EIN: 990303304
UEI: VS18KFLVEY46
Data as of August 21, 2026
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on March 31, 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 October 1, 2025 (325 days ago).
What is a management decision? →Finding 2024.002: Special Tests and Provisions - Sliding Fee Discounts - Significant Deficiency Grantor: U.S. Department of Health and Human Services Federal Program Names: Health Center Program Cluster Community Health Centers COVID-19 - Community Health Centers Affordable Care Act (ACA) Grants for New and Expanded Services Under the Health Grants for New and Expanded Services Under the Health Center Program Federal Assistance Listing Numbers: 93.224 and 93.527 Federal Award Identification Numbers: H80CS00722 - 2023 and 2024, H8FCS41411 - 2023, H8GCS48615 - 2023, H8LCS51009 - 2024, H2ECS50200 - 2023 Criteria Health centers are required to have a corresponding schedule of discounts applied and adjusted on the basis of patients' ability to pay and their eligibility. A patient's eligibility to pay is determined on the basis of the official poverty guideline, as revised by DHHS (42 CFR Sections 51c, 107(b)(5), 56.108(b)(5) and 56.303(f)). The Center should be implementing and monitoring procedures to properly determine, calculate and review sliding fee discounts issued to patients in accordance with the Center's sliding fee scale. Condition The Center did not always apply the sliding fee discount accurately based on the Center's sliding fee discount policy. Cause The Center did not have adequate internal controls in place to effectively ensure that all sliding fee discounts were properly calculated based on approved documentation. Effect The Center did not comply with the appropriate Special Tests and Provisions rules and regulations as per the Uniform Guidance. Questioned Costs None. Context A test of 40 discount transactions was performed and resulted in two instances of a sliding fee discount not being properly calculated based on the respective patient family size and income. Our sample was a statistically valid sample. Identification as a Repeat Finding No. Recommendation The Center should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated based on family size and income. Views of Responsible Officials Management agrees with the audit finding and will strengthen internal controls and accountability to correct the deficiency.
Show full finding ▾Hide full finding ▴Finding 2024.002: Special Tests and Provisions - Sliding Fee Discounts - Significant Deficiency Grantor: U.S. Department of Health and Human Services Federal Program Names: Health Center Program Cluster Community Health Centers COVID-19 - Community Health Centers Affordable Care Act (ACA) Grants for New and Expanded Services Under the Health Grants for New and Expanded Services Under the Health Center Program Federal Assistance Listing Numbers: 93.224 and 93.527 Federal Award Identification Numbers: H80CS00722 - 2023 and 2024, H8FCS41411 - 2023, H8GCS48615 - 2023, H8LCS51009 - 2024, H2ECS50200 - 2023 Criteria Health centers are required to have a corresponding schedule of discounts applied and adjusted on the basis of patients' ability to pay and their eligibility. A patient's eligibility to pay is determined on the basis of the official poverty guideline, as revised by DHHS (42 CFR Sections 51c, 107(b)(5), 56.108(b)(5) and 56.303(f)). The Center should be implementing and monitoring procedures to properly determine, calculate and review sliding fee discounts issued to patients in accordance with the Center's sliding fee scale. Condition The Center did not always apply the sliding fee discount accurately based on the Center's sliding fee discount policy. Cause The Center did not have adequate internal controls in place to effectively ensure that all sliding fee discounts were properly calculated based on approved documentation. Effect The Center did not comply with the appropriate Special Tests and Provisions rules and regulations as per the Uniform Guidance. Questioned Costs None. Context A test of 40 discount transactions was performed and resulted in two instances of a sliding fee discount not being properly calculated based on the respective patient family size and income. Our sample was a statistically valid sample. Identification as a Repeat Finding No. Recommendation The Center should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated based on family size and income. Views of Responsible Officials Management agrees with the audit finding and will strengthen internal controls and accountability to correct the deficiency.
Federal Award Findings and Questioned Costs: Finding 2024.002 - Sliding Fee Scale Documentation Recommendation The Center should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated and supported based on family size and income. Action Taken Management recently migrated their electronic health records from AthenaPractice and Dentrix to EPIC. EPIC is programmed to calculate the sliding fee discount based upon the Family Size and Income that is entered into the system, unlike Dentrix which did not have this capability. In addition, monthly audits are conducted by the Billing Department to ensure that the supporting documentation matches the information entered into EPIC. If there are any question regarding this plan, please e-mail Monique van der Aa at monique@ccmaui.org. Sincerely, Monique van der Aa Chief Financial Officer
FAC accepted this audit on February 14, 2023 — management decision was due August 14, 2023.
