EIN: 621583270
UEI: N5RNGYND27N5
Data as of August 27, 2026
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on March 2, 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 September 2, 2026 (6 days from today).
What is a management decision? →Through testing a statistically valid sample of 25 individual patient balances, we noted one instance in which the sliding fee discount applied was inconsistent with the Organization’s policy. Based on income and family size, the patient received a discount of $262 but qualified for a discount of $302, resulting in a $40 difference. Cause: The billing system was not properly configured to ensure all eligible services were included within the sliding fee discount logic. In addition, the Organization does not currently have a formal monitoring process or policy to ensure discounts are applied correctly to patient balances, which increases the risk that errors may occur and go undetected. Effect: It is possible that sliding fee discounts may not be applied consistently across all patient accounts, and errors may not be identified and corrected in a timely manner, which could result in noncompliance with the Organization’s sliding fee discount program and federal program requirements. Questioned Costs: None Repeat Finding: No Recommendation: The Organization should establish a formal procedure to monitor compliance with its sliding fee discount program. The procedure should assign responsibility for reviewing applied discounts, define the frequency and sample size of reviews, and include consideration for differences between the Medical and Dental systems, with a larger or more frequent sample for Dental due to higher manual processing and volume. The procedure should also include steps to document and correct any errors identified and require supervisory oversight to verify that reviews are performed consistently. Implementing this procedure will help ensure discounts are applied accurately and in accordance with the Organization’s policy and federal requirements. Views of a Responsible Official and Corrective Action Plan: Management agrees with the finding and will develop and implement the recommendations above.
Show full finding ▾Hide full finding ▴Finding Number: 2025 001 Finding Type: Significant Deficiency in Internal Controls Over Compliance related to Special Tests and Provisions Information on the Federal Program: Program Name: Health Center Program Cluster (AL numbers 93.224 and 93.527) Grant Award: 5 H80CS00881-22 from May 1, 2024 through April 30, 2025 and 5 H80CS00881-23 from May 1, 2025 through April 30, 2026 Agency: U.S. Department of Health and Human Services, Health Resources and Services Administration Pass-Through Entity: N/A Criteria: In accordance with Section 330(k)(3)(G) of the Public Health Services Act (42 U.S. Code § 254b), as an FQHC, the Organization must have a sliding fee discount program in which patient charges are adjusted based on the patient’s ability to pay. Condition: Through testing a statistically valid sample of 25 individual patient balances, we noted one instance in which the sliding fee discount applied was inconsistent with the Organization’s policy. Based on income and family size, the patient received a discount of $262 but qualified for a discount of $302, resulting in a $40 difference. Cause: The billing system was not properly configured to ensure all eligible services were included within the sliding fee discount logic. In addition, the Organization does not currently have a formal monitoring process or policy to ensure discounts are applied correctly to patient balances, which increases the risk that errors may occur and go undetected. Effect: It is possible that sliding fee discounts may not be applied consistently across all patient accounts, and errors may not be identified and corrected in a timely manner, which could result in noncompliance with the Organization’s sliding fee discount program and federal program requirements. Questioned Costs: None Repeat Finding: No Recommendation: The Organization should establish a formal procedure to monitor compliance with its sliding fee discount program. The procedure should assign responsibility for reviewing applied discounts, define the frequency and sample size of reviews, and include consideration for differences between the Medical and Dental systems, with a larger or more frequent sample for Dental due to higher manual processing and volume. The procedure should also include steps to document and correct any errors identified and require supervisory oversight to verify that reviews are performed consistently. Implementing this procedure will help ensure discounts are applied accurately and in accordance with the Organization’s policy and federal requirements. Views of a Responsible Official and Corrective Action Plan: Management agrees with the finding and will develop and implement the recommendations above.
Finding: 2025-001 Condition Found: The Organization has not applied sliding fee discounts to patient charges consistent with its sliding fee discount program. Individual(s) Responsible for Corrective Action: Frackson Salak, CFO Planned Corrective Action: Christ Community Health Services will perform monthly audits on patients who receive a sliding fee discount. The monthly audits will include verifying the correct fee was applied based on documents received during the patients sliding fee enrollment. If any errors are found they will be immediately corrected. Anticipated Completion Date: 06/30/2026
FAC accepted this audit on August 2, 2024 — management decision was due February 2, 2025.
