EIN: 752405203
UEI: K38VK6M92M21
Audited by: Henry & Peters, P.C.
Oversight agency: 93 [Department of Health and Human Services]
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Data as of September 2, 2026
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on July 24, 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 January 24, 2026 (223 days ago).
What is a management decision? →Grantee health centers must prepare and apply a sliding fee discount schedule so that the amounts owed for health center services by eligible patients are adjusted (discounted) based on the patient's ability to pay. The Organization adopted a Sliding Fee Discount Schedule based on current Federal poverty guidelines; however, they failed to consistently document the patient's assessment for the discount and retain thepatient's application. 9 out of 25 patients tested (36%) did not have documentation of the sliding fee discount assessment. We were unable to determine whether the sliding fee discount was properly applied to these patients. The effect is reportable non-compliance with the Special Tests compliance requirement for this grant. Further, the Organization has a significant deficiency in internal controls over compliance. The Organization's internal control over compliance was properly designed to ensure patients were assessed for ability to pay; however, it was not operating effectively during the period under audit.
Show full finding ▾Hide full finding ▴Grantee health centers must prepare and apply a sliding fee discount schedule so that the amounts owed for health center services by eligible patients are adjusted (discounted) based on the patient's ability to pay. The Organization adopted a Sliding Fee Discount Schedule based on current Federal poverty guidelines; however, they failed to consistently document the patient's assessment for the discount and retain thepatient's application. 9 out of 25 patients tested (36%) did not have documentation of the sliding fee discount assessment. We were unable to determine whether the sliding fee discount was properly applied to these patients. The effect is reportable non-compliance with the Special Tests compliance requirement for this grant. Further, the Organization has a significant deficiency in internal controls over compliance. The Organization's internal control over compliance was properly designed to ensure patients were assessed for ability to pay; however, it was not operating effectively during the period under audit.
To ensure consistent completion of the Sliding Fee Discount Form for all patients, new procedures have been implemented to improve the collection and documentation of required information. Patient registration forms have been revised to reflect these updates. Clerical staff will now conduct schedule preparation and identify patients who are non-compliant with the Sliding Fee Discount Form requirements. Post visit audits will be conducted to confrim that all necessary data is being accurately captured. The Revenue Cycle Manager will continue to provide on-site training across all locations and will work in close collaboration with clerical support staff, Clinic Managers, the Director of Operations, and the Director of Quality to ensure successful implementation and ongoing compliance.
2023-002
Grantee health centers must prepare and apply a sliding fee discount schedule so that the amounts owed for health center services by eligible patients are adjusted (discounted) based on the patient's ability to pay. The Organization adopted a Sliding Fee Discount Schedule based on current Federal poverty guidelines; however, they failed to consistently document the patient's assessment for the discount and retain thepatient's application. 9 out of 25 patients tested (36%) did not have documentation of the sliding fee discount assessment. We were unable to determine whether the sliding fee discount was properly applied to these patients. The effect is reportable non-compliance with the Special Tests compliance requirement for this grant. Further, the Organization has a significant deficiency in internal controls over compliance. The Organization's internal control over compliance was properly designed to ensure patients were assessed for ability to pay; however, it was not operating effectively during the period under audit.
Show full finding ▾Hide full finding ▴Grantee health centers must prepare and apply a sliding fee discount schedule so that the amounts owed for health center services by eligible patients are adjusted (discounted) based on the patient's ability to pay. The Organization adopted a Sliding Fee Discount Schedule based on current Federal poverty guidelines; however, they failed to consistently document the patient's assessment for the discount and retain thepatient's application. 9 out of 25 patients tested (36%) did not have documentation of the sliding fee discount assessment. We were unable to determine whether the sliding fee discount was properly applied to these patients. The effect is reportable non-compliance with the Special Tests compliance requirement for this grant. Further, the Organization has a significant deficiency in internal controls over compliance. The Organization's internal control over compliance was properly designed to ensure patients were assessed for ability to pay; however, it was not operating effectively during the period under audit.
