EIN: 660585077
UEI: U5AMQ7MF83B1
Audited by: Smart Solutions CPA, Inc
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 November 29, 2025. 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 29, 2026 (92 days ago).
What is a management decision? →The Organization has charged late fees on rent and finance charges on unpaid rent to the federal award. These cost items totaled $157,710, which were charged to the federal program as allowable expenditures. Under Uniform Guidance, these types of charges are unallowable. Criteria: Costs charged to federal awards must be necessary, reasonable, and allowable under applicable cost principles. Late fees on rent, finance charges on unpaid rent, and other penalties for late payment are not allowable and should not be charged to federal programs in accordance with the provisions of Uniform guidance. Cause: The Organization did not have adequate procedures to prevent unallowable late-payment- related charges from being recorded to federal programs. Effect: The Organization charged unallowable costs totaling $157,710 to the federal award. These costs do not meet Uniform Guidance Allowable Cost/Cost Principles and accordingly a refund liability has been recognized by the Organization to Department for the said amount. Recommendation: The Organization should strengthen internal controls so that late fees, finance charges, and penalties are identified and excluded from federal expenditures, provide training to accounting staff on allowable and unallowable costs, and enhance the review of expense coding before charges are allocated to federal programs. Management views and corrective action plans: Management will enhance the review of expense coding before posting charges to federal awards, update the written procedures to clearly identify unallowable cost categories, provide refresher training to finance staff on allowable versus unallowable costs, and perform periodic reviews of expenditures to ensure that any such costs are promptly identified and corrected.
Show full finding ▾Hide full finding ▴Non-compliance with Allowable Cost/Cost principle Condition: The Organization has charged late fees on rent and finance charges on unpaid rent to the federal award. These cost items totaled $157,710, which were charged to the federal program as allowable expenditures. Under Uniform Guidance, these types of charges are unallowable. Criteria: Costs charged to federal awards must be necessary, reasonable, and allowable under applicable cost principles. Late fees on rent, finance charges on unpaid rent, and other penalties for late payment are not allowable and should not be charged to federal programs in accordance with the provisions of Uniform guidance. Cause: The Organization did not have adequate procedures to prevent unallowable late-payment- related charges from being recorded to federal programs. Effect: The Organization charged unallowable costs totaling $157,710 to the federal award. These costs do not meet Uniform Guidance Allowable Cost/Cost Principles and accordingly a refund liability has been recognized by the Organization to Department for the said amount. Recommendation: The Organization should strengthen internal controls so that late fees, finance charges, and penalties are identified and excluded from federal expenditures, provide training to accounting staff on allowable and unallowable costs, and enhance the review of expense coding before charges are allocated to federal programs. Management views and corrective action plans: Management will enhance the review of expense coding before posting charges to federal awards, update the written procedures to clearly identify unallowable cost categories, provide refresher training to finance staff on allowable versus unallowable costs, and perform periodic reviews of expenditures to ensure that any such costs are promptly identified and corrected.
