CHRIST COMMUNITY HEALTH SERVICES INC

Finding Number: 2025 001 Finding Type: Significant Deficiency in Internal Controls Over Compliance related to Special Tests and Provisions Information on the Federal Program: Program Name: Health Center Program Cluster (AL numbers 93.224 and 93.527) Grant Award: 5 H80CS00881-22 from May 1, 2024 through April 30, 2025 and 5 H80CS00881-23 from May 1, 2025 through April 30, 2026 Agency: U.S. Department of Health and Human Services, Health Resources and Services Administration Pass-Through Entity: N/A Criteria: In accordance with Section 330(k)(3)(G) of the Public Health Services Act (42 U.S. Code § 254b), as an FQHC, the Organization must have a sliding fee discount program in which patient charges are adjusted based on the patient’s ability to pay. Condition: Through testing a statistically valid sample of 25 individual patient balances, we noted one instance in which the sliding fee …

Corrective action: Finding: 2025-001 Condition Found: The Organization has not applied sliding fee discounts to patient charges consistent with its sliding fee discount program. Individual(s) Responsible for Corrective Action: Frackson Salak, CFO Planned Corrective Action: Christ Community Health Services will perform monthly audits on patients who receive a sliding fee discount. The monthly audits will include verifying the correct fee was applied based on documents received during the patients sliding fee enrollment. If any errors are found they will be immediately corrected. Anticipated Completion Date: 06/30/2026

Health Center Program Cluster – Assistance Listing Nos. 93.224 and 93.527 U.S. Department of Health and Human Services Award No. 2 H80CS00881-21 and 1 H8FCS41120-01 Program Year 2023 Criteria or Specific Requirement – Reporting – 45 CFR 75.342 Condition – The Organization is required to prepare and submit an annual Uniform Data System (UDS) for each calendar year and an annual Federal Financial Report (FFR) for each grant year. These reports are to be prepared using accurate financial information. Questioned cost – None. Context – One report for each report type listed above was selected for testing with specific data from each report selected for testing. The sampling methodology used is not and is not intended to be statistically valid. Of the nineteen inputs tested, one exceptions were noted related to the annual UDS report. Effect – Potential errors were made on the annual …

Corrective action: Audit Finding Reference Number 2023-002 Criteria or Specific Requirement – Reporting – 45 CFR 75.342 Condition – The Organization is required to prepare and submit an annual Uniform Data System (UDS) for each calendar year and an annual Federal Financial Report (FFR) for each grant year. These reports are to be prepared using accurate financial information. Questioned cost – None. Context – One report for each report type listed above was selected for testing with specific data from each report selected for testing. The sampling methodology used is not and is not intended to be statistically valid. Of the nineteen inputs tested, one exceptions were noted related to the annual UDS rep…

Health Center Program Cluster ? Assistance Listing Nos. 93.224 and 93.527 U.S. Department of Health and Human Services Award No. 6 H80CS00881-20 and 1 H8FCS41120-01 Program Year 2022 Criteria or Specific Requirement ? Procurement ? 45 CFR 75.329 Condition ? The Organization did not maintain documentation supporting procurement requirements for the purchase of goods or services charged to federal awards. Questioned cost ? None Context ? Documentation was not originally maintained by the Organization to support that proper procurement procedures in accordance with the Organization?s policy were followed related to vendor selection. Documentation was later compiled in response to audit inquiries. Effect ? The Organization did not have documentation supporting the procurement activities completed. Cause ? The Organization was not properly following the documentation requirements …

Corrective action: Views of Responsible Officials and Planned Corrective Actions ? ? Vice President of Support Services was hired to lead the procurement process. ? The Procurement Department implemented the use of bids, as they foster competition whenever feasible. All procurement is conducted in a competitive manner with open access to acceptable suppliers. ? The VP of Support Services oversees the procurement policy and will ensure future adherence. The CFO, Talia Peterson, and VP of Support Services, Susan Banning, are responsible for this corrective action plan. Implementation of the above items have already begun and will be completed by August 2023.

Health Center Program Cluster CFDA Nos. 93.224 and 93.527 U.S. Department of Health and Human Services Award No. 6 H80CS00881-17-00 Program Year 2020 Criteria or Specific Requirement ? Reporting (45 CFR 75.342) Condition ? The Organization is required to prepare and submit an annual Federal Financial Report (FFR) for the grant budget period. This report is to be prepared using accurate financial information and submitted by the deadline established in the grant award. Questioned costs ? None Context ? A sample of 19 reporting attributes were tested out of the total population of 28 reporting attributes. The sampling methodology used is not and is not intended to be statistically valid. Program income earned, program income expended, and unexpended program income reported on the FFR were not calculated accurately. The FFR was not filed prior to the deadline. Effect ? Potential error…

Corrective action: Policies and Procedures for federal grant reporting will be reviewed and updated as necessary to ensure the accurate calculation of program income earned and program income expended, to ensure reports are prepared using accurate information and reviewed prior to submission, and filed prior to deadlines. This will include appropriate tracking of upcoming deadlines. The CFO is responsible for this corrective action plan. The above items will be implemented by April 30, 2020.