Operation Samahan, Inc.Non-Profit

Finding – 2024-002 – Special Tests and Provisions – Material Weakness in Internal Control over Compliance Criteria: The recipient is required to comply with specific federal regulations and provisions outlined in 2 CFR Part 200, particularly those related to special tests and provisions for the Health Center Program Cluster. This includes maintaining an effective internal control environment to ensure sliding fee discounts are applied to patient charges consistent with the recipients sliding fee discount schedule. Condition/cause: During the audit, it was identified that the sliding fee discounts for health center patients qualifying for reduced charge visits was not consistently applied for patients based on qualification criteria. This was due to turnover in the billing and admitting departments and an overall a lack of appropriate training over the federal program compliance requirements. Effect or potential effect: Certain patients were billed amounts different than the amounts defined by the sliding fee discount schedule. Questioned costs: None identified. Context: We selected a sample of 25 patient visits from a statistically valid population of patients potentially eligible for benefits under the sliding fee schedule during the fiscal year ended June 30, 2024. In 3 out of 25 samples tested, the Organization’s system limitations resulted in patients being billed less than the amounts defined by the sliding fee discount schedule. Repeat finding: Yes, see Finding 2023-002 Recommendation: We recommend the Organization implement an effective process and a comprehensive training of the process to ensure that the sliding fee scale is accurately applied to all qualifying program participants. Additionally, we would recommend the Organization perform regular reviews to ensure there are no issues with the system. Views of responsible officials: Management is in agreement with this finding. See corrective action plan.

2023-002 Special Tests and Provisions Program Information Federal Organization U.S Department of Health and Human Services Assistance Listing Numbers 93.224 & 93.527 Health Center Program Cluster Award Numbers H80CS26623, H8FCS41667, H8DCS35811, H8HCS45016, H8GCS48510, C14CS39779 Criteria 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 patients ability to pay.” [X] Compliance Finding [ ] Significant Deficiency [X] Material Weakness Condition During our testing of sliding fee discounts for health center patients qualifying for reduced charge visits, we identified several incidents in which the sliding fee applied was not consistent with the entities policies based on the patient’s level of income. Context This finding appears to be a systemic problem. A sample size of 25 patients included 15 who did not have the correct sliding fee applied. In addition, 3 of the 15 misapplied sliding fees were due to lack of application on file or incomplete application and 8 of the 15 misapplied sliding fees were due to the sliding fees scales not being correctly calculated by the billing software after changes to the scale were made. Cause Due to turnover in the billing and admitting staff, there was lack of appropriate training relating to the requirements of the sliding fee system to properly administer the sliding fee program. In addition, the billing software was not properly updated for changes in the sliding fee scale to apply the sliding fees correctly based on the levels supported by the patient applications. Effect Patients may have been granted the incorrect sliding fee adjustment. Questioned Costs None identified. Recommendation We recommend continued effort in training personnel on applying the appropriate sliding fee discount based on the Organization’s approved policy and in compliance with the OMB Compliance Supplement requirements. An appropriate level of review should be conducted on patient accounts to ensure proper document retention, application of sliding fee discounts, and third-party insurance billing. In addition, we recommend that after sliding fee scales are updated sufficient testing of billing software is performed to ensure that sliding fees scales are being properly applied. Views of responsible officials and planned corrective action Management …

2022-003 Reporting (repeat of Finding 2021-003) Program Information Federal Organization U.S Department of Health and Human Services Assistance Listing Numbers 93.224 & 93.527 Health Center Program Cluster Award Numbers H80CS26623, H8FCS41667, H8DCS35811, H8HCS45016, C8ECS44852, C14CS39779 Criteria Based on the standards of documentation of Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards Subpart D requires the Organization to retain adequate records and other supporting documentation for reports submitted to awarding agencies under the compliance requirements for reporting. [X] Compliance Finding [ ] Significant Deficiency [X] Material Weakness Condition The Organization did not maintain sufficient supporting records for the information reported in its calendar year 2021 Uniform Data System (UDS) report. Context This finding appears to be a systemic problem. Cause The Organization?s internal controls over compliance did not include adequate controls over the retention of supporting documentation for UDS reports submitted to awarding agencies. Effect The Organization submitted UDS reports for federal awards that may lack supporting documentation. Questioned Costs None identified Recommendation We recommend the Organization maintain documentation supporting reports filed with awarding agencies. Views of responsible officials and planned corrective action Management agrees with this finding. Management is working on improving controls and procedures to ensure appropriate records and supporting documentations. The UDS reporting is made accurate by using not only ECW reporting capabilities, but also by getting an i2i population health data tool as a secondary verification platform for UDS data. See planned corrective actions in the next section of the Schedule of Audit Findings and Questioned Costs.

