EIN: 650063921
UEI: G5JSKMLY6UA9
Audited by: RLMolina, LLC
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 (144 days from today).
What is a management decision? →FAC accepted this audit on August 25, 2025 — management decision was due February 25, 2026.
FAC accepted this audit on September 4, 2024 — management decision was due March 4, 2025.
Lack of effective internal control procedures could result in unintentional errors that may not be detected in a timely manner by employees in the normal course of performing their assigned duties. Questioned Costs: N/A. Recommendation: Management should undergo additional training of its EPIC system to help mitigate potential patient encounter errors. Additionally, a system of quality control should be implemented to allow periodic assessment and transactions reviewed of patient’s encounter and charts to ensure the process is functioning properly. Management’s Views: Management’s response is included in the “Management’s Views and Corrective Action Plan” included at the end of this report after “Section IV – Status of Financial Statements Findings of Prior Audits.”
Show full finding ▾Hide full finding ▴Ineffective Controls Over the Sliding Fee Scale Eligibility Requirements Federal Agency: Department of Health and Human Service Federal Program: Health Center Program Assistance Listing Number: 93:224/93.527 Type of Finding: Significant Deficiency Condition Community Health Concern, Inc. (“CHC”) did not effectively maintain an internal control system over its sliding fee and clinic service eligibility requirements. During the compliance testing of the Uniform Guidance “Special Tests and Provisions – Sliding Fee Applications” requirements, we noted: • Two (2) patient files/charts did not have the required eligibility information, including sliding fee scale assessments, proof of income, general consent, registration form, etc. • A Medicare patient was assessed a sliding fee scale discount for services that should have been charged to Medicare. Possible Asserted Criteria: Per the Uniform Guidance, health centers must prepare and apply a sliding fee discount schedule (SFDS) so that the amounts owed for health center services by eligible patients are adjusted (discounted) based on the patient’s ability to pay. Possible Asserted Cause: Staff’s inability to fully grasp the new medical health system, EPIC is contributing to the internal controls ineffectiveness over the sliding fee scale application and the patient encounter process. Potential Asserted Effect of Condition: Lack of effective internal control procedures could result in unintentional errors that may not be detected in a timely manner by employees in the normal course of performing their assigned duties. Questioned Costs: N/A. Recommendation: Management should undergo additional training of its EPIC system to help mitigate potential patient encounter errors. Additionally, a system of quality control should be implemented to allow periodic assessment and transactions reviewed of patient’s encounter and charts to ensure the process is functioning properly. Management’s Views: Management’s response is included in the “Management’s Views and Corrective Action Plan” included at the end of this report after “Section IV – Status of Financial Statements Findings of Prior Audits.”
Ineffective Controls Over the Sliding Fee Scale Eligibility Requirements Condition Community Health Concern, Inc. (“CHC”) did not effectively maintain an internal control system over its sliding fee and clinic service eligibility requirements. During the compliance testing of the Uniform Guidance “Special Tests and Provisions – Sliding Fee Applications” requirements, we noted: • Two (2) patient files/charts did not have the required eligibility information, including sliding fee scale assessments, proof of income, general consent, registration form, etc. • A Medicare patient was assessed a sliding fee scale discount for services that should have been charged to Medicare. Management’s Views: CHC implemented a new electronic health record (EHR), Epic Platform, in October 2023 to replace its 15-year-old legacy system, Intergy. After one year of extensive training, CHC with the assistance of Health Choice Network (HCN), a Health Center Controlled Network, rollout the Epic Platform, During and post implementation of the new platform, CHC encountered significant challenges in its front desk operations (e.g. eligibility information, including registration form, general consent, proof of income and sliding fee scale assessments), hence, two patients’ charts did not cross over from the old system to the new platform and challenges with our outreach teams’ encounters. Also, a Medicare beneficiary was incorrectly assessed a sliding fee scale discount for services that should have been charged to Medicare. As a result of the audit findings, we have identified several areas for improvements to enhance the effectiveness and efficiency of our front desk and outreach teams processes. Corrective Action Plan: The following corrective action plan outlines the necessary steps to address these areas: 1. Monthly Chart Audit by the Lead Patient Services Representative (Lead PSR): • Checklist to include: o Eligibility verification o Consent to treat o Registration packet o Sliding Fee Application o Self-declaration 2. Utilization of HCN Teams Chat Tool • Leverage the HCN Teams chat for addressing insurance-related questions, such as duplicate commercial plans, to ensure accurate and timely responses. 3. Retraining Low Performing Staff • Low-performing staff will undergo retraining with the Lead PSR and HCN Revenue Cycle Management consultants to enhance their performance and understanding of the processes. 4. Competency Test Development • Develop and implement a competency test for PSRs to ensure all team members possess the required knowledge and skills. 5. Monthly Meetings • Hold monthly meetings between the PSR and Billing teams to share knowledge, address concerns, and promote continuous learning and improvement. 6. Staff Registration Limitation • Limit the number of staff able to register patients. PSRs will take the lead role in registration, with MAs serving as backup when necessary. 7. Creation of Insurance Quick-Guides • Create quick-guides to aid in the selection and verification of insurance, ensuring staff have easy access to essential information. 8. Hard Stops on EPIC workflow • Request hard stops on EPIC for the input of key information to prevent incomplete or incorrect data entry, thereby improving data integrity and patient care. Anticipated Date of Completion: Management has implemented approximately 80% of the strategies described in the Plan above. These corrective actions are designed to address the identified issues and enhance the efficiency and accuracy of the registration and billing processes. Management believes that these measures will also lead to significant improvements in the overall operations and patient satisfaction. Management anticipates the successful completion date for the entire Plan to be no later than August 31st, 2024. Contact Person: For inquiries regarding this finding, please contact Benjo Reyes at BenjoR@CamillusHealth.org who is responsible for the corrective actions.
