EIN: 680437840
UEI: U9PHWXZ3CGN5
Data as of August 23, 2026
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on March 16, 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 16, 2026 (23 days from today).
What is a management decision? →Finding 2025-001 – Special Tests and Provisions – Significant Deficiency in Internal Control over Compliance Federal Program: U.S Department of Health and Human Services Health Center Program Cluster (Federal Assistance Listing # 93.224/93.527) Federal Agency: U.S. Department of Health and Human Services Award Year: 2024-2025 Criteria: The recipient is required to comply with specific federal regulations and provisions outlined in 2 CFR Part 200, particularly those related to special tests and provisions for the Health Center Program Cluster. This includes maintaining an effective internal control environment to ensure sliding fee discounts are applied to patient charges consistent with the recipients sliding fee discount schedule. Condition/Cause: While the Organization successfully implemented system-level enhancements within their electronic health record system to consistently apply appropriate sliding fee discounts (previously a noted deficiency), the internal control environment remains inconsistently applied. During the audit, it was identified that the Organization’s front office staff had improperly applied the sliding discounts for patients based on qualification criteria. In some instances, the front office staff applied sliding fee discounts without appropriate qualification criteria or qualification criteria which expired. This is primarily due to administrative lapses and high staff turnover, which have hindered the full implementation of training protocols and eligibility documentation requirements. Effect: As a result, certain patients were billed incorrect amounts inconsistent with the sliding fee discount schedule or received discounts without proper documentation to support eligibility. Questioned costs: No questioned costs are identified because the improper application of sliding fee discounts affects patient billing amounts but does not result in the misappropriation of federal funds. Context: This is a repeat finding from the prior year. In the current period, a sample of 25 patient visits was selected from a statistically valid population of patients potentially eligible for sliding fee discounts during the fiscal year ending June 30, 2025. In 6 of the 25 samples tested, the Organization’s internal controls failed to ensure compliance with the sliding fee discount schedule, resulting in improper billing despite enhancements to the functionality and configuration of the Organization’s electronic health record system. This indicates that while the technical cause has been remediated, the administrative and oversight causes remain unaddressed or ineffective. Repeat Finding: This is a repeat finding from the prior year. Recommendation: We recommend the Organization formalize administrative oversight to complement recent enhancements of the Organization’s electronic health record system by implementing a mandatory training and competency program for all eligibility staff to mitigate the impact of departmental turnover. Additionally, the Organization should establish a monthly internal monitoring process such as utilizing standardized eligibility checklists to ensure income documentation is consistently retained and that sliding fee discounts are applied accurately in accordance with federal policy. Views of responsible officials: The Organization is actively developing and delivering targeted training for front office staff on the application of sliding fee discounts. The Organization also plans to update policies and procedures to incorporate monthly internal monitoring, reviews, and administrative oversight of sliding fee discount application to strengthen internal controls.
Show full finding ▾Hide full finding ▴Finding 2025-001 – Special Tests and Provisions – Significant Deficiency in Internal Control over Compliance Federal Program: U.S Department of Health and Human Services Health Center Program Cluster (Federal Assistance Listing # 93.224/93.527) Federal Agency: U.S. Department of Health and Human Services Award Year: 2024-2025 Criteria: The recipient is required to comply with specific federal regulations and provisions outlined in 2 CFR Part 200, particularly those related to special tests and provisions for the Health Center Program Cluster. This includes maintaining an effective internal control environment to ensure sliding fee discounts are applied to patient charges consistent with the recipients sliding fee discount schedule. Condition/Cause: While the Organization successfully implemented system-level enhancements within their electronic health record system to consistently apply appropriate sliding fee discounts (previously a noted deficiency), the internal control environment remains inconsistently applied. During the audit, it was identified that the Organization’s front office staff had improperly applied the sliding discounts for patients based on qualification criteria. In some instances, the front office staff applied sliding fee discounts without appropriate qualification criteria or qualification criteria which expired. This is primarily due to administrative lapses and high staff turnover, which have hindered the full implementation of training protocols and eligibility documentation requirements. Effect: As a result, certain patients were billed incorrect amounts inconsistent with the sliding fee discount schedule or received discounts without proper documentation to support eligibility. Questioned costs: No questioned costs are identified because the improper application of sliding fee discounts affects patient billing amounts but does not result in the misappropriation of federal funds. Context: This is a repeat finding from the prior year. In the current period, a sample of 25 patient visits was selected from a statistically valid population of patients potentially eligible for sliding fee discounts during the fiscal year ending June 30, 2025. In 6 of the 25 samples tested, the Organization’s internal controls failed to ensure compliance with the sliding fee discount schedule, resulting in improper billing despite enhancements to the functionality and configuration of the Organization’s electronic health record system. This indicates that while the technical cause has been remediated, the administrative and oversight causes remain unaddressed or ineffective. Repeat Finding: This is a repeat finding from the prior year. Recommendation: We recommend the Organization formalize administrative oversight to complement recent enhancements of the Organization’s electronic health record system by implementing a mandatory training and competency program for all eligibility staff to mitigate the impact of departmental turnover. Additionally, the Organization should establish a monthly internal monitoring process such as utilizing standardized eligibility checklists to ensure income documentation is consistently retained and that sliding fee discounts are applied accurately in accordance with federal policy. Views of responsible officials: The Organization is actively developing and delivering targeted training for front office staff on the application of sliding fee discounts. The Organization also plans to update policies and procedures to incorporate monthly internal monitoring, reviews, and administrative oversight of sliding fee discount application to strengthen internal controls.