Non-compliance with Allowable Cost/Cost principle: Recommendation: The Organization should strengthen internal control so that late fees, finance charges, and penalties are identified and excluded from federal expenditures, provide training to accounting staff on allowable and unallowable costs, and enhance the review expense coding before charges are allocated to federal programs. Planned corrective action: The Organization wil strengthen our internal controls by implementing clear procedures, increasing oversight by management, and ensuring consistent compliance with financial and operational requirements. Enhanced review processes, staff training, and improved documentation standards will support greater accuracy, transparency, and accountability accross all functions. The business office staff will review targeted training on allowable and unallowable costs to reinforce compliance with federal cost principles. In addition,the Organization will enhance its review process to verify accuracy and compliance before any charges are allocated to federal programs. Contact person responsible for corrective action: Steven Mayers Anticipated completion date: May 30, 2026 Status of Implementation: In progress
Certain expenses included in the Health Center Program (HCP) included amounts that were unallowable under Uniform Guidance allowable cost and compliance requirements. Specifically, these expenses included late fees on rent and finance charges on unpaid rent totaling $8,851. Criteria: Costs included in a federal award must be necessary, reasonable, and allowable under the applicable cost principles. Late fees on rent, finance charges on unpaid rent, and other penalties for late payment are not allowable and should not be included in federal programs in accordance with the provisions of Uniform Guidance. Cause: The inclusion of late fees and finance charges in HCP expenditures appears to have resulted from limitations in the expense coding and review processes, including insufficient procedures to identify and exclude unallowable costs related to late payments before they were included in the federal award. Effect: As a result, unallowable costs totaling $8,851 were included in the Health Center Program federal award. These expenditures do not meet Uniform Guidance allowable cost principles, and accordingly, a refund liability in the amount of $8,851 has been recognized by the Organization as payable to the Department. Recommendation: We recommend that the Organization strengthen its internal controls over the coding, approval, and review of expenditures included in the Health Center Program to ensure compliance with Uniform Guidance allowable cost principles, including establishing procedures to systematically identify and exclude late fees, finance charges, and other penalty-type costs from federal awards, and providing training to finance and program staff on allowable versus unallowable costs. Management views and corrective action plans: Management will update policies and procedures and the chart of accounts to clearly identify and prevent late fees, finance charges, and similar unallowable costs from being included in the Health Center Program, provide additional training to relevant finance and program personnel on Uniform Guidance allowable cost requirements, and implement enhanced review and periodic monitoring of HCP expenditures to ensure that only allowable costs are included in the federal award and that any exceptions are identified and corrected in a timely manner.
Show full finding ▾Hide full finding ▴2025 - 01 Non-compliance with Allowable Cost/Cost principle Condition: Certain expenses included in the Health Center Program (HCP) included amounts that were unallowable under Uniform Guidance allowable cost and compliance requirements. Specifically, these expenses included late fees on rent and finance charges on unpaid rent totaling $8,851. Criteria: Costs included in a federal award must be necessary, reasonable, and allowable under the applicable cost principles. Late fees on rent, finance charges on unpaid rent, and other penalties for late payment are not allowable and should not be included in federal programs in accordance with the provisions of Uniform Guidance. Cause: The inclusion of late fees and finance charges in HCP expenditures appears to have resulted from limitations in the expense coding and review processes, including insufficient procedures to identify and exclude unallowable costs related to late payments before they were included in the federal award. Effect: As a result, unallowable costs totaling $8,851 were included in the Health Center Program federal award. These expenditures do not meet Uniform Guidance allowable cost principles, and accordingly, a refund liability in the amount of $8,851 has been recognized by the Organization as payable to the Department. Recommendation: We recommend that the Organization strengthen its internal controls over the coding, approval, and review of expenditures included in the Health Center Program to ensure compliance with Uniform Guidance allowable cost principles, including establishing procedures to systematically identify and exclude late fees, finance charges, and other penalty-type costs from federal awards, and providing training to finance and program staff on allowable versus unallowable costs. Management views and corrective action plans: Management will update policies and procedures and the chart of accounts to clearly identify and prevent late fees, finance charges, and similar unallowable costs from being included in the Health Center Program, provide additional training to relevant finance and program personnel on Uniform Guidance allowable cost requirements, and implement enhanced review and periodic monitoring of HCP expenditures to ensure that only allowable costs are included in the federal award and that any exceptions are identified and corrected in a timely manner.
Non-compliance with Allowable Cost/Cost principle: a) Recommendation: We recommend that the Organization strengthen its internal controls over the coding, approval, and review of expenditures included in the Health Center Program to ensure compliance with Uniform Guidance allowable cost principles, including establishing procedures to systematically identify and exclude late fees, finance charges, and other penalty-type costs from federal awards, and providing training to finance and program staff on allowable versus unallowable costs. b) Planned corrective action: Agreed. Invoices are to be coded appropriately to ensure properassignment to grants. This exercise will include assigning late fees and other non-allowable expenses to general funds. c) Contact person responsible for corrective action: Steven Mayers d) Anticipated completion date: Implemented immediately, 6/10/2026 e) Status of implementation: Implemented.
