San Diego American Indian Health CenterNon-Profit

Finding 2021-003 U.S. Department of Health and Human Services Assistance Listing Number: 93.193 Urban Indian Health Services Compliance Requirement: Activities Allowed/Allowable Costs Criteria: San Diego American Indian Health Services is required to use the Urban Indian Health Services grant awards to provide health-related services to Urban Indians as outlined in the notice of grant awards and to maintain documentation that supports the grant expenditures. Condition: Auditor was unable to test 2 of 40 disbursements to supporting invoices. All records pertaining to federal grant expenditures and subject to a Uniform Guidance audit are required to be maintained. Context: San Diego American Indian Health Services was unable to provide invoice support for 2 of 40 disbursements tested, therefore internal control procedures over maintaining records to support the Urban Indian Health Services grant awards were not followed. Cause: The cause for the above invoice support not being able to be located is due to the processes and procedures over filing invoice documentation not being followed properly, caused by turnover that occurred in positions in the accounting and business office. Effect: It is possible that nonallowable costs could be charged to the federal major program. Questioned Costs: None Recommendation: We recommend management review all disbursements for supporting invoices and review processes and procedures over filing invoices so records are properly maintained and able to be located. View of Responsible Officials: Management agrees with the finding and has prepared a corrective action plan.

Finding 2020-003 U.S. Department of Health and Human Services CFDA Number: 93.224/93.527 Health Centers Cluster Award: 6H80CS28993-05-02 Direct N ? Special Tests and Provisions Criteria: Health centers must prepare and apply a 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. Condition: In testing of patients receiving discounts under San Diego American Indian Health Center?s sliding fee schedule, we noted that five of 68 patients selected for testing received an incorrect computed discount, based upon the patient?s signed application and income documentation. In two of the five cases where an incorrect discount was provided, it was determined the patient received a discounted fee available to Native American under various Indian Health Services programs, when the patient was non-native and, therefore, only eligible for discounts under the sliding fee program. In three of five cases the incorrect scale was applied based on patient income. For two of sixty-eight patients, an application could not be located, therefore the auditor was not able to conclude as to if the sliding fee program was followed. We observed that three of the five patients who received incorrect discounts and both patients who had missing applications were from dates prior to San Diego American Indian Health Center beginning its corrective action plan related to the 2019 audit. Cause: The possible causes for the above errors are lack of review process in place to verify the application was completed and filed, the applicable sliding fee discount was applied, and error by staff in determining the patient?s ability to pay. Effect: The sliding fee discount was incorrectly applied and was not in accordance with San Diego American Indian Health Center?s policy, resulting in an increased risk that patients are either over or undercharged. Questioned Costs: None Recommendation: We recommend San Diego American Indian Health Center periodically review patients receiving discounts under the sliding fee schedule program to ensure that the sliding fee discount is properly determined, reviewed, and applied. View of Responsible Officials: Management believes the corrective action plan from the 2019 audit was partially completed in 2020 and is continuing efforts on completion of the corrective action plan.

Finding 2019.002 U.S. Department of Health and Human Services CFDA Number: 93.224/93.527 Health Centers Cluster Award: 6H80CS28993-04-05 Direct N ? Special Tests and Provisions Criteria: Health centers must prepare and apply a 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. Condition: In testing of patients receiving discounts under San Diego American Indian Health Center?s sliding fee schedule, we noted that 5 of 40 patients selected for testing received an incorrect computed discount, based upon the patient?s signed application and income documentation. We also noted that 3 of 40 patients did not provide information regarding their income. Cause: The possible causes for the above errors are lack of review process in place to verify the applicable sliding fee discount was applied and error by staff in determining the patient?s ability to pay. Effect: The sliding fee discount was incorrectly applied and was not in accordance with San Diego American Indian Health Center?s policy, resulting in incorrectly billing of its patients. Questioned Costs: None Recommendation: We recommend San Diego American Indian Health Center periodically review patients receiving discounts under the sliding fee schedule program to ensure that the sliding fee discount is properly determined, reviewed, and applied. View of Responsible Officials: Management agrees with the finding and has prepared a corrective action plan.

Finding 2019.003 U.S. Department of Health and Human Services CFDA Number: 93.243 Projects of Regional and National Significance Award: 5H79SM080135, 6H79SM081550, IH79SM062909 Direct and Pass-Through A ? Activities Allowed or Unallowed and B ? Allowable Costs/Cost Principles Criteria: 2 CFR 200.405(a) states that "A cost is allocable to a particular Federal award or other cost objective if the goods or services involved are chargeable or assignable to that Federal award or cost objective in accordance with relative benefits received.? Condition: In testing direct and indirect costs charged to the Federal award, we observed that 1 of 35 costs selected for testing did not have documentation supporting how costs were allocated to the Federal award. Cause: Oversite and review processes were not sufficiently implemented to ensure all costs expended by the Federal award were properly approved, coded, and supported. Effect: Costs may be charged to the Federal award which were not incurred specifically for that Federal award or costs may be charged to the Federal award for items not necessary or within the principles of the Federal award program. Questioned Costs: None Recommendation: We recommend assigning a program coordinator for each Federal award and ensuring all costs coded to the Federal award are properly reviewed and approved. In accordance with 2 CFR 200.333, all records pertinent to a Federal award must be retained for a period of three years from the date of submission of the final expenditure report, unless otherwise noted. View of Responsible Officials: Management agrees with the finding and has prepared a corrective action plan.