As required by OMB Uniform Guidance, we have provided below our response and corrective action plan addressing the findings in the “Report on Federal Awards in Accordance with the OMB Uniform Guidance” for the year ended June 30, 2025. Management’s Views and Corrective Action Plan Finding 2025-001 – Special Tests and Provisions – Significant Deficiency in Internal Control over Compliance It was identified during the current year audit that while the Organization successfully implemented system-level enhancements within their electronic health record system to consistently apply appropriate sliding fee discounts (previously a noted deficiency), the internal control environment remains inconsistently applied. The Organization’s front office staff responsible for patient intake did not obtain the necessary qualification criteria, or incorrectly billed patients under the sliding fee discount schedule. As a result, they did not consistently apply the appropriate sliding fee discounts for patients based on qualification criteria and certain patients were billed for the incorrect amounts under the sliding fee discount schedule. This was primarily due to administrative lapses and high staff turnover, which have hindered the full implementation of training protocols and eligibility documentation requirements. To address the finding related to patient intake that resulted in patients being billed for incorrect amounts specified in the sliding fee discount schedule, the Organization will implement a comprehensive corrective action plan. The Organization is actively developing and delivering targeted training for front office staff on the application of sliding fee discounts. The Organization partnered with its electronic health record vendor, OCHIN, to implement a Financial Assistance Module which will create the system a revenue cycle staff person will use to review each sliding fee scale application for completeness prior to approving patient access to sliding fee discounts. Additionally, the Organization also plans to update policies and procedures to incorporate monthly internal monitoring, reviews of data capture accuracy, and administrative oversight of sliding fee discount application to strengthen internal controls. Finally, thorough documentation of all corrective actions taken will be maintained. The Chief Financial Officer will report findings to management monthly. Through these measures, the Organization aims to enhance billing accuracy, ensure compliance with federal requirements, and prevent future discrepancies. Anticipated Date of Corrective Action: July 31, 2026 Party Responsible for Corrective Action: Molly Jouaneh, Chief Financial Officer
2024-001
FAC accepted this audit on November 13, 2024 — management decision was due May 13, 2025.
Finding 2024-001 – Special Tests and Provisions – Significant Deficiency in Internal Control over Compliance Federal Program: U.S. Department of Health and Human Services Health Center Program Cluster (Federal Assistance Listing # 93.224/93.527) Federal Agency: U.S. Department of Health and Human Services Award Year: 2023-2024 Criteria: The recipient is required to comply with specific federal regulations and provisions outlined in 2 CFR Part 200, particularly those related to special tests and provisions for the Health Center Program Cluster. This includes maintaining an effective internal control environment to ensure sliding fee discounts are applied to patient charges consistent with the recipients sliding fee discount schedule. Condition/Cause: During the audit, it was identified that the implementation of the new electronic health record system significantly impacted the Organization’s control environment. As a result, the control system did not consistently apply the appropriate sliding fee discounts for patients based on qualification criteria. Effect: Certain patients were billed amounts less than the amounts defined by the sliding fee discount schedule due to the control system inconsistencies. Questioned costs: None since patients were billed amounts less than the sliding fee discount schedule. Context: We selected a sample of 25 patient visits from a statistically valid population of patients potentially eligible for benefits under the sliding fee schedule during the fiscal year ended June 30, 2024. In 11 out of 25 samples tested, the Organization’s system limitations resulted in patients being billed less than the amounts defined by the sliding fee discount schedule. Repeat Finding: This is not a repeat finding. Recommendation: We recommend the Organization ensures its third-party IT service provider appropriately configures its electronic health record system for compliance with federal award requirements, and that staff using the electronic health record system are provided comprehensive training of the system to ensure that the sliding fee scale is accurately applied to all qualifying program participants. Additionally, we would recommend the Organization perform regular reviews to ensure there are no issues with the system. Views of responsible officials: The Organization has started conversations with its third-party IT service provide who facilitated the implementation of its electronic health record system, to address concerns regarding the system’s current configuration. It plans to collaborate with the provider to rectify the identified limitations within the system, as well as update its policies and procedures to include regular system reviews to ensure the system is effectively operating.