To ensure consistent completion of the Sliding Fee Discount Form for all patients, new procedures have been implemented to improve the collection and documentation of required information. Patient registration forms have been revised to reflect these updates. Clerical staff will now conduct schedule preparation and identify patients who are non-compliant with the Sliding Fee Discount Form requirements. Post visit audits will be conducted to confrim that all necessary data is being accurately captured. The Revenue Cycle Manager will continue to provide on-site training across all locations and will work in close collaboration with clerical support staff, Clinic Managers, the Director of Operations, and the Director of Quality to ensure successful implementation and ongoing compliance.
2023-002
FAC accepted this audit on March 16, 2026 — management decision was due September 16, 2026.
Grantee health centers must prepare and apply a sliding fee discount schedule so that the amounts owed for health center services by eligible patients are adjusted (discounted) based on the patient's ability to pay. The Organization adopted a Sliding Fee Discount Schedule based on current Federal poverty guidelines; however, they failed to consistently document the patient's assessment for the discount and retain thepatient's application. 9 out of 25 patients tested (36%) did not have documentation of the sliding fee discount assessment. We were unable to determine whether the sliding fee discount was properly applied to these patients. The effect is reportable non-compliance with the Special Tests compliance requirement for this grant. Further, the Organization has a significant deficiency in internal controls over compliance. The Organization's internal control over compliance was properly designed to ensure patients were assessed for ability to pay; however, it was not operating effectively during the period under audit.
Show full finding ▾Hide full finding ▴Grantee health centers must prepare and apply a sliding fee discount schedule so that the amounts owed for health center services by eligible patients are adjusted (discounted) based on the patient's ability to pay. The Organization adopted a Sliding Fee Discount Schedule based on current Federal poverty guidelines; however, they failed to consistently document the patient's assessment for the discount and retain thepatient's application. 9 out of 25 patients tested (36%) did not have documentation of the sliding fee discount assessment. We were unable to determine whether the sliding fee discount was properly applied to these patients. The effect is reportable non-compliance with the Special Tests compliance requirement for this grant. Further, the Organization has a significant deficiency in internal controls over compliance. The Organization's internal control over compliance was properly designed to ensure patients were assessed for ability to pay; however, it was not operating effectively during the period under audit.
To ensure consistent completion of the Sliding Fee Discount Form for all patients, new procedures have been implemented to improve the collection and documentation of required information. Patient registration forms have been revised to reflect these updates. Clerical staff will now conduct schedule preparation and identify patients who are non-compliant with the Sliding Fee Discount Form requirements. Post visit audits will be conducted to confrim that all necessary data is being accurately captured. The Revenue Cycle Manager will continue to provide on-site training across all locations and will work in close collaboration with clerical support staff, Clinic Managers, the Director of Operations, and the Director of Quality to ensure successful implementation and ongoing compliance.
2023-002
Grantee health centers must prepare and apply a sliding fee discount schedule so that the amounts owed for health center services by eligible patients are adjusted (discounted) based on the patient's ability to pay. The Organization adopted a Sliding Fee Discount Schedule based on current Federal poverty guidelines; however, they failed to consistently document the patient's assessment for the discount and retain thepatient's application. 9 out of 25 patients tested (36%) did not have documentation of the sliding fee discount assessment. We were unable to determine whether the sliding fee discount was properly applied to these patients. The effect is reportable non-compliance with the Special Tests compliance requirement for this grant. Further, the Organization has a significant deficiency in internal controls over compliance. The Organization's internal control over compliance was properly designed to ensure patients were assessed for ability to pay; however, it was not operating effectively during the period under audit.
Show full finding ▾Hide full finding ▴Grantee health centers must prepare and apply a sliding fee discount schedule so that the amounts owed for health center services by eligible patients are adjusted (discounted) based on the patient's ability to pay. The Organization adopted a Sliding Fee Discount Schedule based on current Federal poverty guidelines; however, they failed to consistently document the patient's assessment for the discount and retain thepatient's application. 9 out of 25 patients tested (36%) did not have documentation of the sliding fee discount assessment. We were unable to determine whether the sliding fee discount was properly applied to these patients. The effect is reportable non-compliance with the Special Tests compliance requirement for this grant. Further, the Organization has a significant deficiency in internal controls over compliance. The Organization's internal control over compliance was properly designed to ensure patients were assessed for ability to pay; however, it was not operating effectively during the period under audit.
