Financial Officer and has been completed. The questioned costs have been repaid and the matter is considered closed.
FAC accepted this audit on September 18, 2024 — management decision was due March 18, 2025.
FAC accepted this audit on March 30, 2023 — management decision was due September 30, 2023.
FAC accepted this audit on February 9, 2023 — management decision was due August 9, 2023.
FAC accepted this audit on January 26, 2021 — management decision was due July 26, 2021.
FAC accepted this audit on September 30, 2019 — management decision was due March 30, 2020.
FAC accepted this audit on November 26, 2018 — management decision was due May 26, 2019.
FAC accepted this audit on January 1, 2018 — management decision was due July 1, 2018.
GSA_MIGRATION
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GSA_MIGRATION
2016-001
FAC accepted this audit on April 4, 2017 — management decision was due October 4, 2017.
GSA_MIGRATION
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GSA_MIGRATION
2015-001
GSA_MIGRATION
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