Show full finding ▾Hide full finding ▴Finding 2024-001 – Special Tests and Provisions – Significant Deficiency in Internal Control over Compliance Federal Program: U.S. Department of Health and Human Services Health Center Program Cluster (Federal Assistance Listing # 93.224/93.527) Federal Agency: U.S. Department of Health and Human Services Award Year: 2023-2024 Criteria: The recipient is required to comply with specific federal regulations and provisions outlined in 2 CFR Part 200, particularly those related to special tests and provisions for the Health Center Program Cluster. This includes maintaining an effective internal control environment to ensure sliding fee discounts are applied to patient charges consistent with the recipients sliding fee discount schedule. Condition/Cause: During the audit, it was identified that the implementation of the new electronic health record system significantly impacted the Organization’s control environment. As a result, the control system did not consistently apply the appropriate sliding fee discounts for patients based on qualification criteria. Effect: Certain patients were billed amounts less than the amounts defined by the sliding fee discount schedule due to the control system inconsistencies. Questioned costs: None since patients were billed amounts less than the sliding fee discount schedule. Context: We selected a sample of 25 patient visits from a statistically valid population of patients potentially eligible for benefits under the sliding fee schedule during the fiscal year ended June 30, 2024. In 11 out of 25 samples tested, the Organization’s system limitations resulted in patients being billed less than the amounts defined by the sliding fee discount schedule. Repeat Finding: This is not a repeat finding. Recommendation: We recommend the Organization ensures its third-party IT service provider appropriately configures its electronic health record system for compliance with federal award requirements, and that staff using the electronic health record system are provided comprehensive training of the system to ensure that the sliding fee scale is accurately applied to all qualifying program participants. Additionally, we would recommend the Organization perform regular reviews to ensure there are no issues with the system. Views of responsible officials: The Organization has started conversations with its third-party IT service provide who facilitated the implementation of its electronic health record system, to address concerns regarding the system’s current configuration. It plans to collaborate with the provider to rectify the identified limitations within the system, as well as update its policies and procedures to include regular system reviews to ensure the system is effectively operating.
Finding 2024‐001 – Special Tests and Provisions – Significant Deficiency in Internal Control over Compliance It was identified that the implementation of a new electronic health record system significantly impacted the control environment as it relates to compliance with federal awards. As a result, the control system did not consistently apply the appropriate sliding fee discounts for patients based on qualification criteria and certain patients were billed amounts less than the sliding fee discount schedule. To address the finding related to system limitations that resulted in patients being billed amounts lower than those specified in the sliding fee discount schedule, the Organization will implement a comprehensive corrective action plan. First, a thorough review of the electronic health record system will be conducted to identify specific limitations as it relates to data capture of federal poverty level at time of patient registration. This has already been completed. Second, the Organization will modify the set-up of its electronic health record to systematically seek approved and active documentation related to sliding fee discounts and will modify the system to not allow sliding fee discounts without the presence of said documentation. The Organization is in the process of setting a meeting to modify its system build, which it expects to be finalized in 30 calendar days. To ensure ongoing compliance, regular monitoring procedures will be established to review data capture accuracy, with the Chief Financial Officer overseeing this effort and the first review scheduled for 30 calendar days from the date on which the electronic health record system fix is implemented. Finally, thorough documentation of all corrective actions taken, including system changes and monitoring results, will be maintained. The Chief Financial Officer will report findings to management on a monthly basis, with the first report due one month from date on which the system fix is implemented. Through these measures, the Organization aims to enhance billing accuracy, ensure compliance with federal requirements, and prevent future discrepancies.
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