EIN: 952281302
UEI: JL7AMM93NLM5
Audited by: DZA PLLC
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 March 4, 2026. 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 September 4, 2026 (1 day from today).
What is a management decision? →FAC accepted this audit on February 14, 2025 — management decision was due August 14, 2025.
FAC accepted this audit on February 20, 2024 — management decision was due August 20, 2024.
FAC accepted this audit on March 30, 2023 — management decision was due September 30, 2023.
FAC accepted this audit on May 12, 2022 — management decision was due November 12, 2022.
In our testing of 40 sliding fee discounts for health center patients qualifying for reduced charge visits, we identified one instance where no application was maintained. We also identified one incident where the incorrect sliding fee was applied to the patient. Cause: The District did not have a review process in place to verify eligible patients completed the required application to receive a sliding fee discount and that each application contained the required information. Additionally, the District did not verify the correct sliding fee discount was based on the District?s sliding fee scale. Context: The finding appears to be an isolated problem. Effect: Missing applications could indicate that patients who received a sliding fee discount may not have been eligible. Additionally, the sliding fee discount could be applied incorrectly and not in accordance with the District?s policy. Recommendation: It is recommended to develop proper controls around the collection of sliding fee applications, verifying required patient information is present and complete, and apply the sliding fee discount in accordance with written policy. To ensure sliding fee discounts are properly calculated and documented, the District should increase the frequency of random reviews of its sliding fee discount applications to help detect and correct errors or incomplete applications on a timely basis. In addition, the District should provide additional training of staff involved in the application of sliding fee discounts. View of responsible officials and planned corrective action: See corrective action plan.
Show full finding ▾Hide full finding ▴Federal Agency U.S. Department of Health and Human Services Federal Assistance Listing Number: 93.224 and 93.527 Health Center Program Cluster Award Number: H80CS26610 Criteria: [X] Compliance Finding [ ] Significant Deficiency [ ] Material Weakness OMB 2 CFR 200, Subpart F Compliance Supplement, Part 4, Compliance Requirement N, Special Tests and Provisions states, ?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: In our testing of 40 sliding fee discounts for health center patients qualifying for reduced charge visits, we identified one instance where no application was maintained. We also identified one incident where the incorrect sliding fee was applied to the patient. Cause: The District did not have a review process in place to verify eligible patients completed the required application to receive a sliding fee discount and that each application contained the required information. Additionally, the District did not verify the correct sliding fee discount was based on the District?s sliding fee scale. Context: The finding appears to be an isolated problem. Effect: Missing applications could indicate that patients who received a sliding fee discount may not have been eligible. Additionally, the sliding fee discount could be applied incorrectly and not in accordance with the District?s policy. Recommendation: It is recommended to develop proper controls around the collection of sliding fee applications, verifying required patient information is present and complete, and apply the sliding fee discount in accordance with written policy. To ensure sliding fee discounts are properly calculated and documented, the District should increase the frequency of random reviews of its sliding fee discount applications to help detect and correct errors or incomplete applications on a timely basis. In addition, the District should provide additional training of staff involved in the application of sliding fee discounts. View of responsible officials and planned corrective action: See corrective action plan.
Correction action planned: A random selection of 40 charts will be reviewed to ensure compliance with sliding fee discount schedule and policy. The review will include: ? Patient was given a correct discount percentage for services received based on the Community Health Center policy ? Patient application for sliding fee discount was retained in the patient?s medical record ? Patient?s income on the sliding fee discount application agreed with the information entered into the demographic section of the patient?s medical record Patient charts will be reviewed quarterly. Any errors or omission will be corrected immediately or on the patient?s next visit. The results will be presented to the CHC Quality Committee. Staff will be retrained as needed based on the results of the chart review. Anticipated completion date: Completed as of December 1, 2020 Contact person responsible for corrective action: Deborah Anderson, CFO
2020-001
FAC accepted this audit on November 10, 2020 — management decision was due May 10, 2021.