The Federal government may: • Require the funds to be paid back immediately. • Require the use of a more stringent cash drawdown method for the program. • Potential interest liability may be required. Questioned Costs: $967,117. Recommendation: We recommend that CHC improve its procedures to ensure that Federal cash is requested based on immediate cash needs and within the correct period. Additionally, management should consult with its Project Officer for helpful guidance and/or actions to take during cases of looming uncertainties such as government shutdowns, missing project deadlines, etc. Management’s Views: Management’s response is included inthe “Management’s Views and Corrective Action Plan” included at the end of this report after “Section IV – Status of Financial Statements Findings of Prior Audits.”
Show full finding ▾Hide full finding ▴Ineffective Controls Over the Cash Management Requirement Federal Agency: Department of Health and Human Service Federal Program: Health Center Program Assistance Listing Number: 93:224/93.527 Type of Finding: Significant Deficiency Condition Community Health Concern, Inc. (“CHC”) did not minimize the times between drawdowns and disbursements of Federal funds in accordance with Federal regulations. There were three cash drawdowns made by management that were at least two months (60 days) in advance of actual expenditures or immediate requirement need for payment. Possible Asserted Criteria: In accordance with 2 CFR 200.305 (b), for non-Federal entities other than states, payment methods must minimize the time elapsing between the transfer of funds from the United States Treasury or the pass-through entity and the disbursement by the non-Federal entity whether the payment is made by electronic funds transfer, or issuance or redemption of checks, warrants, or payment by other means. Advance payments to a non-Federal entity must be limited to the minimum amounts needed and be timed to be in accordance with the actual, immediate cash requirements of the non-Federal entity in carrying out the purpose of the approved program or project. Possible Asserted Cause: Management made two (2) early drawdowns to have funds available fearing a government shutdown. An additional early drawdown was made to meet a project deadline. Potential Asserted Effect of Condition: The Federal government may: • Require the funds to be paid back immediately. • Require the use of a more stringent cash drawdown method for the program. • Potential interest liability may be required. Questioned Costs: $967,117. Recommendation: We recommend that CHC improve its procedures to ensure that Federal cash is requested based on immediate cash needs and within the correct period. Additionally, management should consult with its Project Officer for helpful guidance and/or actions to take during cases of looming uncertainties such as government shutdowns, missing project deadlines, etc. Management’s Views: Management’s response is included inthe “Management’s Views and Corrective Action Plan” included at the end of this report after “Section IV – Status of Financial Statements Findings of Prior Audits.”
Ineffective Controls Over the Cash Management Requirement Condition Community Health Concern, Inc. (“CHC”) did not minimize the times between drawdowns and disbursements of Federal funds in accordance with Federal regulations. There were three cash drawdowns made by management that were at least two months (60 days) in advance of actual expenditures or immediate requirement needed for payment. Management’s Views: Management concurs with the audit findings and will implement various steps that will strengthen our internal control processes to mitigate any potential cash drawdown noncompliance in the future. Corrective Action Plan: In response to the Cash Management finding, the following actions will be implemented to ensure compliance with federal grant guidelines and to maintain transparency and accountability, CHC will: 1. Seek HRSA Guidance • In situations that are out of the ordinary or not explicitly covered by existing grant guidelines, the Director of Finance or his/her designee will seek guidance from the Health Resources and Services Administration (HRSA). • This step ensures that all actions taken are compliant with HRSA’s grant guidelines, 2. Consult the External Auditor • For additional guidance and to ensure proper procedure, the Director of Finance or his/her designee will consult with the external auditor. • If HRSA guidance is available, it will be shared with the external auditor to confirm that all steps align with federal requirements and best practices. 3. Continually Communicate and Engage with the Finance Committee and the Board of Directors • Ongoing communication and engagement with the Finance Committee and the Board of Directors will be maintained. • Regular updates will be provided on the status of grant fund requests, drawdowns, and any guidance received from HRSA or the external auditor. • This practice ensures that the Finance Committee and the Board of Directors are fully informed and can provide oversight and support as needed. Anticipated Date of Completion: Management has implemented approximately 85% of the strategies described in the Plan above. Management believes by implementing these actions, the compliance with federal grant guidelines will be enhanced to ensure transparency to the financial operations as well as maintain robust oversight by involving key stakeholders in the process. Management anticipates the successful completion date for the entire Plan to be no later than August 31st, 2024. Contact Person: For inquiries regarding this finding, please contact Benjo Reyes at BenjoR@CamillusHealth.org who is responsible for the corrective actions.
FAC accepted this audit on August 15, 2023 — management decision was due February 15, 2024.
FAC accepted this audit on August 9, 2022 — management decision was due February 9, 2023.
FAC accepted this audit on August 8, 2021 — management decision was due February 8, 2022.
FAC accepted this audit on August 5, 2020 — management decision was due February 5, 2021.
FAC accepted this audit on August 13, 2019 — management decision was due February 13, 2020.
FAC accepted this audit on July 12, 2018 — management decision was due January 12, 2019.
FAC accepted this audit on November 19, 2017 — management decision was due May 19, 2018.
FAC accepted this audit on May 24, 2017 — management decision was due November 24, 2017.
Data source: This information comes from the Federal Audit Clearinghouse, the official repository of Single Audit data. All data is public domain. Verify this organization's audit history at fac.gov.
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