PECOS VALLEY MEDICAL CENTER, INC. -3 MONTH AUDIT-LINK TO 111103

EIN: 850300494

UEI: GSA_MIGRATION

Data as of August 24, 2026

PECOS VALLEY MEDICAL CENTER, INC. -3 MONTH AUDIT-LINK TO 1111035 audit years3 findings1 repeat
5
Audit Years
3
Total Findings
1
Repeat Findings

FY 2019-09-30

Management decision deadline — for entities that funded this organization

The FAC accepted this audit on May 19, 2020. 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 November 19, 2020 (2104 days ago).

What is a management decision? →
2019-001
Special Tests & Provisions
REPEAT

Funding Agency: U.S. Department of Health and Human Services Title: Community Health Centers CFDA #: 93.224 Award Period: FY 2019 Estimated Questioned Costs: None Statement of Condition Sliding fee discounts were not applied in accordance with Board policies for 4 of the 25 patient records reviewed. It should be noted all 4 exceptions related to dental visits. Criteria Per the Uniform Guidance compliance supplement, ?Health centers must prepare and apply a sliding fee discount schedule (SFDS) so that the amounts owed for health center services by eligible patients are adjusted (discounted) based on the patient?s ability to pay.? Additionally, auditors are required to review a sample of financial records for patients treated during the audit period to determine whether patient charges were appropriately adjusted based on income and family size by applying the health center?s sliding fee discount schedule. Cause It does not appear PVMC?s updated sliding fee discount schedule was made available to dental facility administrative staff. Effect PVMC applied incorrect sliding fee discounts for dental services provided to individuals and families. Recommendation PVMC should ensure all administrative staff are continually updated with current discount schedules to ensure compliance with federal regulations. View of Responsible Officials Due to turnover of both CEO and CFO positions, the Board did not approve the new Sliding Fee Discount schedule based on 2019 Federal poverty guidelines until mid-2019. Prior to that date, the past Dental manager was manually sliding dental accounts in the e-clinical works health records system using an outdated schedule. Corrective Action Plan Timeline When this finding was brought to our attention, the most current sliding fee schedule was provided to staff and posted at our medical and dental front desk areas and pharmacy window. Also, post-merger, PVMC now utilizes the NextGen electronic health record where the patient?s account is automatically slid and it is the sole responsibility of the PMS Reimbursement Department to oversee any additional write-off adjustments. Designation of Employee Position Responsible For Meeting Deadline PMS Reimbursement Department

Show full finding ▾
Full finding narrative

Funding Agency: U.S. Department of Health and Human Services Title: Community Health Centers CFDA #: 93.224 Award Period: FY 2019 Estimated Questioned Costs: None Statement of Condition Sliding fee discounts were not applied in accordance with Board policies for 4 of the 25 patient records reviewed. It should be noted all 4 exceptions related to dental visits. Criteria Per the Uniform Guidance compliance supplement, ?Health centers must prepare and apply a sliding fee discount schedule (SFDS) so that the amounts owed for health center services by eligible patients are adjusted (discounted) based on the patient?s ability to pay.? Additionally, auditors are required to review a sample of financial records for patients treated during the audit period to determine whether patient charges were appropriately adjusted based on income and family size by applying the health center?s sliding fee discount schedule. Cause It does not appear PVMC?s updated sliding fee discount schedule was made available to dental facility administrative staff. Effect PVMC applied incorrect sliding fee discounts for dental services provided to individuals and families. Recommendation PVMC should ensure all administrative staff are continually updated with current discount schedules to ensure compliance with federal regulations. View of Responsible Officials Due to turnover of both CEO and CFO positions, the Board did not approve the new Sliding Fee Discount schedule based on 2019 Federal poverty guidelines until mid-2019. Prior to that date, the past Dental manager was manually sliding dental accounts in the e-clinical works health records system using an outdated schedule. Corrective Action Plan Timeline When this finding was brought to our attention, the most current sliding fee schedule was provided to staff and posted at our medical and dental front desk areas and pharmacy window. Also, post-merger, PVMC now utilizes the NextGen electronic health record where the patient?s account is automatically slid and it is the sole responsibility of the PMS Reimbursement Department to oversee any additional write-off adjustments. Designation of Employee Position Responsible For Meeting Deadline PMS Reimbursement Department