FAC accepted this audit on June 15, 2026 — management decision was due December 15, 2026.
The Organization has charged late fees on rent and finance charges on unpaid rent to the federal award. These cost items totaled $157,710, which were charged to the federal program as allowable expenditures. Under Uniform Guidance, these types of charges are unallowable. Criteria: Costs charged to federal awards must be necessary, reasonable, and allowable under applicable cost principles. Late fees on rent, finance charges on unpaid rent, and other penalties for late payment are not allowable and should not be charged to federal programs in accordance with the provisions of Uniform guidance. Cause: The Organization did not have adequate procedures to prevent unallowable late-payment- related charges from being recorded to federal programs. Effect: The Organization charged unallowable costs totaling $157,710 to the federal award. These costs do not meet Uniform Guidance Allowable Cost/Cost Principles and accordingly a refund liability has been recognized by the Organization to Department for the said amount. Recommendation: The Organization should strengthen internal controls so that late fees, finance charges, and penalties are identified and excluded from federal expenditures, provide training to accounting staff on allowable and unallowable costs, and enhance the review of expense coding before charges are allocated to federal programs. Management views and corrective action plans: Management will enhance the review of expense coding before posting charges to federal awards, update the written procedures to clearly identify unallowable cost categories, provide refresher training to finance staff on allowable versus unallowable costs, and perform periodic reviews of expenditures to ensure that any such costs are promptly identified and corrected.
Show full finding ▾Hide full finding ▴Non-compliance with Allowable Cost/Cost principle Condition: The Organization has charged late fees on rent and finance charges on unpaid rent to the federal award. These cost items totaled $157,710, which were charged to the federal program as allowable expenditures. Under Uniform Guidance, these types of charges are unallowable. Criteria: Costs charged to federal awards must be necessary, reasonable, and allowable under applicable cost principles. Late fees on rent, finance charges on unpaid rent, and other penalties for late payment are not allowable and should not be charged to federal programs in accordance with the provisions of Uniform guidance. Cause: The Organization did not have adequate procedures to prevent unallowable late-payment- related charges from being recorded to federal programs. Effect: The Organization charged unallowable costs totaling $157,710 to the federal award. These costs do not meet Uniform Guidance Allowable Cost/Cost Principles and accordingly a refund liability has been recognized by the Organization to Department for the said amount. Recommendation: The Organization should strengthen internal controls so that late fees, finance charges, and penalties are identified and excluded from federal expenditures, provide training to accounting staff on allowable and unallowable costs, and enhance the review of expense coding before charges are allocated to federal programs. Management views and corrective action plans: Management will enhance the review of expense coding before posting charges to federal awards, update the written procedures to clearly identify unallowable cost categories, provide refresher training to finance staff on allowable versus unallowable costs, and perform periodic reviews of expenditures to ensure that any such costs are promptly identified and corrected.