2022-004 Special Tests and Provisions Program Information Federal Organization U.S Department of Health and Human Services Assistance Listing Numbers 93.224 & 93.527 Health Center Program Cluster Award Numbers H80CS26623, H8FCS41667, H8DCS35811, H8HCS45016, C8ECS44852, C14CS39779 Criteria 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 patients ability to pay.? [X] Compliance Finding [ ] Significant Deficiency [X] Material Weakness Condition During our testing of sliding fee discounts for health center patients qualifying for reduced charge visits, we identified several incidents in which the sliding fee applied was not consistent with the entities policies based on the patient?s level of income. Context This finding appears to be a systemic problem. A sample size of 25 patients included 10 who did not have the correct sliding fee applied. In addition, 7 of the 10 misapplied sliding fees were due to lack of application on file. Cause Due to turnover in the billing and admitting staff, there was lack of appropriate training relating to the requirements of the sliding fee system to properly administer the sliding fee program. Effect Patients may have been granted the incorrect sliding fee adjustment. Questioned Costs None identified. Recommendation We recommend continued effort in training personnel on applying the appropriate sliding fee discount based on the Organization?s approved policy and in compliance with the OMB Compliance Supplement requirements. An appropriate level of review should be conducted on patient accounts to ensure proper document retention, application of sliding fee discounts, and third-party insurance billing. Views of responsible officials and planned corrective action Management agrees with this finding. Management has already taken steps and has updated the clinic?s Sliding Fee Discount Program, the clinic?s fee schedule, and retraining of staff. See planned corrective actions in the next section of the Schedule of Audit Findings and Questioned Costs.

2022-005 Allowable Costs Program Information Federal Organization U.S Department of Health and Human Services Assistance Listing Numbers 93.224 & 93.527 Health Center Program Cluster Award Numbers H80CS26623, H8FCS41667, H8DCS35811, H8HCS45016, C8ECS44852, C14CS39779 Criteria Entities receiving Health Center Program funds must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. [ ] Compliance Finding [X] Significant Deficiency [ ] Material Weakness Condition During our testing of payroll expenditures, it was noted several employees were paid at rates in excess of the approved rate of pay per the respective employee?s personnel file. Context This finding appears to be a systemic problem. A sample size of 34 employees included 7 that were paid at a rate greater than the most recent approved rate per the employee?s personnel file and 2 additional employees who did not have documentation of the approved rate in their personnel file. Cause Due to high turnover in all departments, the human resources department was not able to properly file and retrieve all required documentation relating to the approved rates of pay for new hires and rate increases approved by management and the Board during the year. Effect Rates of pay being paid to employees are not supportable by the Organization?s personnel files. Questioned Costs None identified. Recommendation We recommend each employee?s personnel file be complete and kept up to date to include all rate increases whether due to performance or cost of living increases in order to support the amounts being paid to employees. Views of responsible officials and planned corrective action HR is keeping track and documenting all salary raises and as part of procedure, filling out form (Personnel Action Form) prepared by HR and signed by the CEO every time a raise is given. The form will be put in the employee file. See planned corrective actions in the next section of the Schedule of Audit Findings and Questioned Costs.

Program Information Federal Organization U.S Department of Health and Human Services Assistance Listing Numbers 93.224 & 93.527 Health Center Program Cluster Award Numbers H80CS26623, H8FCS41667, H8DCS35811, H8ECS38608, C14CS39779 Criteria [X] Compliance Finding [ ] Significant Deficiency [X] Material Weakness Based on the standards of documentation of Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards Subpart D requires the Organization to retain adequate records and other supporting documentation for reports submitted to awarding agencies under the compliance requirements for reporting. Condition The Organization did not maintain sufficient supporting records for the information reported in its calendar year 2020 Uniform Data System (UDS) report. Context This finding appears to be an isolated problem. Cause The Organization?s internal controls over compliance did not include adequate controls over the retention of supporting documentation for UDS reports submitted to awarding agencies. Effect The Organization submitted UDS reports for federal awards that may lack supporting documentation. Questioned Costs None identified Recommendation We recommend the Organization maintain documentation supporting reports filed with awarding agencies. Views of responsible officials and planned corrective action Management is in agreement with this finding. Management has policies relating to documentation and is working on improving controls and procedures to ensure appropriate records and supporting documentation is maintained for the required length of time.

2019-002 Application of Sliding Fee Adjustments (repeat of Finding 2018-002) Program Information Federal Organization U.S Department of Health and Human Services CFDA 93.224 & 93.527 Health Centers Cluster Award Numbers H80CS26623 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 patients ability to pay.? Condition During our testing of sliding fee discounts for health center patients qualifying for reduced charge visits, we identified two incidents in which the incorrect sliding fee was applied. Context This finding appears to be an isolated incident. A sample size of 25 patients included 2 which did not have the correct sliding fee applied. Cause While many improvements from prior audits were noted, there was still weakness in the training and review system to properly administer the sliding fee program. Effect Patients may have been granted the incorrect sliding fee adjustment. Questioned Costs None identified

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