Butte Silver Bow Primary Health Care Clinic d/b/a Southwest Montana Community Health Center

2024-002 U.S. Department of Health and Human Services Federal Financial Assistance Listing #93.526 Grants for Capital Development in Health Centers Procurement, Suspension and Debarment Significant Deficiency In Internal Control Over Compliance Criteria – 2 CFR 200.303(a) establishes that the auditee must establish and maintain effective internal control over the federal award that provides assurance that the entity is managing the federal award in compliance with federal statutes, regulations, and conditions of the federal award. Condition – There was no evidence retained that the Community Health Center reviewed vendors to determine their status in regards to the suspension and debarment requirement. Furthermore, the Community Health Center did not have written suspension and debarment policies. Cause – The Community Health Center did not have an internal control policy in place to ensure a documented review and approval of the vendors for suspension and debarment took place prior to utilizing under the federal funds. Effect – The lack of adequate policies governing review and approval increases the risk that employees participating in the federal awards administration may not be able to detect and correct noncompliance in a timely manner. Questioned Costs – None reported. Context/Sampling – A nonstatistical sample of 2 out of 4 vendors were selected for detail testing and did not include evidence of a review for suspension and debarment. The Procurement Policy was reviewed in its entirety. Repeat Finding from Prior Years – No. Recommendation – We recommend the development of a Suspension and Debarment Policy as either a separate policy or part of the Procurement Policy which would require that vendors are investigated to ensure they have not been declared ineligible to receive federal dollars. The policy should include guidance on the need to maintain that documentation. Views of Responsible Officials – Management agrees with the finding.

2024-003 U.S. Department of Health and Human Services Federal Financial Assistance Listing #93.526 Grants for Capital Development in Health Centers Procurement, Suspension and Debarment Significant Deficiency In Internal Control Over Compliance Criteria – Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) requires contract to contain applicable provisions described in Appendix II to Part 200 for contracts under Federal Awards. The OMB Compliance Supplement states that non-Federal entities are prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. Non-Federal entities may verify that a party is not suspended or debarred by checking the Excluded Parties List System, collecting a certification from the entity, or adding a clause or condition to the covered transaction. Condition – Certain applicable provisions described in Appendix II to Part 200 were not included in the contract as required. Cause – The Community Health Center did not have an internal control policy to ensure contracts under Federal awards contained all of the applicable provisions or to ensure that all procurement procedures were completed and documented. Effect – Contractors may not be aware of additional terms and conditions required to be followed to be in compliance with the procurement standards within the Uniform Guidance. Questioned Costs – None reported. Context/Sampling – A nonstatistical sample of 2 out of 4 vendors were selected for detail testing, including one contract subject to Appendix II to Part 200. The contract was missing certain applicable provisions, which include termination clauses, equal employment opportunity, and anti-lobbying, among others. Repeat Finding from Prior Years – No. Recommendation – We recommend the Community Health Center enhance internal control policies to ensure all contracts under Federal awards contain the applicable provisions in Appendix II to Part 200. Views of Responsible Officials – Management agrees with the finding.

2022-001 ? Application of Sliding Fee Schedule Discount Criteria: The Community Health Center is required to have a schedule of fees or payments for the provision of their health services consistent with locally prevailing rates or charges and designed to cover the reasonable costs of operation. The corresponding sliding fee schedule of discounts applied and adjusted should be based on the patient?s ability to pay. The patient?s ability to pay is determined based on the official poverty guidelines, as revised annually by the U.S. Department of Health and Human Services. Condition: During our testing of the sliding fee schedule, we noted the Community Health Center has a sliding fee schedule, whereby the basis of the patient?s ability to pay is based upon the patient?s income, using the federal poverty guidelines as a basis for the percentage of the sliding fee schedule discount. However, in three of the forty patient files tested, the sliding fee schedule discount was calculated incorrectly causing the sliding fee schedule discount to be improperly applied. Cause: The Community Health Center is not following policies and procedures set in place to ensure the sliding fee schedule discount is correctly determined and applied to patient accounts. Effect: The sliding fee discount applied is incorrect. Indication of Repeat Finding: This is a repeat finding. The finding in the prior audit was 2021-001. Recommendation: We recommend the Community Health Center?s sliding fee schedule discount be correctly applied by following established policies and procedures regarding the sliding fee schedule calculation. Views of Responsible Officials and Planned Corrective Actions: The Community Health Center has been focused on continuous improvement and ongoing focused training for the past two years. The Clinic has continued to implement new workflows and procedures. In January 2022, we started to internally review 100% of the sliding fee documents and correct any errors as soon as they are discovered. Additionally, our Billing department does a review of a random sample to ensure our internal audit is performing as planned. Our organization?s leadership and Board of Directors understand the importance of the requirement to apply our policies and procedures accurately and appropriately regarding the sliding fee discount calculations. The Community Health Center has taken swift and direct actions to improve our adherence to our policies and procedures related to the sliding fee discounts.

