HEALTH SERVICES OF NORTH TEXAS INC

CFDA No. 93.914, HIV Emergency Relief Project Grants U.S. Department of Health and Human Services Grant #2019-004-6844 Program Year 2022 Criteria or Specific Requirement - Patient eligibility verification should be obtained and documented in accordance with the Clinic's policy. Condition - Although management has written policies and procedures in place for personnel to follow when documenting eligibility including proper documentation and retention of patient files to support a patient's proof of residency, proof of income and HIV lab reports we noted instances in our sample of non-compliance with the documentation retention. Effect - Patients received services that were not documented to be eligible for the Grant. Cause - Certain staff made errors in the scanning of documents into the database used for documenting the Eligibility Determination. Recommendation - Management should revisit their policy and procedures related to the Eligibility Determination and the retention of documents reviewed. This should include training for the staff involved in the Eligibility Determination and approval process. Views of Responsible Officials and Plan of Corrective Action - Health Services of North Texas is commited to addressing this condition promptly, thoroughly and will continue to monitor for policy and procedure adherence.

CORRECTIVE ACTION PLAN Audit Finding Reference Number: 2022-001 Contact Information: Pam Barnes Chief Financial Officer Health Services of North Texas, Inc. Plan of Corrective Action: HSNT is committed to addressing this condition promptly, thoroughly and will continue to monitor for policy and procedure adherence. The case manager will ensure overall compliance with eligibility determination every six (6) months by collecting proof of income, including assessing income within 500% federal poverty level (FPL), proof of residence, and obtaining documentation of HIV diagnosis from testing agency. The eligibility process will be conducted annually and at 6-month eligibility recertification. The manager of programs will monitor case managers? new clients enrolled into Ryan White daily to verify eligibility documents are complete. Additionally for existing patients, appointment calendars are monitored and cross-referenced for documents in the patient?s Electronic Medical Record. Ryan White standards of care eligibility is verified every six months. In the interim a process to standardize the naming convention of eligibility documents has been completed to allow further auditing and oversight of the collection of eligibility documents. In consultation with our Ryan White program Monitor (Dallas County) we have received technical assistance and guidance related to eligibility. All items above have been completed on March 31st, 2023 Anticipated Completion Date: March 31, 2023

CFDA No. 93.917, HIV Care Formula Grant U.S. Department of Health and Human Services Grant #2019-004-6844 Program Year 2022 Criteria or Specific Requirement - Patient eligibility verification should be obtained and documented in accordance with the Clinic's policy. Condition - Although management has written policies and procedures in place for personnel to follow when documenting eligibility including proper documentation and retention of patient files to support a patient's proof of residency, proof of income and HIV lab reports we noted instances in our sample of non-compliance with the documentation retention. Effect - Patients received services that were not documented to be eligible for the Grant. Cause - Certain staff made errors in the scanning of documents into the database used for documenting the Eligibility Determination. Recommendation - Management should revisit their policy and procedures related to the Eligibility Determination and the retention of documents reviewed. This should include training for the staff involved in the Eligibility Determination and approval process. Views of Responsible Officials and Plan of Corrective Action - Health Services of North Texas is commited to addressing this condition promptly, thoroughly and will continue to monitor for policy and procedure adherence.

CORRECTIVE ACTION PLAN Audit Finding Reference Number: 2022-002 Contact Information: Pam Barnes Chief Financial Officer Health Services of North Texas, Inc. Plan of Corrective Action: HSNT is committed to addressing this condition promptly, thoroughly and will continue to monitor for policy and procedure adherence. The case manager will ensure overall compliance with eligibility determination every six (6) months by collecting proof of income, including assessing income within 500% federal poverty level (FPL), proof of residence, and obtaining documentation of HIV diagnosis from testing agency. The eligibility process will be conducted annually and at 6-month eligibility recertification. The manager of programs will monitor case managers? new clients enrolled into Ryan White daily to verify eligibility documents are complete. Additionally for existing patients, appointment calendars are monitored and cross-referenced for documents in the patient?s Electronic Medical Record. Ryan White standards of care eligibility is verified every six months. In the interim a process to standardize the naming convention of eligibility documents has been completed to allow further auditing and oversight of the collection of eligibility documents. In consultation with our Ryan White program Monitor (Dallas County) we have received technical assistance and guidance related to eligibility. All items above have been completed on March 31st, 2023 Anticipated Completion Date: March 31, 2023

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