Non-compliance with Allowable Cost/Cost principle: Recommendation: The Organization should strengthen internal control so that late fees, finance charges, and penalties are identified and excluded from federal expenditures, provide training to accounting staff on allowable and unallowable costs, and enhance the review expense coding before charges are allocated to federal programs. Planned corrective action: The Organization wil strengthen our internal controls by implementing clear procedures, increasing oversight by management, and ensuring consistent compliance with financial and operational requirements. Enhanced review processes, staff training, and improved documentation standards will support greater accuracy, transparency, and accountability accross all functions. The business office staff will review targeted training on allowable and unallowable costs to reinforce compliance with federal cost principles. In addition,the Organization will enhance its review process to verify accuracy and compliance before any charges are allocated to federal programs. Contact person responsible for corrective action: Steven Mayers Anticipated completion date: May 30, 2026 Status of Implementation: In progress
Certain expenses included in the Health Center Program (HCP) included amounts that were unallowable under Uniform Guidance allowable cost and compliance requirements. Specifically, these expenses included late fees on rent and finance charges on unpaid rent totaling $8,851. Criteria: Costs included in a federal award must be necessary, reasonable, and allowable under the applicable cost principles. Late fees on rent, finance charges on unpaid rent, and other penalties for late payment are not allowable and should not be included in federal programs in accordance with the provisions of Uniform Guidance. Cause: The inclusion of late fees and finance charges in HCP expenditures appears to have resulted from limitations in the expense coding and review processes, including insufficient procedures to identify and exclude unallowable costs related to late payments before they were included in the federal award. Effect: As a result, unallowable costs totaling $8,851 were included in the Health Center Program federal award. These expenditures do not meet Uniform Guidance allowable cost principles, and accordingly, a refund liability in the amount of $8,851 has been recognized by the Organization as payable to the Department. Recommendation: We recommend that the Organization strengthen its internal controls over the coding, approval, and review of expenditures included in the Health Center Program to ensure compliance with Uniform Guidance allowable cost principles, including establishing procedures to systematically identify and exclude late fees, finance charges, and other penalty-type costs from federal awards, and providing training to finance and program staff on allowable versus unallowable costs. Management views and corrective action plans: Management will update policies and procedures and the chart of accounts to clearly identify and prevent late fees, finance charges, and similar unallowable costs from being included in the Health Center Program, provide additional training to relevant finance and program personnel on Uniform Guidance allowable cost requirements, and implement enhanced review and periodic monitoring of HCP expenditures to ensure that only allowable costs are included in the federal award and that any exceptions are identified and corrected in a timely manner.
Show full finding ▾Hide full finding ▴2025 - 01 Non-compliance with Allowable Cost/Cost principle Condition: Certain expenses included in the Health Center Program (HCP) included amounts that were unallowable under Uniform Guidance allowable cost and compliance requirements. Specifically, these expenses included late fees on rent and finance charges on unpaid rent totaling $8,851. Criteria: Costs included in a federal award must be necessary, reasonable, and allowable under the applicable cost principles. Late fees on rent, finance charges on unpaid rent, and other penalties for late payment are not allowable and should not be included in federal programs in accordance with the provisions of Uniform Guidance. Cause: The inclusion of late fees and finance charges in HCP expenditures appears to have resulted from limitations in the expense coding and review processes, including insufficient procedures to identify and exclude unallowable costs related to late payments before they were included in the federal award. Effect: As a result, unallowable costs totaling $8,851 were included in the Health Center Program federal award. These expenditures do not meet Uniform Guidance allowable cost principles, and accordingly, a refund liability in the amount of $8,851 has been recognized by the Organization as payable to the Department. Recommendation: We recommend that the Organization strengthen its internal controls over the coding, approval, and review of expenditures included in the Health Center Program to ensure compliance with Uniform Guidance allowable cost principles, including establishing procedures to systematically identify and exclude late fees, finance charges, and other penalty-type costs from federal awards, and providing training to finance and program staff on allowable versus unallowable costs. Management views and corrective action plans: Management will update policies and procedures and the chart of accounts to clearly identify and prevent late fees, finance charges, and similar unallowable costs from being included in the Health Center Program, provide additional training to relevant finance and program personnel on Uniform Guidance allowable cost requirements, and implement enhanced review and periodic monitoring of HCP expenditures to ensure that only allowable costs are included in the federal award and that any exceptions are identified and corrected in a timely manner.
Non-compliance with Allowable Cost/Cost principle: a) Recommendation: We recommend that the Organization strengthen its internal controls over the coding, approval, and review of expenditures included in the Health Center Program to ensure compliance with Uniform Guidance allowable cost principles, including establishing procedures to systematically identify and exclude late fees, finance charges, and other penalty-type costs from federal awards, and providing training to finance and program staff on allowable versus unallowable costs. b) Planned corrective action: Agreed. Invoices are to be coded appropriately to ensure properassignment to grants. This exercise will include assigning late fees and other non-allowable expenses to general funds. c) Contact person responsible for corrective action: Steven Mayers d) Anticipated completion date: Implemented immediately, 6/10/2026 e) Status of implementation: Implemented.