Health Center Program Cluster – Assistance Listing Nos. 93.224 and 93.527 U.S. Department of Health and Human Services Award No. 2 H80CS00881-21 and 1 H8FCS41120-01 Program Year 2023 Criteria or Specific Requirement – Reporting – 45 CFR 75.342 Condition – The Organization is required to prepare and submit an annual Uniform Data System (UDS) for each calendar year and an annual Federal Financial Report (FFR) for each grant year. These reports are to be prepared using accurate financial information. Questioned cost – 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 nineteen inputs tested, one exceptions were noted related to the annual UDS report. Effect – Potential errors were made on the annual UDS 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, if applicable – Not a repeat finding. Recommendation – The Organization should review its policy over federal reporting and ensure proper staff education on the policy is established to ensure reports are prepared using accurate information and that supporting documentation for federal grant reports is maintained. In addition, the Organization should review the policy on an annual basis to ensure it is consistent with Uniform Guidance. Views of Responsible Officials and Planned Corrective Actions – Management will ensure the Grants Management Policy within the Finance Department will be adhered to when doing all external reporting. To ensure this is followed the additional protocol will be put into place: -All reporting involving federal reporting will be reviewed and approved by the CFO with supporting documentation to ensure accuracy of the report. -Staff preparing reports that contain federal grant data will participate in training to ensure reports are prepared accurately and in accordance with Uniform Guidance. The interim CFO, Jessica Hughes, is responsible for this corrective action plan. Implementaiton of the items are expected to be completed by December 31, 2024 before the next reporting cycle of the annual UDS report.
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. 2 H80CS00881-21 and 1 H8FCS41120-01 Program Year 2023 Criteria or Specific Requirement – Reporting – 45 CFR 75.342 Condition – The Organization is required to prepare and submit an annual Uniform Data System (UDS) for each calendar year and an annual Federal Financial Report (FFR) for each grant year. These reports are to be prepared using accurate financial information. Questioned cost – 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 nineteen inputs tested, one exceptions were noted related to the annual UDS report. Effect – Potential errors were made on the annual UDS 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, if applicable – Not a repeat finding. Recommendation – The Organization should review its policy over federal reporting and ensure proper staff education on the policy is established to ensure reports are prepared using accurate information and that supporting documentation for federal grant reports is maintained. In addition, the Organization should review the policy on an annual basis to ensure it is consistent with Uniform Guidance. Views of Responsible Officials and Planned Corrective Actions – Management will ensure the Grants Management Policy within the Finance Department will be adhered to when doing all external reporting. To ensure this is followed the additional protocol will be put into place: -All reporting involving federal reporting will be reviewed and approved by the CFO with supporting documentation to ensure accuracy of the report. -Staff preparing reports that contain federal grant data will participate in training to ensure reports are prepared accurately and in accordance with Uniform Guidance. The interim CFO, Jessica Hughes, is responsible for this corrective action plan. Implementaiton of the items are expected to be completed by December 31, 2024 before the next reporting cycle of the annual UDS report.
Audit Finding Reference Number 2023-002 Criteria or Specific Requirement – Reporting – 45 CFR 75.342 Condition – The Organization is required to prepare and submit an annual Uniform Data System (UDS) for each calendar year and an annual Federal Financial Report (FFR) for each grant year. These reports are to be prepared using accurate financial information. Questioned cost – 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 nineteen inputs tested, one exceptions were noted related to the annual UDS report. Effect – Potential errors were made on the annual UDS 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, if applicable – Not a repeat finding. Recommendation – The Organization should review its policy over federal reporting and ensure proper staff education on the policy is established to ensure reports are prepared using accurate information and that supporting documentation for federal grant reports is maintained. In addition, the Organization should review the policy on an annual basis to ensure it is consistent with Uniform Guidance. Views of Responsible Officials and Planned Corrective Actions – Management will ensure the Grants Management Policy within the Finance Department will be adhered to when doing all external reporting. To ensure this is followed the additional protocol will be put into place: -All reporting involving federal reporting will be reviewed and approved by the CFO with supporting documentation to ensure accuracy of the report. -Staff preparing reports that contain federal grant data will participate in training to ensure reports are prepared accurately and in accordance with Uniform Guidance. The interim CFO, Jessica Hughes, is responsible for this corrective action plan. Implementaiton of the items are expected to be completed by December 31, 2024 before the next reporting cycle of the annual UDS report.
FAC accepted this audit on April 20, 2023 — management decision was due October 20, 2023.
Health Center Program Cluster ? Assistance Listing Nos. 93.224 and 93.527 U.S. Department of Health and Human Services Award No. 6 H80CS00881-20 and 1 H8FCS41120-01 Program Year 2022 Criteria or Specific Requirement ? Procurement ? 45 CFR 75.329 Condition ? The Organization did not maintain documentation supporting procurement requirements for the purchase of goods or services charged to federal awards. Questioned cost ? None Context ? Documentation was not originally maintained by the Organization to support that proper procurement procedures in accordance with the Organization?s policy were followed related to vendor selection. Documentation was later compiled in response to audit inquiries. Effect ? The Organization did not have documentation supporting the procurement activities completed. Cause ? The Organization was not properly following the documentation requirements of 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. Views of Responsible Officials and Planned Corrective Actions ? ? Vice President of Support Services was hired to lead the procurement process. ? The Procurement Department implemented the use of bids, as they foster competition whenever feasible. All procurement is conducted in a competitive manner with open access to acceptable suppliers. ? The VP of Support Services oversees the procurement policy and will ensure future adherence. The CFO, Talia Peterson, and VP of Support Services, Susan Banning, are responsible for this corrective action plan. Implementation of the above items have already begun and will be completed by August 2023.
