EIN: 931191794
UEI: EN5DQN9HKRB6
Audited by: BDMP ASSURANCE, LLP
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 September 30, 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 March 30, 2026 (160 days ago).
What is a management decision? →FAC accepted this audit on July 5, 2024 — management decision was due January 5, 2025.
FAC accepted this audit on September 27, 2023 — management decision was due March 27, 2024.
The Organization has not applied sliding fee discounts to patient charges consistent with its sliding fee discount program. Through testing a statistically valid sample of transactions for the appropriate application of the Organization's sliding fee discount program to 25 individual patient balances, we noted two patients did not have a valid application in effect for the date of service tested, resulting in the ineligible patients receiving discounts of approximately $275 and $168, respectively. Cause: Due to HRSA reporting requirements on the annual Universal Data System (UDS) report for specific patient demographic information, including patient income and family size, the same reporting tool within the the Organization's electronic health records (EHR) is used to capture data for both UDS reporting and sliding fee discount program eligibility. Patients applying for the sliding fee discount program would have the box "self declared" checked, for self declared income and family size, which would then be verified through the formal sliding fee discount application process. Patient accounts with this box checked will be automatically adjusted for sliding fee discounts. Patients not applying for the sliding fee discount program will have the box "self declared - pending approval" checked, resulting in data accumulation only. For the two patients in our sample, the incorrect box was checked resulting in the sliding fee discount being applied to the patient balances without a valid sliding fee application. The Organization has implemented internal monitoring procedures which include the review of sliding fee applications, however the procedures are not currently designed to sample discounts provided to patients to help ensure patients receiving a sliding fee discount are eligible and have a valid sliding fee application in accordance with the Organization's sliding fee discount policy. Effect: The Organization may not be applying sliding fee discounts to patient charges consistent with its sliding fee discount program, resulting in patients not eligible to receive a discount being provided a discount. Questioned Costs: None Repeat Finding: No Recommendation: We recommend management provide training to individuals involved in the patient intake and billing processes specific to the patient income and family size entry process and to modify internal monitoring procedures to include an emphasis in the sampling discounts applied to patient balances. Views of a Responsible Official and Corrective Action Plan: Management agrees with the finding and has implemented additional training and will update monitoring procedures to increase compliance with program requirements.
Show full finding ▾Hide full finding ▴Finding Number: 2022-001 Finding Type(s): Significant deficiency in internal control over compliance; Non compliance related to sliding fee discounts special tests and provisions compliance requirement Information on the Federal Program: Program Name: Health Center Program Cluster (AL 93.224 and 93.527) Grant Award: 5 H80CS10593-14 from May 1, 2021 - April 30, 2022 and 5 H80CS10593-15 from May 1, 2022 - April 30, 2023 Agency: U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA) Criteria: In accordance with Section 330(k)(3)(G) of the Public Health Service Act (42 U.S. Code ? 254b), as an FQHC, the Organization must have a sliding fee discount program in which the Organization?s fee schedule is discounted based on a patient?s ability to pay. Condition: The Organization has not applied sliding fee discounts to patient charges consistent with its sliding fee discount program. Through testing a statistically valid sample of transactions for the appropriate application of the Organization's sliding fee discount program to 25 individual patient balances, we noted two patients did not have a valid application in effect for the date of service tested, resulting in the ineligible patients receiving discounts of approximately $275 and $168, respectively. Cause: Due to HRSA reporting requirements on the annual Universal Data System (UDS) report for specific patient demographic information, including patient income and family size, the same reporting tool within the the Organization's electronic health records (EHR) is used to capture data for both UDS reporting and sliding fee discount program eligibility. Patients applying for the sliding fee discount program would have the box "self declared" checked, for self declared income and family size, which would then be verified through the formal sliding fee discount application process. Patient accounts with this box checked will be automatically adjusted for sliding fee discounts. Patients not applying for the sliding fee discount program will have the box "self declared - pending approval" checked, resulting in data accumulation only. For the two patients in our sample, the incorrect box was checked resulting in the sliding fee discount being applied to the patient balances without a valid sliding fee application. The Organization has implemented internal monitoring procedures which include the review of sliding fee applications, however the procedures are not currently designed to sample discounts provided to patients to help ensure patients receiving a sliding fee discount are eligible and have a valid sliding fee application in accordance with the Organization's sliding fee discount policy. Effect: The Organization may not be applying sliding fee discounts to patient charges consistent with its sliding fee discount program, resulting in patients not eligible to receive a discount being provided a discount. Questioned Costs: None Repeat Finding: No Recommendation: We recommend management provide training to individuals involved in the patient intake and billing processes specific to the patient income and family size entry process and to modify internal monitoring procedures to include an emphasis in the sampling discounts applied to patient balances. Views of a Responsible Official and Corrective Action Plan: Management agrees with the finding and has implemented additional training and will update monitoring procedures to increase compliance with program requirements.
