BLUE RIDGE COMMUNITY HEALTH SERVICES, INC.

Material Weakness Finding: 2025-002 Cash Management – Federal Grants Federal Programs: Department of Health and Human Services Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement Assistance Listing No. 93.912 Criteria: Cash Management, 2 CFR 200.305(b)(1) Condition: The Organization did not reconcile federal grant expenditures in a timely manner, resulting in a lack of draws of federal funds for which qualifying expenditures had been made prior to the end of the Organization’s financial statement year end. This resulted in unrecorded revenue and receivables of approximately $224,564 at March 31, 2025. Without proper reconciliations and timely draws of federal grant funds, the Organization could be impacted by lost federal funding. Cause: The Organization did not reconcile federal grant expenditures or m…

Corrective action: In Finding 2025-002, it was reported that the Organization’s did not reconcile federal grant expenditures in a timely manner, resulting in a lack of draws of federal funds for which qualifying expenditures had been made prior to the end of the Organization’s financial statement year end. Management recognizes the importance of complying with federal grant guidelines. In response to Finding 2025-002, the Organization understands the importance of timely reconciliations of federal grant expenditures and timely draws of federal grant funds. The Organization will review its processes and procedures to ensure that federal grants are reconciled in a timely manner.

Finding: 2021-002 Procurement, Suspension, and Debarment Federal Programs: Department of Health and Human Services Health Center Program Cluster CFDA 93.224 and 93.527 Criteria: Procurement 45 CFR 75.329 and 45 CFR 75.213 Condition: The Organization?s procurement policies were not updated to conform to applicable standards under the Uniform Guidance, and the Organization did not verify that certain vendors were not suspended, debarred, or otherwise excluded from participating in federal programs before entering into transactions with them. Cause: The Organization did not have proper procedures in place to ensure that procurement policies were updated to conform to the requirements identified in the Uniform Guidance, and the Organization did not follow its policy regarding debarment searches. Effect: The Organization?s procurement policy did not conform to applicable…

Corrective action: In Finding 2021-002, a condition was noted in which the Organization did not ensure that certain vendors were not suspended, debarred, or otherwise excluded from participating in federal programs before entering into transactions with them. Management recognizes the importance of complying with procurement, debarment, and suspension guidelines. In response to Finding 2021-002, procedures will be implemented to ensure debarment searches are completed to verify that all vendors subject to debarment requirements are not suspended, debarred, or otherwise excluded from participating in Federal programs before the Organization enters into transactions with them.

Finding: 2021-003 Sliding Fee Discounts Federal Programs: Department of Health and Human Services Health Center Program Cluster CFDA 93.224 and 93.527 Criteria: Uniform Guidance, Special Tests & Provisions, Sliding Fee Discounts, 42 CFR, 56.303 Condition: Health Centers receiving funding under the Health Center Program Cluster must prepare and apply a sliding fee discount so that the amounts owed for health center services by eligible patients are discounted based on the patient?s ability to pay. During compliance testing, it was determined that the Organization did not properly apply the sliding fee discounts for 5 patients out of a sample of 20 patients for the year ended March 31, 2021. Cause: There were deficiencies in internal controls to ensure that proper documentation was obtained and that proper sliding fee discounts were applied to patient accounts in accord…

Corrective action: In Finding 2021-003, it was reported that the Organization did not properly apply the sliding fee discounts for certain patients with visits to the Organization during the year ended March 31, 2021. Management recognizes the importance of complying with sliding fee guidelines. In response to Finding 2021-003, proper training will be given to employees and sliding fee discounts will be reviewed by a supervisor on a periodic basis the ensure compliance with the sliding fee scale.