The District lacked adequate controls over its sliding fee discount program to ensure applications were properly processed, recorded, and patients received the correct discount. For patient files reviewed who received a sliding fee discount, the following instances of noncompliance were noted: For two of 40 patient files reviewed who received a sliding fee discount, the patient was given an incorrect discount percentage based on the District's policy. For four of 40 patient files reviewed who received a sliding fee discount, the patient applications were not retained. For five of 40 patient files reviewed who received a sliding fee discount, the patient's income on the application did not agree to the information entered into the system. Cause: The District did not have a review process in place to verify that eligible patients completed the required application to receive a sliding fee discount and each application contained the required information. Additionally, the District did not verify the applicable sliding fee discount was applied according to the District?s policy. Effect: Missing applications and income information could indicate that patients who received a sliding fee discount may not have been eligible. Additionally, the sliding fee discount could be applied incorrectly and not in accordance with the District?s policy. Recommendation: It is recommended to develop proper controls around the collection of sliding fee applications, verifying required patient information is present and complete, and apply the sliding fee discount in accordance with written police. This will ensure the District can detect and prevent ineligible patients from receiving the discount and comply with federal compliance requirements. To help ensure that sliding fee discounts are properly calculated and documented, the District should increase the frequency of random reviews of its sliding fee discounts applications in order to help detect and correct errors or incomplete applications on a timely basis. View of Responsible Officials: See corrective action plan.
Show full finding ▾Hide full finding ▴Criteria: Health centers must prepare and apply the sliding fee discount schedule and policy so that the amounts owed for health center services by eligible patients are adjusted based on the patient's ability to pay (42 USC 254(k)(3)(E), (F), and (G); 42 CFR sections 51c.303(e), (f), and (g); and 42 CFR sections 56.303(e), (f), and (g)). Condition: The District lacked adequate controls over its sliding fee discount program to ensure applications were properly processed, recorded, and patients received the correct discount. For patient files reviewed who received a sliding fee discount, the following instances of noncompliance were noted: For two of 40 patient files reviewed who received a sliding fee discount, the patient was given an incorrect discount percentage based on the District's policy. For four of 40 patient files reviewed who received a sliding fee discount, the patient applications were not retained. For five of 40 patient files reviewed who received a sliding fee discount, the patient's income on the application did not agree to the information entered into the system. Cause: The District did not have a review process in place to verify that eligible patients completed the required application to receive a sliding fee discount and each application contained the required information. Additionally, the District did not verify the applicable sliding fee discount was applied according to the District?s policy. Effect: Missing applications and income information could indicate that patients who received a sliding fee discount may not have been eligible. Additionally, the sliding fee discount could be applied incorrectly and not in accordance with the District?s policy. Recommendation: It is recommended to develop proper controls around the collection of sliding fee applications, verifying required patient information is present and complete, and apply the sliding fee discount in accordance with written police. This will ensure the District can detect and prevent ineligible patients from receiving the discount and comply with federal compliance requirements. To help ensure that sliding fee discounts are properly calculated and documented, the District should increase the frequency of random reviews of its sliding fee discounts applications in order to help detect and correct errors or incomplete applications on a timely basis. View of Responsible Officials: See corrective action plan.
A random selection of forty charts will be reviewed to ensure compliance with sliding fee discount schedule and policy. The review will include: patient was given correct discount percentage for services based on the Community Health Center policy, patient application for sliding fee discount was retained in the patient's medical record, patient's income on the sliding fee discount program agreed with the information entered into the demographics section of the patient's medical record. Patient charts will be reviewed quarterly. Any errors or omission will be corrected immediately or on the patient's next visit. The results will be presented to the CHC Quality Committee. Staff will be retrained as needed based on the results of the chart review. Person responsible: Jacqueline Combs, CEO. Timing for implementation: December 1, 2020.
FAC accepted this audit on November 19, 2019 — management decision was due May 19, 2020.
FAC accepted this audit on December 20, 2018 — management decision was due June 20, 2019.
FAC accepted this audit on November 20, 2017 — management decision was due May 20, 2018.
FAC accepted this audit on March 12, 2017 — management decision was due September 12, 2017.
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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