Finding: 2022-001 Condition Found: The Organization has not applied sliding fee discounts to patient charges consistent with its sliding fee discount program. Through testing a statistically valid sample of transactions for the appropriate application of the Organization's sliding fee discount program to 25 individual patient balances, two patients did not have a valid application in effect for the date of service tested, resulting in the ineligible patients receiving discounts of approximately $275 and $168. Individual(s) Responsible for Corrective Action: Primary: Nicole Townsend Treber, Front Desk Supervisor Support: Brendan Johnson, Director of Quality Support: Lora Ressler, Executive Administrative Assistant Planned Corrective Action: ? Front Desk Supervisor will provide on-going training to individuals involved in the patient intake and billing processes specific to the patient income and family size entry process; ? Monthly: Director of Quality will provide reports that show SFS adjustments vs completed SFS applications; ? Monthly: Designated employee will be responsible for audit sampling; ? Monthly: Results of audit sampling will be forwarded to Front Desk Supervisor and if needed, will provide additional training. Anticipated Completion Date: January 1, 2024
FAC accepted this audit on February 9, 2023 — management decision was due August 9, 2023.
In a nonstatistical sample, one of two annual Federal Financial Reports tested included certain amounts which were not supported by underlying accounting records. The report was to be completed on the accrual basis of accounting, however based on our procedures we determined the report was completed on the cash basis of accounting. The "Federal share of expenditures" reported on line 10.e. represented cumulative cash draws in the amount of $2,736,184. Upon review of the underlying accounting records, the Organization had cumulative federal grant expenditures for the period of $2,856,184. As a result, the Organization underreported the "Federal share of expenditures" on line 10.e. and overstated the "Unobligated balance of Federal Funds" on line 10.h. by $120,000. Cause: The Organization's system of internal control over the preparation of annual federal expenditure reports did not include an adequate level of review and analysis to detect and correct potential material errors in the reports Effect: Inaccurate reports could result in the loss of grant dollars or the repayment of previously received grant dollars. Questioned Costs: None Repeat Finding: No Recommendation: We recommend management develop a process to enhance the review of federal reports to help ensure the reports are completed accurately and fully supported by the Organization's accounting records. Views of a Responsible Official and Corrective Action Plan: Management agrees with the finding. A process will be established related to the review and approval of all federal reports.
Show full finding ▾Hide full finding ▴Finding Number: 2021 002 Finding Type(s): Material weakness over compliance Noncompliance related to reporting compliance requirement Information on the Federal Program: Program Name: COVID 19 Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) (AL 93.224 and 93.224) Federal Awards Project Title: Health Center Program Award Period: May 1, 2020 - April 30, 2021 Award Number: 5 H80CS10593 13 00 Agency: U.S. Department of Health and Human Services (HHS), Health Resources and Services Administration (HRSA) Criteria: Management is responsible for ensuring required reports for federal awards include all activity of the reporting period, are supported by applicable accounting or performance records, and are fairly presented in accordance with governing requirements. Condition: In a nonstatistical sample, one of two annual Federal Financial Reports tested included certain amounts which were not supported by underlying accounting records. The report was to be completed on the accrual basis of accounting, however based on our procedures we determined the report was completed on the cash basis of accounting. The "Federal share of expenditures" reported on line 10.e. represented cumulative cash draws in the amount of $2,736,184. Upon review of the underlying accounting records, the Organization had cumulative federal grant expenditures for the period of $2,856,184. As a result, the Organization underreported the "Federal share of expenditures" on line 10.e. and overstated the "Unobligated balance of Federal Funds" on line 10.h. by $120,000. Cause: The Organization's system of internal control over the preparation of annual federal expenditure reports did not include an adequate level of review and analysis to detect and correct potential material errors in the reports Effect: Inaccurate reports could result in the loss of grant dollars or the repayment of previously received grant dollars. Questioned Costs: None Repeat Finding: No Recommendation: We recommend management develop a process to enhance the review of federal reports to help ensure the reports are completed accurately and fully supported by the Organization's accounting records. Views of a Responsible Official and Corrective Action Plan: Management agrees with the finding. A process will be established related to the review and approval of all federal reports.
Finding: 2022-002 Condition Found: In a nonstatistical sample, one of two annual Federal Financial Reports tested included certain amounts which were not supported by underlying accounting records. The report was to be completed on the accrual basis of accounting, however based on our procedures we determined the report was completed on the cash basis of accounting. The "Federal share of expenditures" reported on line 10.e. represented cumulative cash draws in the amount of $2,736,184. Upon review of the underlying accounting records, the Organization had cumulative federal grant expenditures for the period of $2,856,184. As a result, the Organization underreported the "Federal share of expenditures" on line 10.e. and overstated the "Unobligated balance of Federal Funds" on line 10.h. by $120,000. Individual(s) Responsible for Corrective Action: Kenneth Boardman, CFO Planned Corrective Action: We plan to review the above issues and come up with a solid plan to correct the issues accordingly. Anticipated Completion Date: On or before 7/30/2023
FAC accepted this audit on March 27, 2022 — management decision was due September 27, 2022.
FAC accepted this audit on March 9, 2021 — management decision was due September 9, 2021.
FAC accepted this audit on September 26, 2019 — management decision was due March 26, 2020.
GSA_MIGRATION
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GSA_MIGRATION
2017-003
FAC accepted this audit on September 20, 2018 — management decision was due March 20, 2019.
GSA_MIGRATION
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GSA_MIGRATION
FAC accepted this audit on September 18, 2017 — management decision was due March 18, 2018.
GSA_MIGRATION
Show full finding ▾Hide full finding ▴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.
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