2021-001 ? Application of Sliding Fee Schedule Discount Criteria: The Community Health Center is required to have a schedule of fees or payments for the provision of their health services consistent with locally prevailing rates or charges and designed to cover the reasonable costs of operation. The corresponding sliding fee schedule of discounts applied and adjusted should be based on the patient?s ability to pay. The patient?s ability to pay is determined based on the official poverty guidelines, as revised annually by the U.S. Department of Health and Human Services. Condition: During our testing of the sliding fee schedule, we noted the Community Health Center has a sliding fee schedule, whereby the basis of the patient?s ability to pay is based upon the patient?s income, using the federal poverty guidelines as a basis for the percentage of the sliding fee schedule discount. However, in four of the forty patient files tested, the sliding fee schedule discount was calculated incorrectly causing the sliding fee schedule discount to be improperly applied. Cause: The Community Health Center is not following policies and procedures set in place to ensure the sliding fee schedule discount is correctly determined and applied to patient accounts. Effect: The sliding fee discount applied is incorrect. Indication of Repeat Finding: This is a repeat finding. The finding in the prior audit was 2020-001. Recommendation: We recommend the Community Health Center?s sliding fee schedule discount be correctly applied by following established policies and procedures regarding the sliding fee schedule calculation. Views of Responsible Officials and Planned Corrective Actions: The Community Health Center is keenly aware of the need to apply our policies and procedures accurately and appropriately regarding the sliding fee discount calculations. The Community Health Center will take immediate actions to improve our adherence to our policies and procedures related to the sliding fee discounts.

2020-001: Material Weakness - Application of SFS Discount Criteria The Organization is required to have a schedule of fees or payments for the provision of their health services consistent with locally prevailing rates or charges and designed to cover the reasonable costs of operation. The corresponding schedule of discounts applied and adjusted should be based on the patient?s ability to pay. The patient?s ability to pay is determined based on the official poverty guidelines, as revised annually by the U.S. Department of Health and Human Services. Condition During our testing of the Sliding Fee Schedule (SFS), we noted the Organization properly has an SFS schedule whereby the basis of the patient?s ability to pay is based upon the patient?s income,using the federal poverty guidelines as a basis for the percentage of the SFS discount. However, in two of the forty patient files tested, the patient?s income was improperly calculated causing the SFS discount to be improperly applied and the patient should have paid more. In one of the forty files tested, income information was not timely entered and due to the automation of slide calculation and application, no slide was applied to the services rendered. In one of the forty files tested, the patient?s application and income information were not maintained to substantiate the slide application. In addition, the Organization did not follow their internal controls policy regarding the SFS discount on the same four files. Cause The Organization is not following policies and procedures set in place to ensure the SFS discount is correctly determined and applied to patient accounts. Effect The SFS discount applied is incorrect. Recommendation We recommend management correctly apply the SFS discount. Management should review policies and procedures regarding the SFS program with staff that is responsible for determining the SFS discount. Views of Responsible Officials and Planned Corrective Actions Management will correctly apply the SFS discounts to all patient accounts and review all current accounts for proper SFS discounts. Management will train and guide Patient Services to verify income status and assure SFS are applied correctly. Indication of Repeat Finding This is not a repeat finding.

2020-002: Significant Deficiency - Reporting Criteria The Organization is required to have written policies/procedures exist outlining processes and control activities for ensuring reporting to Federal awarding agencies and pass-through entities is complete and accurate. Condition During our testing of Quarterly FFR reporting and annual UDS reporting, we noted that the reports were timely and accurately filed. However, we also noted that the Organization does not have a formal written policy for preparation and review of said reports, ensuring that reporting submitted to the federal awarding agency is complete and accurate. Cause The Organization does not have procedures in place allowing knowledgeable supervisors to review reports for completeness and accuracy before final reporting. Effect The reports submitted to federal awarding agencies could be incomplete and inaccurate. Recommendation We recommend management implement policies and procedures regarding the preparation and review of reporting for federal agencies. Views of Responsible Officials and Planned Corrective Actions Management will implement policies and procedures to ensure reporting submitted to federal awarding agencies are complete and accurate. Indication of Repeat Finding This is not a repeat finding.