FAC accepted this audit on April 3, 2025 — management decision was due October 3, 2025.
FAC accepted this audit on April 3, 2025 — management decision was due October 3, 2025.
FAC accepted this audit on May 7, 2023 — management decision was due November 7, 2023.
Item 2022-003 - 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 certain patients selected for testing based on the sliding fee scale in effect for the year ended February 28, 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 the sixty patients selected for testing based on the sliding fee scale in effect for the year ended February 28, 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 February 28, 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 a repeat finding - see 2021-003. 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 scale is calculated properly. Views of Responsible Official The Center concurs with this finding and will ensure that controls are established to ensure proper training and review of the sliding fee discounts.
Show full finding ▾Hide full finding ▴Item 2022-003 - 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 certain patients selected for testing based on the sliding fee scale in effect for the year ended February 28, 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 the sixty patients selected for testing based on the sliding fee scale in effect for the year ended February 28, 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 February 28, 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 a repeat finding - see 2021-003. 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 scale is calculated properly. Views of Responsible Official The Center concurs with this finding and will ensure that controls are established to ensure proper training and review of the sliding fee discounts.
CORRECTIVE ACTION PLAN March 27, 2023 Health Resources and Services Administration St. Thomas East End Medical Center Corporation and Affiliate respectfully submits the following corrective action plan for the year ended February 28, 2022. ____________________________________________________________________________________ CohnReznick LLP 1301 Avenue of the Americas New York, NY 10019 Audit Period: February 28, 2022 The findings from the February 28, 2022 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the number assigned in the schedule. FINDINGS ? FINANCIAL STATEMENT AUDIT Finding 2022-001 ? Pension MATERIAL WEAKNESS Recommendation We recommend that the Center implement policies and procedures that allow for the timely payments of the pension plan payments. Action Taken & Completion Date The Center is working hard to make sure that all pension payments are made on time by strengthening our controls to ensure that the pension payments process is monitored properly. Completion Date October 1, 2023 Finding 2022-002 ? Account Analyses MATERIAL WEAKNESS Recommendation We recommend that the Center ensure that all accounting records are analyzed and reconciled on a monthly basis. Action Taken & Completion Date Management is working with staff to ensure that all accounting records are reviewed, analyzed and reconciled on a monthly basis. A new Chief Financial Officer started working at the Center on April 3, 2023. We are in the process of working together to create tighter protocols within the financial department. COMPLETEION DATE: October 1, 2023 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 2022-003 ? Special Tests and Provisions MATERIAL WEAKNESS 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 scale is calculated properly. Action Taken St. Thomas East End Medical Center has already provided some training to staff regarding the Sliding Fee Discount Program and is in the process of developing a training area within the Business Office to ensure the staff is appropriately trained regarding the scale. We are also creating new processes for quality improvement and compliance. Completion Date October 1, 2023 Finding 2022-004 ? Reporting MATERIAL WEAKNESS Recommendation We recommend that the Center establish controls to ensure all accounting records are analyzed and proper support is available in order to ensure that the financial statement audit is submitted on a timely basis to the federal government. Action Taken & Completion Date St. Thomas East End Medical Center is currently onboarding new leadership. As a part of this change, we are working diligently to ensure that the Business Office is restructured, to include development of quality controls, appropriate processes and procedures surrounding analysis and reconciliation of accounts. We are also working with team to ensure that all reporting is done on time. Completion October 1, 2023 If the Health Resources and Services Administration has questions regarding this plan, please call Tess G. Richards, M.D. Interim Executive Director at 340-775-3700, ext. 3023. Sincerely yours,
2021-003
Item 2022-004 - Reporting U.S. Department of Health and Human Services, COVID-19 Health Center Program Cluster (Assistance Listing Number 93.224/93.527) Criteria In accordance with the Uniform Guidance, annual audit reports of recipients of federal funds are required to be submitted to the Federal Audit Clearing House, within the earlier of 30 days after the receipt of the audit report or 9 months after the end of the audit period. Statement of Condition The Center did not submit their annual audit in accordance with the Uniform Guidance on a timely basis. Questioned Costs None Context The Center did not submit their annual audit on a timely basis. Cause Due to turnover in the financial leadership position, the Center's finance department was not able to perform detailed review of accounts and adjust books accordingly, which delayed the filing of the annual audit report. Effect The Center did not comply with the appropriate rules and regulations as per the Uniform Guidance. Identification as a Repeat Finding Condition is not a repeat finding. Recommendation We recommend that the Organization establish controls to ensure all accounting records are analyzed and proper support is available in order to ensure that the financial statement audit is submitted on a timely basis to the federal government. Views of Responsible Official Management and the Board of Directors agree. The reporting for the fiscal year 2022 audit was deficient due to turnover in the financial leadership position and the lack of appropriate resources in the finance department. The Organization is onboarding new leadership in 2023 and the Organization expects to enact the recommendations for the fiscal year 2023 audit.