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 H80CS00881-20 and 1 H8FCS41120-01 Program Year 2022 Criteria or Specific Requirement ? Procurement ? 45 CFR 75.329 Condition ? The Organization did not maintain documentation supporting procurement requirements for the purchase of goods or services charged to federal awards. Questioned cost ? None Context ? Documentation was not originally maintained by the Organization to support that proper procurement procedures in accordance with the Organization?s policy were followed related to vendor selection. Documentation was later compiled in response to audit inquiries. Effect ? The Organization did not have documentation supporting the procurement activities completed. Cause ? The Organization was not properly following the documentation requirements of 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. Views of Responsible Officials and Planned Corrective Actions ? ? Vice President of Support Services was hired to lead the procurement process. ? The Procurement Department implemented the use of bids, as they foster competition whenever feasible. All procurement is conducted in a competitive manner with open access to acceptable suppliers. ? The VP of Support Services oversees the procurement policy and will ensure future adherence. The CFO, Talia Peterson, and VP of Support Services, Susan Banning, are responsible for this corrective action plan. Implementation of the above items have already begun and will be completed by August 2023.
Views of Responsible Officials and Planned Corrective Actions ? ? Vice President of Support Services was hired to lead the procurement process. ? The Procurement Department implemented the use of bids, as they foster competition whenever feasible. All procurement is conducted in a competitive manner with open access to acceptable suppliers. ? The VP of Support Services oversees the procurement policy and will ensure future adherence. The CFO, Talia Peterson, and VP of Support Services, Susan Banning, are responsible for this corrective action plan. Implementation of the above items have already begun and will be completed by August 2023.
FAC accepted this audit on November 19, 2019 — management decision was due May 19, 2020.
Health Center Program Cluster CFDA Nos. 93.224 and 93.527 U.S. Department of Health and Human Services Award No. 6 H80CS00881-17-00 Program Year 2020 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 the grant budget period. This report is to be prepared using accurate financial information and submitted by the deadline established in the grant award. Questioned costs ? None Context ? A sample of 19 reporting attributes were tested out of the total population of 28 reporting attributes. The sampling methodology used is not and is not intended to be statistically valid. Program income earned, program income expended, and unexpended program income reported on the FFR were not calculated accurately. The FFR was not filed prior to the deadline. Effect ? Potential errors were made on the annual FFR and the FFR was not filed timely. Cause ? The Organization?s policies and procedures in effect at June 30, 2019, did not address how to properly calculate program income earned and program income expended on the FFR. The electronic alerts of the reporting deadline were not effective at ensuring required reporting was completed timely. Identification as a repeat finding ? Repeat finding ? Finding 2018-004 Recommendation ? Policies and procedures over federal grant reporting should be modified to address how to accurately calculate program income earned and program income expended, to ensure reports are prepared using accurate information and reviewed prior to submission, and filed prior to deadlines.
Show full finding ▾Hide full finding ▴Health Center Program Cluster CFDA Nos. 93.224 and 93.527 U.S. Department of Health and Human Services Award No. 6 H80CS00881-17-00 Program Year 2020 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 the grant budget period. This report is to be prepared using accurate financial information and submitted by the deadline established in the grant award. Questioned costs ? None Context ? A sample of 19 reporting attributes were tested out of the total population of 28 reporting attributes. The sampling methodology used is not and is not intended to be statistically valid. Program income earned, program income expended, and unexpended program income reported on the FFR were not calculated accurately. The FFR was not filed prior to the deadline. Effect ? Potential errors were made on the annual FFR and the FFR was not filed timely. Cause ? The Organization?s policies and procedures in effect at June 30, 2019, did not address how to properly calculate program income earned and program income expended on the FFR. The electronic alerts of the reporting deadline were not effective at ensuring required reporting was completed timely. Identification as a repeat finding ? Repeat finding ? Finding 2018-004 Recommendation ? Policies and procedures over federal grant reporting should be modified to address how to accurately calculate program income earned and program income expended, to ensure reports are prepared using accurate information and reviewed prior to submission, and filed prior to deadlines.
Policies and Procedures for federal grant reporting will be reviewed and updated as necessary to ensure the accurate calculation of program income earned and program income expended, to ensure reports are prepared using accurate information and reviewed prior to submission, and filed prior to deadlines. This will include appropriate tracking of upcoming deadlines. The CFO is responsible for this corrective action plan. The above items will be implemented by April 30, 2020.
2018-004
FAC accepted this audit on December 20, 2018 — management decision was due June 20, 2019.
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