EIN: 952671433
UEI: X2NUFZLDSCU3
Audited by: CHW LLP
Oversight agency: 93 [Department of Health and Human Services]
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Data as of August 28, 2026
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on May 14, 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 November 14, 2026 (76 days from today).
What is a management decision? →In our sample of 40 tested items three patients received the incorrect sliding fee discount based on the family size and income level. Questioned Cost: None. Effect: Lack of strict enforcement of the policy of sliding fee eligibility determination and compliance may have resulted in the Center providing discounted services greater to or less than the appropriate amounts to beneficiaries. Cause: Inadequate understanding of the sliding fee program requirements, how the electronic health record system processes sliding fee transactions, or Center policies by employees involved in sliding fee determination and billing. Recommendation: Training should be provided to employees on the sliding fee program requirements and how the program is managed by the electronic health record system. The Center should perform regular audits of sliding fee transactions to identify weaknesses in compliance. Views of Responsible Officials and Corrective Action Plan: Management agrees with the finding and is moving forward with its corrective action plan to address it. Please see page 31.
Show full finding ▾Hide full finding ▴2025-001 Sliding Fee Discount Determination ALN: 93.224 Program: Community Health Center Cluster Agency: US Department of Health and Human Services Compliance Requirement: N Special Tests and Provisions Repeat Finding: No Criteria: Federal grant compliance provisions require that the Center correctly identify a patient's ability to pay and that the rates for services be adjusted accordingly based on the sliding fee schedule. The Center is required to follow its sliding fee policy when providing discounts to eligible patients. Finding/ Condition: In our sample of 40 tested items three patients received the incorrect sliding fee discount based on the family size and income level. Questioned Cost: None. Effect: Lack of strict enforcement of the policy of sliding fee eligibility determination and compliance may have resulted in the Center providing discounted services greater to or less than the appropriate amounts to beneficiaries. Cause: Inadequate understanding of the sliding fee program requirements, how the electronic health record system processes sliding fee transactions, or Center policies by employees involved in sliding fee determination and billing. Recommendation: Training should be provided to employees on the sliding fee program requirements and how the program is managed by the electronic health record system. The Center should perform regular audits of sliding fee transactions to identify weaknesses in compliance. Views of Responsible Officials and Corrective Action Plan: Management agrees with the finding and is moving forward with its corrective action plan to address it. Please see page 31.
Name of Contact Person: Sarah Ross, Chief Operating Officer Corrective Action: Under the leadership of Open Door’s Chief Operations Officer and Director of Patient Access, we will implement the following actions to address SFDP compliance findings and reduce the risk of future errors. 1. Staff Retraining and Competency Validation Retrain all Office Managers and Front Office staff on SFDP requirements, documentation standards, and processing procedures in collaboration with EMR and Learning & Development. Staff will be required to successfully complete a knowledge check prior to independently handling SFDP documentation. SFDP training will also be incorporated into new-hire onboarding and reinforced through ongoing training as needed. 2. Ongoing Monitoring and Accountability Implement a formal monitoring and accountability process to ensure sustained compliance. SFDP accuracy will be reviewed weekly, with Front Office Managers maintaining an error log to track errors, trends, and corrective actions. Continued or repeated errors will be addressed through expectation conversations and progressive disciplinary action, while accurate and consistent performance will be recognized. 3. Monthly Reporting and Targeted Corrective Training Identify trends and common error types, utilizing monthly SFDP reporting, to inform targeted retraining and process improvements. The reporting infrastructure is currently being developed using the Smartsheet Intelligent Work Management Platform to support leadership oversight and continuous improvement. 4. Leadership Oversight and Site-Level Accountability Administrative Directors at all health centers will actively participate in SFDP oversight by meeting with staff to reinforce program expectations and consequences for non-compliance. Monthly site-level SFDP performance reviews will be conducted with the Director of Patient Access, Administrative Directors, and Office Managers to review findings, trends, and corrective actions. 5. Integration into Performance Evaluations SFDP compliance will be formally integrated into staff performance evaluations. Compliance measures are currently included in Office Manager scorecards and will be added to Receptionist performance evaluations to reinforce accountability and sustain compliance. 6. Process Improvement Through Automation To further reduce the risk of human error, Open Door is planning a transition toward increased SFDP automation within the EMR to standardize determinations and improve documentation accuracy over time. Proposed Completion Date: June 30, 2026
FAC accepted this audit on April 29, 2025 — management decision was due October 29, 2025.
FAC accepted this audit on April 30, 2024 — management decision was due October 30, 2024.
FAC accepted this audit on April 27, 2023 — management decision was due October 27, 2023.
FAC accepted this audit on May 11, 2022 — management decision was due November 11, 2022.
FAC accepted this audit on November 2, 2021 — management decision was due May 2, 2022.
FAC accepted this audit on April 1, 2020 — management decision was due October 1, 2020.
FAC accepted this audit on March 27, 2019 — management decision was due September 27, 2019.
FAC accepted this audit on April 29, 2018 — management decision was due October 29, 2018.
FAC accepted this audit on March 29, 2017 — management decision was due September 29, 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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