EIN: 581319204
UEI: HCESMANF9GD7
Data as of August 27, 2026
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on December 4, 2022. 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 June 4, 2023 (1180 days ago).
What is a management decision? →Item 2022-001 - Special Tests and Provisions U.S Department of Health and Human Services, COVID-19 Health Center Program Cluster (Assistance Listing Number 93.224/93.527) Criteria Health centers are required to have a corresponding schedule of discounts applied and adjusted on the basis of patients' ability to pay and their eligibility. A patient's eligibility to pay is determined on the basis of the official poverty guideline, as revised by DHHS (42 CFR Sections 51c, 107(b)(5), 56.108(b)(5) and 56.303(f)). The Center should be implementing and monitoring procedures to properly determine, calculate and review sliding fee discounts issued to patients in accordance with the Center's sliding fee scale. Statement of Condition While performing our audit, we noted that the Center did not properly determine the sliding fee discount category given to patients selected for testing based on the sliding fee scale in effect for the year ended March 31, 2022. Questioned Costs None Context While performing our audit, we noted that the Center did not properly determine the sliding fee discount category given to two out of thirty-five patients selected for testing based on the sliding fee scale in effect for the year ended March 31, 2022. Cause The condition can be attributed to human error and the lack of internal controls to review and ensure that the proper sliding fee documentation is being maintained and applied. Effect The Center did not comply with the determination of sliding fee discounts based on the federal poverty guidelines in effect for the year ended March 31, 2022. In addition, the Center may not have properly calculated the sliding fee or discount given to the patients and the discount given, if any, may not have been based on the patient's ability to pay. Identification as a Repeat Finding Condition is not a repeat finding. Recommendation We recommend that proper training be given to employees at registration to ensure that the sliding fee discounts are monitored and reviewed by a supervisor on a periodic basis to ensure compliance with the sliding fee scale. In addition, management should conduct internal audits to ensure the sliding fee is calculated properly. Views of Responsible Official The Center concurs with this finding and will ensure that additional controls have been put in place to timely detect system and human errors in the sliding fee discount calculation. The Center will implement additional education to registration staff, improve orientation of new registration staff and strengthen its internal audits to monitor compliance with the sliding fee discount policies and procedures. The Center is also moving to a new Electronic Health Record, EPIC, in November 2022 that should help with ensuring that previous system limitations are no longer an issue.
Show full finding ▾Hide full finding ▴Item 2022-001 - Special Tests and Provisions U.S Department of Health and Human Services, COVID-19 Health Center Program Cluster (Assistance Listing Number 93.224/93.527) Criteria Health centers are required to have a corresponding schedule of discounts applied and adjusted on the basis of patients' ability to pay and their eligibility. A patient's eligibility to pay is determined on the basis of the official poverty guideline, as revised by DHHS (42 CFR Sections 51c, 107(b)(5), 56.108(b)(5) and 56.303(f)). The Center should be implementing and monitoring procedures to properly determine, calculate and review sliding fee discounts issued to patients in accordance with the Center's sliding fee scale. Statement of Condition While performing our audit, we noted that the Center did not properly determine the sliding fee discount category given to patients selected for testing based on the sliding fee scale in effect for the year ended March 31, 2022. Questioned Costs None Context While performing our audit, we noted that the Center did not properly determine the sliding fee discount category given to two out of thirty-five patients selected for testing based on the sliding fee scale in effect for the year ended March 31, 2022. Cause The condition can be attributed to human error and the lack of internal controls to review and ensure that the proper sliding fee documentation is being maintained and applied. Effect The Center did not comply with the determination of sliding fee discounts based on the federal poverty guidelines in effect for the year ended March 31, 2022. In addition, the Center may not have properly calculated the sliding fee or discount given to the patients and the discount given, if any, may not have been based on the patient's ability to pay. Identification as a Repeat Finding Condition is not a repeat finding. Recommendation We recommend that proper training be given to employees at registration to ensure that the sliding fee discounts are monitored and reviewed by a supervisor on a periodic basis to ensure compliance with the sliding fee scale. In addition, management should conduct internal audits to ensure the sliding fee is calculated properly. Views of Responsible Official The Center concurs with this finding and will ensure that additional controls have been put in place to timely detect system and human errors in the sliding fee discount calculation. The Center will implement additional education to registration staff, improve orientation of new registration staff and strengthen its internal audits to monitor compliance with the sliding fee discount policies and procedures. The Center is also moving to a new Electronic Health Record, EPIC, in November 2022 that should help with ensuring that previous system limitations are no longer an issue.
CORRECTIVE ACTION PLAN November 4, 2022 Health Resources and Services Administration Tri-County Community Health Council, Inc. (d/b/a CommWell Health) respectfully submits the following corrective action plan for the year ended March 31, 2022. ____________________________________________________________________________________ CohnReznick LLP 1301 Avenue of the Americas New York, NY 10019 Audit Period: March 31, 2022 The findings from the March 31, 2022 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the number assigned in the schedule. FINDINGS ? FEDERAL AWARDS PROGRAM AUDIT U.S. Department of Health and Human Services, COVID-19 Health Centers Program Cluster (Assistance listing number 93.224/93.527) Finding 2022-001 - Special Tests and Provisions SIGNIFICANT DEFICIENCY Recommendation We recommend that proper training be given to employees at registration to ensure that the sliding fee discounts be monitored and reviewed by a supervisor on a periodic basis to ensure compliance with the sliding fee scale. In addition, management should conduct internal audits to ensure the sliding fee is calculated properly. Action Taken CommWell Health concurs with the recommendation and has designed a series of enhancements to existing registration orientation and ongoing training. Additional training time will be dedicated with current front desk registration colleagues to ensure that they can determine household income from the documentation given to them by patients. This education will be completed by December 31, 2022. New hire orientation training will include a thorough review of the Front Desk Handbook and slide fee procedures. Post-test will be given to each front desk colleague upon completion of education. Scores of at least 90% will required or training and testing will be repeated. In addition, CommWell Health is moving to a new electronic health record (EHR), EPIC, beginning November 7, 2022. This system has much better controls built in to help ensure that slide fee is documented correctly. EPIC also does not have many of the system limitations our previous EHR had. Audits of 100% of slide fee records will be done every day by designated colleagues to ensure slide fee documentation is correct. Supervisors will review daily audit findings and ensure additional training is given accordingly. Corrective action will be taken on any errors noted during audits. Finance staff will conduct random internal audits of slide fee records each month to evaluate for compliance with applicable requirements. Results of internal audits will be reviewed monthly in Utilization Review Committee. If the Health Resources and Services Administration has questions regarding this plan, please call Cheryl Stanley, Chief Financial Officer, at 910-567-7008.
FAC accepted this audit on November 21, 2016 — management decision was due May 21, 2017.
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