Show full finding ▾Hide full finding ▴Item 2022-004 - Reporting U.S. Department of Health and Human Services, COVID-19 Health Center Program Cluster (Assistance Listing Number 93.224/93.527) Criteria In accordance with the Uniform Guidance, annual audit reports of recipients of federal funds are required to be submitted to the Federal Audit Clearing House, within the earlier of 30 days after the receipt of the audit report or 9 months after the end of the audit period. Statement of Condition The Center did not submit their annual audit in accordance with the Uniform Guidance on a timely basis. Questioned Costs None Context The Center did not submit their annual audit on a timely basis. Cause Due to turnover in the financial leadership position, the Center's finance department was not able to perform detailed review of accounts and adjust books accordingly, which delayed the filing of the annual audit report. Effect The Center did not comply with the appropriate rules and regulations as per the Uniform Guidance. Identification as a Repeat Finding Condition is not a repeat finding. Recommendation We recommend that the Organization establish controls to ensure all accounting records are analyzed and proper support is available in order to ensure that the financial statement audit is submitted on a timely basis to the federal government. Views of Responsible Official Management and the Board of Directors agree. The reporting for the fiscal year 2022 audit was deficient due to turnover in the financial leadership position and the lack of appropriate resources in the finance department. The Organization is onboarding new leadership in 2023 and the Organization expects to enact the recommendations for the fiscal year 2023 audit.
CORRECTIVE ACTION PLAN March 27, 2023 Health Resources and Services Administration St. Thomas East End Medical Center Corporation and Affiliate respectfully submits the following corrective action plan for the year ended February 28, 2022. ____________________________________________________________________________________ CohnReznick LLP 1301 Avenue of the Americas New York, NY 10019 Audit Period: February 28, 2022 The findings from the February 28, 2022 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the number assigned in the schedule. FINDINGS ? FINANCIAL STATEMENT AUDIT Finding 2022-001 ? Pension MATERIAL WEAKNESS Recommendation We recommend that the Center implement policies and procedures that allow for the timely payments of the pension plan payments. Action Taken & Completion Date The Center is working hard to make sure that all pension payments are made on time by strengthening our controls to ensure that the pension payments process is monitored properly. Completion Date October 1, 2023 Finding 2022-002 ? Account Analyses MATERIAL WEAKNESS Recommendation We recommend that the Center ensure that all accounting records are analyzed and reconciled on a monthly basis. Action Taken & Completion Date Management is working with staff to ensure that all accounting records are reviewed, analyzed and reconciled on a monthly basis. A new Chief Financial Officer started working at the Center on April 3, 2023. We are in the process of working together to create tighter protocols within the financial department. COMPLETEION DATE: October 1, 2023 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 2022-003 ? Special Tests and Provisions MATERIAL WEAKNESS 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 scale is calculated properly. Action Taken St. Thomas East End Medical Center has already provided some training to staff regarding the Sliding Fee Discount Program and is in the process of developing a training area within the Business Office to ensure the staff is appropriately trained regarding the scale. We are also creating new processes for quality improvement and compliance. Completion Date October 1, 2023 Finding 2022-004 ? Reporting MATERIAL WEAKNESS Recommendation We recommend that the Center establish controls to ensure all accounting records are analyzed and proper support is available in order to ensure that the financial statement audit is submitted on a timely basis to the federal government. Action Taken & Completion Date St. Thomas East End Medical Center is currently onboarding new leadership. As a part of this change, we are working diligently to ensure that the Business Office is restructured, to include development of quality controls, appropriate processes and procedures surrounding analysis and reconciliation of accounts. We are also working with team to ensure that all reporting is done on time. Completion October 1, 2023 If the Health Resources and Services Administration has questions regarding this plan, please call Tess G. Richards, M.D. Interim Executive Director at 340-775-3700, ext. 3023. Sincerely yours,
FAC accepted this audit on May 25, 2022 — management decision was due November 25, 2022.