To ensure consistent completion of the Sliding Fee Discount Form for all patients, new procedures have been implemented to improve the collection and documentation of required information. Patient registration forms have been revised to reflect these updates. Clerical staff will now conduct schedule preparation and identify patients who are non-compliant with the Sliding Fee Discount Form requirements. Post visit audits will be conducted to confrim that all necessary data is being accurately captured. The Revenue Cycle Manager will continue to provide on-site training across all locations and will work in close collaboration with clerical support staff, Clinic Managers, the Director of Operations, and the Director of Quality to ensure successful implementation and ongoing compliance.
2023-002
FAC accepted this audit on September 30, 2024 — management decision was due March 30, 2025.
Grantee health centers must prepare and apply a sliding fee discount schedule so that the amounts owed for health center services by eligible patients are adjusted (discounted) based on the patient's ability to pay. The Organization adopted a Sliding Fee Discount Schedule based on current Federal poverty guidelines; however, they failed to consistently document the patient's assessment for the discount and retain thepatient's application. 7 out of 25 patients tested (28%) did not have documentation of the sliding fee discount assessment. We were unable to determine whether the sliding fee discount was properly applied to these patients. The effect is reportable non-compliance with the Special Tests compliance requirement for this grant. Further, the Organization has a significant deficiency in internal controls over compliance. The Organization's internal control over compliance was properly designed to ensure patients were assessed for ability to pay; however, it was not operating effectively during the period under audit.
Show full finding ▾Hide full finding ▴Grantee health centers must prepare and apply a sliding fee discount schedule so that the amounts owed for health center services by eligible patients are adjusted (discounted) based on the patient's ability to pay. The Organization adopted a Sliding Fee Discount Schedule based on current Federal poverty guidelines; however, they failed to consistently document the patient's assessment for the discount and retain thepatient's application. 7 out of 25 patients tested (28%) did not have documentation of the sliding fee discount assessment. We were unable to determine whether the sliding fee discount was properly applied to these patients. The effect is reportable non-compliance with the Special Tests compliance requirement for this grant. Further, the Organization has a significant deficiency in internal controls over compliance. The Organization's internal control over compliance was properly designed to ensure patients were assessed for ability to pay; however, it was not operating effectively during the period under audit.
To ensure that the Sliding Fee Discount Form is being completed for all patients, the Revenue Cycle Manager will conduct new onsite trainings at all locations. The Revenue Cycle Manager will work closely with front line support staff, Clinic Managers, Director of Operations and the Director of Quality. They will conduct weekly audits to 5% of patient charts to ensure that the trainings are being successful.
FAC accepted this audit on August 1, 2023 — management decision was due February 1, 2024.
FAC accepted this audit on August 30, 2022 — management decision was due March 2, 2023.
Internal controls are necessary to ensure errors or fraud are detected on a timely basis in order to accurately report financial results. In addition, grantees expending Federal funds to procure goods and services are required to establish and maintain internal controls to ensure that covered transactions comply with the procurement standards as set forth by the Uniform Guidance. Covered transactions require formal documentation of the procurement process to ensure open and fair competition, a price analysis was performed, and that contracts are not awarded to suspended or debarred vendors Context: Audit procedures detected six instances out of a sample of 40 where internal controls over procurement of goods and services did not operate as management intended. Effect: The effect of inadequate internal control is material noncompliance with the Procurement Compliance requirement (2021-002) and a qualified opinion. Cause: Internal controls were properly designed, but not operating effectively to prevent non-compliance with the Procurement compliance requirement. Recommendation: Management should adhere to established policies for procurement of goods and services.
Show full finding ▾Hide full finding ▴FINDING 2021-001 Criteria or specific requirement: Material Weakness in Internal Control Related to Financial Reporting and Internal Control over the Procurement Compliance requirement Condition: Internal controls are necessary to ensure errors or fraud are detected on a timely basis in order to accurately report financial results. In addition, grantees expending Federal funds to procure goods and services are required to establish and maintain internal controls to ensure that covered transactions comply with the procurement standards as set forth by the Uniform Guidance. Covered transactions require formal documentation of the procurement process to ensure open and fair competition, a price analysis was performed, and that contracts are not awarded to suspended or debarred vendors Context: Audit procedures detected six instances out of a sample of 40 where internal controls over procurement of goods and services did not operate as management intended. Effect: The effect of inadequate internal control is material noncompliance with the Procurement Compliance requirement (2021-002) and a qualified opinion. Cause: Internal controls were properly designed, but not operating effectively to prevent non-compliance with the Procurement compliance requirement. Recommendation: Management should adhere to established policies for procurement of goods and services.