Finding 2022-001: Reporting Grantor: U.S. Department of Health and Human Services Federal Program Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Numbers: 93.498 Criteria The Coronavirus Aid, Relief, and Economic Security (CARES) Act and American Rescue Plan (ARP) Act of 2021 appropriated funds to reimburse eligible healthcare providers for health carerelated expenses or lost revenues attributable to COVID-19. These funds were distributed by Health Resources and Services Administration (HRSA). HRSA developed the Provider Relief Fund (PRF) Reporting Portal to enable PRF and ARP Rural recipients to comply with mandatory reporting requirements. Condition The Center's submission to the PRF Portal included inconsistencies with the accounting records. Context There were inconsistencies with the COVID-19 related reporting on the PRF Portal which led to the PRF portal not matching the respective accounting records. It is noted that the Center had an adequate amount of lost revenue to earn the PRF funding received. Questioned Costs None. Cause The Center misinterpreted the guidance provided by Health Resources and Services Administration (HRSA) Provider Relief Fund (PRF) and American Rescue Plan (ARP) program. Effect The Center did not complete the PRF Reporting Portal properly in accordance with guidance provided by Health Resources and Services Administration (HRSA) Provider Relief Fund (PRF) and American Rescue Plan (ARP) program and as a result the data on the report was not correct. Recommendation The Center should strengthen their system of internal controls to ensure that all reporting is consistent with requirements and instructions as provided by regulatory agencies. Views of Responsible Officials Management agrees with the audit finding and will strengthen internal controls and accountability to correct the deficiency.
Show full finding ▾Hide full finding ▴Finding 2022-001: Reporting Grantor: U.S. Department of Health and Human Services Federal Program Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Numbers: 93.498 Criteria The Coronavirus Aid, Relief, and Economic Security (CARES) Act and American Rescue Plan (ARP) Act of 2021 appropriated funds to reimburse eligible healthcare providers for health carerelated expenses or lost revenues attributable to COVID-19. These funds were distributed by Health Resources and Services Administration (HRSA). HRSA developed the Provider Relief Fund (PRF) Reporting Portal to enable PRF and ARP Rural recipients to comply with mandatory reporting requirements. Condition The Center's submission to the PRF Portal included inconsistencies with the accounting records. Context There were inconsistencies with the COVID-19 related reporting on the PRF Portal which led to the PRF portal not matching the respective accounting records. It is noted that the Center had an adequate amount of lost revenue to earn the PRF funding received. Questioned Costs None. Cause The Center misinterpreted the guidance provided by Health Resources and Services Administration (HRSA) Provider Relief Fund (PRF) and American Rescue Plan (ARP) program. Effect The Center did not complete the PRF Reporting Portal properly in accordance with guidance provided by Health Resources and Services Administration (HRSA) Provider Relief Fund (PRF) and American Rescue Plan (ARP) program and as a result the data on the report was not correct. Recommendation The Center should strengthen their system of internal controls to ensure that all reporting is consistent with requirements and instructions as provided by regulatory agencies. Views of Responsible Officials Management agrees with the audit finding and will strengthen internal controls and accountability to correct the deficiency.
CORRECTIVE ACTION PLAN 2/10/2023 United States Department of Health and Human Services Community Clinic of Maui, Inc. (Malama I Ke Ola Health Center) respectfully submits the following corrective action plan for the year ended June 30, 2022. CohnReznick LLP 350 Church Street Hartford, CT 06103 Audit Period: June 30, 2022 The findings from the June 30, 2022 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FEDERAL AWARDS FINDINGS AND QUESTIONED COSTS SIGNIFICANT DEFICIENCY 2022-001 ? Reporting Recommendation The Center will strengthen their internal controls to ensure that all reporting is consistent with requirements and instructions as provided by regulatory agencies. Action Taken The guidance for the Provider Relief Fund Reporting Portal provided by the regulatory agency was not interpreted correctly. This error in the reporting of costs will not be repeated in reporting period 4. If the Cognizant or Oversight Agency for Audit has questions regarding this plan, please call: Monique van der Aa, CFO at (808)872-4017. Sincerely yours, Monique van der Aa Chief Financial Officer
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