Item 2021-003 - Special Tests and Provisions U.S. Department of Health and Human Services, COVID-19 Health Center Program Cluster (CFDA 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 certain patients selected for testing based on the sliding fee scale in effect for the year ended February 28, 2021. In addition, for one of the patients selected for testing, supporting documentation was not maintained on file to support the slide the patient was given. Questioned Costs None Context While performing our audit, we noted that the Center did not properly determine the sliding fee discount category given to three out of the sixty patients selected for testing based on the sliding fee scale in effect for the year ended February 28, 2021. In addition, the Center did not properly maintain the supporting documentation on file to support the sliding fee discount category given to an additional patient selected for testing. 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 February 28, 2021. 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 a repeat finding - see 2020-002. 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 proper documentation is maintained on file to support the sliding fee discounts given. Views of Responsible Official The Center concurs with this finding and will ensure that controls are established to ensure proper training and review of the sliding fee discounts.
Show full finding ▾Hide full finding ▴Item 2021-003 - Special Tests and Provisions U.S. Department of Health and Human Services, COVID-19 Health Center Program Cluster (CFDA 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 certain patients selected for testing based on the sliding fee scale in effect for the year ended February 28, 2021. In addition, for one of the patients selected for testing, supporting documentation was not maintained on file to support the slide the patient was given. Questioned Costs None Context While performing our audit, we noted that the Center did not properly determine the sliding fee discount category given to three out of the sixty patients selected for testing based on the sliding fee scale in effect for the year ended February 28, 2021. In addition, the Center did not properly maintain the supporting documentation on file to support the sliding fee discount category given to an additional patient selected for testing. 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 February 28, 2021. 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 a repeat finding - see 2020-002. 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 proper documentation is maintained on file to support the sliding fee discounts given. Views of Responsible Official The Center concurs with this finding and will ensure that controls are established to ensure proper training and review of the sliding fee discounts.
CORRECTIVE ACTION PLAN April 4, 2022 Health Resources and Services Administration St. Thomas East End Medical Center Corporation and Affiliate respectfully submits the following corrective action plan for the year ended February 28, 2021. CohnReznick LLP 1301 Avenue of the Americas New York, NY 10019 Audit Period: February 28, 2021 The findings from the February 28, 2021 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDING - FINANCIAL STATEMENT AUDIT Finding 2021-001 - Pension MATERIAL WEAKNESS Recommendation We recommend that the Center implement policies and procedures that allow for the timely payments of the pension plan payments. Action Taken At present, St. Thomas East End Medical Center is current on all 403(8) liability obligations. We will continue to make timely payments once the funds are available Completion Date May 1, 2022 Finding 2021-002 - Account Analyses MATERIAL WEAKNESS Recommendation We recommend that the Center ensure that all accounting records are analyzed and reconciled on a monthly basis. Action Taken Management will ensure that all accounting records are analyzed and reconciled on a monthly basis. Completion Date May 1, 2022 FINDINGS - FEDERAL AWARDS PROGRAM AUDIT U.S. Department of Health and Human Services, COVID-19 Health Center Program Cluster (CFDA 93.224/93.527) Finding 2021-003 - Special Tests and Provisions MATERIAL WEAKNESS 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 proper documentation is maintained on file to support the sliding fee discounts given. Action Taken St. Thomas East End Medical Center is in agreement with this recommendation. We will ensure that the relevant employees receive the necessary training and occasional audits will be conducted by management to ensure compliance Completion Date May 1, 2022 If the Health Resources and Services Administration has questions regarding this plan, please call Eric Baynes, CFO at 340-775-3700.