While internal controls and procurement policies were in place at the time, they were not necessarily up-to-date or followed by all staff as necessary. Special Health Resources recognized this weakness in late 2021. The prior Procurement policy was replaced with two policies, 404.00 Formal Procurements ($150,000 and above) and 404.01 Informal Procurements (under $150,000). Both policies reflect appropriate steps required when Federal funds are involved. All applicable staff have been trained either in-person or virtually, with a recorded training provided as well. Purchasing and Finance staff have attended several additional training opportunities on Uniform Guidance and procurement standards. This training remains as an on-going priority. All policies are accessible by all staff via the SHR intranet. These policies are reinforced by the fiscal review and multi-level approval process prior to payments being processed.
Repeated instances of failure to adhere to the Organization's established Procurement Policy. Context: Audit procedures detected actual questioned costs of $221,351 out of a sample of $561,183. The questioned costs were attributed to the Organization not complying with the Procurement standards established by the Organization (a non-federal entity) to promote open and fair competition when Federal funds are used to procure goods and services. The non-compliance included repeated instances of not obtaining multiple quotes on micro and small purchases, and not adhering to the formal procurement methods (e.g. competitive bids) when the acquisition amount exceeded $150,000. Effect: The effect of the material non-compliance indicates a systematic failure resulting in a qualified opinion on compliance with the Procurement compliance requirements. Cause: Internal controls over compliance with the Procurement requirement are properly designed; however they are not operating effectively. Recommendation: It is recommended that management re-educate its staff and reinforce the Procurement Policy the Organization has established with those individuals responsible for procuring goods and services with Federal funds. In addition, management should establish a monitoring control to ensure the procurement guidelines are being adhered to.
Show full finding ▾Hide full finding ▴FINDING 2021-002 Criteria or specific requirement: Procurement ? Qualified Opinion on Compliance Condition: Repeated instances of failure to adhere to the Organization's established Procurement Policy. Context: Audit procedures detected actual questioned costs of $221,351 out of a sample of $561,183. The questioned costs were attributed to the Organization not complying with the Procurement standards established by the Organization (a non-federal entity) to promote open and fair competition when Federal funds are used to procure goods and services. The non-compliance included repeated instances of not obtaining multiple quotes on micro and small purchases, and not adhering to the formal procurement methods (e.g. competitive bids) when the acquisition amount exceeded $150,000. Effect: The effect of the material non-compliance indicates a systematic failure resulting in a qualified opinion on compliance with the Procurement compliance requirements. Cause: Internal controls over compliance with the Procurement requirement are properly designed; however they are not operating effectively. Recommendation: It is recommended that management re-educate its staff and reinforce the Procurement Policy the Organization has established with those individuals responsible for procuring goods and services with Federal funds. In addition, management should establish a monitoring control to ensure the procurement guidelines are being adhered to.
Similar to the response for Finding 2021-001, additional internal controls that are in place coupled with the updated Formal Procurement policy 404.00 will ensure that all proper procurement steps, documentation, approvals, and contracts (if needed) are in place prior to making purchases in excess of $150,000.
Missing invoices to substantiate the expenditure of Federal funds. Context: Audit procedures detected actual questioned costs of $4,456 out of a sample of $561,183 and a population of $17,039,788. The costs are in question because the Organization was not able to provide substantiation for the expenditure of the Federal funds; therefore, a conclusion could not be reached as to whether the costs were allowable. Effect: The effect is reportable non-compliance. Cause: The cause is inadequate record-keeping, specifically related to credit card transactions. Recommendation: It is recommended that management ensure that proper documentation is obtained prior to expending Federal funds and maintained afterwards to be able to substantiate the allowable costs.
