EIN: 640620763
UEI: MF17UELZJ753
Data as of August 27, 2026
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on November 15, 2023. 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 May 15, 2024 (834 days ago).
What is a management decision? →A majority of the board members or their immediate family are not users of the health center services. Compliance conditions state that more than fifty percent of board members should “utilize the health center as their principal source of primary health care” in order for them to give substantive input into the Organization’s strategic direction and policy. Cause: The above exception resulted from the failure to follow established procedures requiring board members or their immediate families to be active users of the health center. Effect: This non-compliance with federal grant requirements could result in a reduction of grant funds or additional grant restrictions. Questioned Costs: None reported Context/Sampling: The finding appears to be a systemic issue. Repeat Finding from Prior Year: No Recommendation: It is recommended that procedures be established to ensure that more than fifty percent of board members are active users of the health center. Views of Responsible Officials: Management concurs with the audit finding. Procedures will be established to ensure that more than 50 percent of the board members are users of the health center. Contact Person: Clifton Rodgers, CEO Anticipated Date of Completion: July 31, 2023
Show full finding ▾Hide full finding ▴Finding: 2023-001-Board Member Compliance Federal Programs: Department of Health and Human Services Health Center Program Cluster CFDA 93.224 and 93.527 Criteria: Health Center Program Compliance Manual Condition: A majority of the board members or their immediate family are not users of the health center services. Compliance conditions state that more than fifty percent of board members should “utilize the health center as their principal source of primary health care” in order for them to give substantive input into the Organization’s strategic direction and policy. Cause: The above exception resulted from the failure to follow established procedures requiring board members or their immediate families to be active users of the health center. Effect: This non-compliance with federal grant requirements could result in a reduction of grant funds or additional grant restrictions. Questioned Costs: None reported Context/Sampling: The finding appears to be a systemic issue. Repeat Finding from Prior Year: No Recommendation: It is recommended that procedures be established to ensure that more than fifty percent of board members are active users of the health center. Views of Responsible Officials: Management concurs with the audit finding. Procedures will be established to ensure that more than 50 percent of the board members are users of the health center. Contact Person: Clifton Rodgers, CEO Anticipated Date of Completion: July 31, 2023
In Finding 2023-001, a condition was noted that a majority of the board members or their immediate family are not users of the health center services. Compliance conditions state that more than fifty percent of board members should “utilize the health center as their principal source of primary health care” in order for them to give substantive input into the Organization’s strategic direction and policy. Management recognizes the importance of complying with board member compliance guidelines. In response to Finding 2023-001, procedures will be established to ensure that more than 50 percent of the board members are users of the health center. This will be completed by the Chief Executive Officer by July 31, 2023.
FAC accepted this audit on August 9, 2021 — management decision was due February 9, 2022.
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 discounts for 5 patients out of a sample of 20 patients for the year ended March 31, 2021. Cause: There were deficiencies in internal controls to ensure that proper documentation was obtained and that proper sliding fee discounts were applied to patient accounts in accordance with the Organization?s sliding fee scale. The sliding fee scale file was not properly utilized in the application of discounts provided to patients. Effect: Discounts were not properly applied to patient accounts. Questioned Costs: None reported Context/Sampling: For 5 of 20 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 the 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: Dee Miller, CFO Anticipated Date of Completion: July 31, 2021
Show full finding ▾Hide full finding ▴Finding: 2021-001 Sliding Fee Discounts Federal Programs: Department of Health and Human Services Health Center Program Cluster CFDA 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 discounts for 5 patients out of a sample of 20 patients for the year ended March 31, 2021. Cause: There were deficiencies in internal controls to ensure that proper documentation was obtained and that proper sliding fee discounts were applied to patient accounts in accordance with the Organization?s sliding fee scale. The sliding fee scale file was not properly utilized in the application of discounts provided to patients. Effect: Discounts were not properly applied to patient accounts. Questioned Costs: None reported Context/Sampling: For 5 of 20 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 the 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: Dee Miller, CFO Anticipated Date of Completion: July 31, 2021
In Finding 2021-001, 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 March 31, 2021. It was also reported that discounts were provided to certain patients for which the Organization could not locate sliding fee applications. Management recognizes the importance of complying with sliding fee guidelines. In response to Finding 2021-001, proper training will be given to employees and sliding fee discounts will be reviewed by a supervisor on a periodic basis the ensure compliance with the sliding fee scale. This will be implemented by the Chief Executive Officer by July 31, 2021.
The Organization?s procurement policies were not updated to conform to applicable standards under the Uniform Guidance, and the Organization did not verify that certain employees 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 that procurement policies were updated to conform to the requirements identified in the Uniform Guidance, and 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. In addition, the Organization did not verify that certain employees 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: It is recommended that the Organization update its procurement policies to conform to the requirements identified in Uniform Guidance, and that procedures are established to ensure that the debarment policy is followed. 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. The Organization will also establish procedures to ensure that debarment searches are completed to verify that employees subject to debarment requirements are not suspended, debarred, or otherwise excluded from participating in Federal programs before the Organization enters into transactions with them. Contact Person: Dee Miller, CFO Anticipated Date of Completion: July 31, 2021
Show full finding ▾Hide full finding ▴Finding: 2021-002 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: The Organization?s procurement policies were not updated to conform to applicable standards under the Uniform Guidance, and the Organization did not verify that certain employees 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 that procurement policies were updated to conform to the requirements identified in the Uniform Guidance, and 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. In addition, the Organization did not verify that certain employees 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: It is recommended that the Organization update its procurement policies to conform to the requirements identified in Uniform Guidance, and that procedures are established to ensure that the debarment policy is followed. 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. The Organization will also establish procedures to ensure that debarment searches are completed to verify that employees subject to debarment requirements are not suspended, debarred, or otherwise excluded from participating in Federal programs before the Organization enters into transactions with them. Contact Person: Dee Miller, CFO Anticipated Date of Completion: July 31, 2021
In Finding 2021-002, 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 2021-002, policies and controls that were previously designed will be implemented to verify that employees are not suspended or debarred or otherwise excluded from participating in Federal programs before entering into transactions with the employee. This review will be performed by the Chief Financial Officer and completed by July 31, 2021
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