2020-002
FAC accepted this audit on February 11, 2021 — management decision was due August 11, 2021.
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 certain patients selected for testing based on the sliding fee scale in effect for the year ended February 29, 2020. In addition, for one of the patients selected for testing, supporting documentation was not maintained on file to support the slide the patient was given. Questioned Costs None Context While performing our audit, we noted that the Center did not properly determine the sliding fee discount category given to three out of the thirty-four patients selected for testing based on the sliding fee scale in effect for the year ended February 29, 2020. In addition, the Center di dnot properly maintain the supporting documentation on file to support the sliding fee discount category given to an additional patient selected for testing. 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 February 29, 2020. 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 a repeat finding ? see 2019-003. 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 proper documentation is maintained on file to support the sliding fee discounts given. Views of Responsible Official The Center concurs with this finding and will ensure that controls are established to ensure proper training and review of the sliding fee discounts.
Show full finding ▾Hide full finding ▴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 certain patients selected for testing based on the sliding fee scale in effect for the year ended February 29, 2020. In addition, for one of the patients selected for testing, supporting documentation was not maintained on file to support the slide the patient was given. Questioned Costs None Context While performing our audit, we noted that the Center did not properly determine the sliding fee discount category given to three out of the thirty-four patients selected for testing based on the sliding fee scale in effect for the year ended February 29, 2020. In addition, the Center di dnot properly maintain the supporting documentation on file to support the sliding fee discount category given to an additional patient selected for testing. 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 February 29, 2020. 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 a repeat finding ? see 2019-003. 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 proper documentation is maintained on file to support the sliding fee discounts given. Views of Responsible Official The Center concurs with this finding and will ensure that controls are established to ensure proper training and review of the sliding fee discounts.
The Center concurs with this finding and will ensure that controls are established to ensure proper training and review of the sliding fee discounts.
2019-003
FAC accepted this audit on November 19, 2019 — management decision was due May 19, 2020.
Item 2019-003 ? Special Tests and Provisions 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 February 28, 2019. 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 the thirty-three patients selected for testing based on the sliding fee scale in effect for the year ended February 28, 2019. 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 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 February 28, 2019. 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 be monitored and reviewed by a supervisor on a periodic basis to ensure compliance with the sliding fee scale. Views of Responsible Official The Center concurs with this finding and will ensure that controls are established to ensure proper training and review of the sliding fee discounts.
Show full finding ▾Hide full finding ▴Item 2019-003 ? Special Tests and Provisions 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 February 28, 2019. 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 the thirty-three patients selected for testing based on the sliding fee scale in effect for the year ended February 28, 2019. 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 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 February 28, 2019. 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 be monitored and reviewed by a supervisor on a periodic basis to ensure compliance with the sliding fee scale. Views of Responsible Official The Center concurs with this finding and will ensure that controls are established to ensure proper training and review of the sliding fee discounts.
The Center concurs with this finding and will ensure that controls are established to ensure proper training and review of the sliding fee discounts.
FAC accepted this audit on January 3, 2019 — management decision was due July 3, 2019.
GSA_MIGRATION
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GSA_MIGRATION
2017-003
FAC accepted this audit on July 15, 2018 — management decision was due January 15, 2019.
GSA_MIGRATION
Show full finding ▾Hide full finding ▴FAC accepted this audit on November 21, 2016 — management decision was due May 21, 2017.
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