Show full finding ▾Hide full finding ▴FINDING 2021-003 Criteria or specific requirement: Activities Allowed/Allowable Costs - reportable noncompliance Condition: Missing invoices to substantiate the expenditure of Federal funds. Context: Audit procedures detected actual questioned costs of $4,456 out of a sample of $561,183 and a population of $17,039,788. The costs are in question because the Organization was not able to provide substantiation for the expenditure of the Federal funds; therefore, a conclusion could not be reached as to whether the costs were allowable. Effect: The effect is reportable non-compliance. Cause: The cause is inadequate record-keeping, specifically related to credit card transactions. Recommendation: It is recommended that management ensure that proper documentation is obtained prior to expending Federal funds and maintained afterwards to be able to substantiate the allowable costs.
Updated policies have been put in place that address Internal Controls (400.02) and Business Credit Card Use (400.05) and Procurements (404.00, 404.01). These policies all require fully supportive documentation prior to processing or approving of a financial transaction. Internal procedures for journal entries now include the maintenance of a log sheet, proper supporting documentation for all journal entries, and a review/posting by a second staff person in finance. All journal entries are then scanned and saved in a central file. These policies and internal procedure will maintain accuracy and accountability of all purchases and journal entries going forward.
FAC accepted this audit on August 31, 2021 — management decision was due March 3, 2022.
FAC accepted this audit on June 30, 2020 — management decision was due December 30, 2020.
The Organization adopted a Sliding Fee Discount Schedule based on current Federal poverty guidelines; however they failed to consistently document the patient's assessment for the discount. Context: 8 out of 40 patients tested (20%) did not have documentation of the sliding fee discount assessment. We were unable to determine whether the sliding fee discount was properly applied to these patients. Effect: The effect is reportable non-compliance with the Special Tests compliance requirement for this grant. Further, the Organization has a material weakness in internal controls over compliance. Cause: The Organization's internal control over compliance was properly designed to ensure patients were assessed for ability to pay; however it was not operating effectively during the period under audit. Recommendation: It is recommended that the Organization ensure that the Sliding Fee Discount Form is completed for every patient on their initial visit, updated annually, and included within their patient record. The form documents the patient's household income and eligible dependents to properly assess their ability to pay based upon the Federal poverty guidelines. Views of responsible officials and planned corrective actions: Management agrees with the findings and will take corrective action to enhance current systems to improve redundancy and quality assurance on a company wide basis in order to prevent reoccurrence.
Show full finding ▾Hide full finding ▴FINDING 2019-001 CFDA 93.527 Grants for New and Expanded Services under the Health Center Program Criteria or specific requirement: Grantee health centers must prepare and apply a sliding fee discount schedule so that the amounts owed for health center services by eligible patients are adjusted (discounted) based on the patient's ability to pay. Condition: The Organization adopted a Sliding Fee Discount Schedule based on current Federal poverty guidelines; however they failed to consistently document the patient's assessment for the discount. Context: 8 out of 40 patients tested (20%) did not have documentation of the sliding fee discount assessment. We were unable to determine whether the sliding fee discount was properly applied to these patients. Effect: The effect is reportable non-compliance with the Special Tests compliance requirement for this grant. Further, the Organization has a material weakness in internal controls over compliance. Cause: The Organization's internal control over compliance was properly designed to ensure patients were assessed for ability to pay; however it was not operating effectively during the period under audit. Recommendation: It is recommended that the Organization ensure that the Sliding Fee Discount Form is completed for every patient on their initial visit, updated annually, and included within their patient record. The form documents the patient's household income and eligible dependents to properly assess their ability to pay based upon the Federal poverty guidelines. Views of responsible officials and planned corrective actions: Management agrees with the findings and will take corrective action to enhance current systems to improve redundancy and quality assurance on a company wide basis in order to prevent reoccurrence.
Management will take corrective action to enhance current systems to improve redundancy and quality assurance on a company wide basis in order to prevent re-occurrence.
FAC accepted this audit on July 22, 2019 — management decision was due January 22, 2020.
GSA_MIGRATION
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2017-002
FAC accepted this audit on October 1, 2018 — management decision was due April 1, 2019.
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2016-001
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GSA_MIGRATION
FAC accepted this audit on September 27, 2017 — management decision was due March 27, 2018.
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