Corrective Action Plan

View of Responsible Officials Due to turnover of both CEO and CFO positions, the Board did not approve the new Sliding Fee Discount schedule based on 2019 Federal poverty guidelines until mid-2019. Prior to that date, the past Dental manager was manually sliding dental accounts in the e-clinical works health records system using an outdated schedule. Corrective Action Plan Timeline When this finding was brought to our attention, the most current sliding fee schedule was provided to staff and posted at our medical and dental front desk areas and pharmacy window. Also, post-merger, PVMC now utilizes the NextGen electronic health record where the patient?s account is automatically slid and it is the sole responsibility of the PMS Reimbursement Department to oversee any additional write-off adjustments. Designation of Employee Position Responsible For Meeting Deadline PMS Reimbursement Department

Prior Finding References

2019-001

About Special Tests and Provisions →

FY 2019-06-30

FAC accepted this audit on March 24, 2020 — management decision was due September 24, 2020.

2019-001
Special Tests & Provisions

Statement of Condition Sliding fee discounts were not applied in accordance with Board policies for 9 of the 25 patient records reviewed. It should be noted all 9 exceptions related to dental visits. Criteria Per the Uniform Guidance compliance supplement, ?Health centers must prepare and apply a sliding fee discount schedule (SFDS) so that the amounts owed for health center services by eligible patients are adjusted (discounted) based on the patient?s ability to pay.? Additionally, auditors are required to review a sample of financial records for patients treated during the audit period to determine whether patient charges were appropriately adjusted based on income and family size by applying the health center?s sliding fee discount schedule. Cause It does not appear PVMC?s updated sliding fee discount schedule was made available to dental facility administrative staff. Effect PVMC applied incorrect sliding fee discounts for dental services provided to individuals and families. Recommendation PVMC should ensure all administrative staff are continually updated with current discount schedules to ensure compliance with federal regulations. View of Responsible Officials Due to turnover of both CEO and CFO positions, the Board did not approve the new Sliding Fee Discount schedule based on 2019 Federal poverty guidelines until mid-2019. Prior to that date, the past Dental manager was manually sliding dental accounts in the e-clinical works health records system using an outdated schedule.Corrective Action Plan Timeline When this finding was brought to our attention, the most current sliding fee schedule was provided to staff and posted at our medical and dental front desk areas and pharmacy window. Also, post-merger, PVMC now utilizes the NextGen electronic health record where the patient?s account is automatically slid and it is the sole responsibility of the PMS Reimbursement Department to oversee any additional write-off adjustments. Designation of Employee Position Responsible For Meeting Deadline PMS Reimbursement Department

Show full finding ▾
Full finding narrative

Statement of Condition Sliding fee discounts were not applied in accordance with Board policies for 9 of the 25 patient records reviewed. It should be noted all 9 exceptions related to dental visits. Criteria Per the Uniform Guidance compliance supplement, ?Health centers must prepare and apply a sliding fee discount schedule (SFDS) so that the amounts owed for health center services by eligible patients are adjusted (discounted) based on the patient?s ability to pay.? Additionally, auditors are required to review a sample of financial records for patients treated during the audit period to determine whether patient charges were appropriately adjusted based on income and family size by applying the health center?s sliding fee discount schedule. Cause It does not appear PVMC?s updated sliding fee discount schedule was made available to dental facility administrative staff. Effect PVMC applied incorrect sliding fee discounts for dental services provided to individuals and families. Recommendation PVMC should ensure all administrative staff are continually updated with current discount schedules to ensure compliance with federal regulations. View of Responsible Officials Due to turnover of both CEO and CFO positions, the Board did not approve the new Sliding Fee Discount schedule based on 2019 Federal poverty guidelines until mid-2019. Prior to that date, the past Dental manager was manually sliding dental accounts in the e-clinical works health records system using an outdated schedule.Corrective Action Plan Timeline When this finding was brought to our attention, the most current sliding fee schedule was provided to staff and posted at our medical and dental front desk areas and pharmacy window. Also, post-merger, PVMC now utilizes the NextGen electronic health record where the patient?s account is automatically slid and it is the sole responsibility of the PMS Reimbursement Department to oversee any additional write-off adjustments. Designation of Employee Position Responsible For Meeting Deadline PMS Reimbursement Department

Corrective Action Plan

View of Responsible Officials Due to turnover of both CEO and CFO positions, the Board did not approve the new Sliding Fee Discount schedule based on 2019 Federal poverty guidelines until mid-2019. Prior to that date, the past Dental manager was manually sliding dental accounts in the e-clinical works health records system using an outdated schedule. Corrective Action Plan Timeline When this finding was brought to our attention, the most current sliding fee schedule was provided to staff and posted at our medical and dental front desk areas and pharmacy window. Also, post-merger, PVMC now utilizes the NextGen electronic health record where the patient?s account is automatically slid and it is the sole responsibility of the PMS Reimbursement Department to oversee any additional write-off adjustments. Designation of Employee Position Responsible For Meeting Deadline PMS Reimbursement Department

About Special Tests and Provisions →
2019-002
Other

Statement of Condition Although PVMC has designed internal controls in administering its federal award program, it does not appear the controls are being properly implemented. We noted the following exceptions for the 20 drawdowns reviewed: "See Schedule of Findings and Questioned Costs for chart/table. Criteria Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (the Uniform Guidance), states in section 200.303 that non-federal entities must establish and maintain effective internal control over federal awards that provides the non-federal entity is managing the federal award in compliance with federal statutes, regulations, and the terms of the federal award. These internal controls should be in compliance the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). Cause PVMC experienced turnover at both CEO and CFO positions during 2019. Effect PVMC has not complied with the specific requirements as described in the Uniform Guidance. Recommendation We recommend PVMC review and maintain its policies and internal control procedures and formalize written policies and procedures for administering federal grant awards, in compliance with Uniform Guidance. View of Responsible Officials Due to turnover in both the CEO/CFO positions there were several employees who were charged with working on the construction grant during the early months of 2019. In addition, PVMC also experienced turnover with respect to USDA project officers and construction superintendents. USDA was ultimately responsible for approving all draws and required all approval documents for each draw down and signed documents most likely exist but were not returned to PVMC. Corrective Action Plan Timeline Because the construction project is complete and USDA has approved all drawdowns with adequate documentation, management believes no further action is necessary. Designation of Employee Position Responsible For Meeting Deadline Because the construction project is complete and USDA has approved all drawdowns with adequate documentation, management believes no further action is necessary.

Show full finding ▾
Full finding narrative

Statement of Condition Although PVMC has designed internal controls in administering its federal award program, it does not appear the controls are being properly implemented. We noted the following exceptions for the 20 drawdowns reviewed: "See Schedule of Findings and Questioned Costs for chart/table. Criteria Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (the Uniform Guidance), states in section 200.303 that non-federal entities must establish and maintain effective internal control over federal awards that provides the non-federal entity is managing the federal award in compliance with federal statutes, regulations, and the terms of the federal award. These internal controls should be in compliance the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). Cause PVMC experienced turnover at both CEO and CFO positions during 2019. Effect PVMC has not complied with the specific requirements as described in the Uniform Guidance. Recommendation We recommend PVMC review and maintain its policies and internal control procedures and formalize written policies and procedures for administering federal grant awards, in compliance with Uniform Guidance. View of Responsible Officials Due to turnover in both the CEO/CFO positions there were several employees who were charged with working on the construction grant during the early months of 2019. In addition, PVMC also experienced turnover with respect to USDA project officers and construction superintendents. USDA was ultimately responsible for approving all draws and required all approval documents for each draw down and signed documents most likely exist but were not returned to PVMC. Corrective Action Plan Timeline Because the construction project is complete and USDA has approved all drawdowns with adequate documentation, management believes no further action is necessary. Designation of Employee Position Responsible For Meeting Deadline Because the construction project is complete and USDA has approved all drawdowns with adequate documentation, management believes no further action is necessary.

Corrective Action Plan

View of Responsible Officials Due to turnover in both the CEO/CFO positions there were several employees who were charged with working on the construction grant during the early months of 2019. In addition, PVMC also experienced turnover with respect to USDA project officers and construction superintendents. USDA was ultimately responsible for approving all draws and required all approval documents for each draw down and signed documents most likely exist but were not returned to PVMC. Corrective Action Plan Timeline Because the construction project is complete and USDA has approved all drawdowns with adequate documentation, management believes no further action is necessary. Designation of Employee Position Responsible For Meeting Deadline Because the construction project is complete and USDA has approved all drawdowns with adequate documentation, management believes no further action is necessary.

About Other →

Data source: This information comes from the Federal Audit Clearinghouse, the official repository of Single Audit data. All data is public domain. Verify this organization's audit history at fac.gov.

Are you this organization?

Track your findings and corrective action plans across audit cycles.

Start tracking findings →

Do you fund this organization?

Monitor subrecipient audit findings and compliance status.

Start monitoring →

Product

Resources

Legal

Single Audit Intelligence is an independent tool powered by Federal Audit Clearinghouse data. Not affiliated with GSA, OMB, or any federal agency.

© 2026 Single Audit Intelligence. All data is public domain.