LAWNDALE CHRISTIAN HEALTH CENTER

Procurement Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) Assistance Listing Number: 93.323 Federal Award Number: NU50CK000556 Award Periods: January 1, 2024 – July 31, 2024 Criteria: 2 CFR section 200.320 outlines the acceptable methods of procurement. Purchases below the simplified acquisition threshold, but above the micro-purchase threshold, require that price or rate quotations be obtained from an adequate number of qualified sources as determined by the non- Federal entity. Furthermore, the Organization's procurement policies require the maintaining of records sufficient to detail the history of procurement including the rationale for the method of procurement, selection of contract type, contractor selection or rejection, and the basis for the contract price. Condition: The Orga…

Corrective action: Procurement Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) Program – Assistance Listing No. 93.323 Condition: The Organization did not follow the procedures outlined within its internal policies related to maintaining documentation associated with purchases made via the simplified acquisition method of procurement. Recommendation: We recommend the organization consistently follow its established policies and procedures related to the maintaining of necessary documentation to support the method of procurement utilized. The Organization may also consider qualifying multiple vendors for particular goods/service and then utilizing an approved vendors list. Explanation of disa…

Suspension and Debarment Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) Assistance Listing Number: 93.323 Federal Award Number: NU50CK000556 Award Periods: January 1, 2024 – July 31, 2024 Criteria: 2 CFR sections 200.212 and 200.318(h); 2 CFR section 180.300; 48 CFR section 52.209-6 outlines that the non-Federal entity must verify that the agency in which it is entering into a contract is not suspended or debarred or otherwise excluded from participating in the transaction. Condition: The organization did not document that SAM.gov was checked prior to entering into a contract with a vendor. Questioned Costs: None. Context: This condition impacted five of five transactions selected for testing. None of the entities transacted with were determined to be excluded parties per SAM.gov. Cause…

Corrective action: Suspension and Debarment Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) Program – Assistance Listing No. 93.323 Condition: The organization did not document that Sam.gov was checked prior to entering into a contract with a vendor. Recommendation: We recommend that the organization retain documentation that Sam.gov was used to verify that a vendor was not suspended, debarred, or otherwise excluded from participating in the transaction prior to contract. To the extent practicable, the organization can engage with a third party that will verify any new and existing vendors have not been suspended or debarred on a monthly basis. Explanation of disagreement with audit finding:…

Finding 2024-001 – Cash Management Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Health Center Cluster Assistance Listing Number: 93.224 & 93.527 Federal Award Identification Number: H80CS00725-22-03 & H80CS00725-23-00 Award Periods: June 1, 2023 – May 31, 2024 & June 1, 2024 – May 31, 2025 Criteria: CFR § 200.303 Internal controls states that the non-Federal entity must: (a) 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. Furthermore, CFR § 200.305(b) indicates that the non-Federal entity should minimize the time lapsing between the transfer of funds from the Federal agency and the disbursement of funds by the recipient. Condi…

Corrective action: Action taken in response to finding: LCHC management has implemented a robust task-management software to assist with internal controls, especially when related to grant management. Furthermore, a cloud-hosted warehouse for internal procedures was implemented to properly manage the assignment and transfer of accounting roles/responsibilities like the review and approval of grant drawdown request. Name(s) of the contact person(s) responsible for corrective action: Jeff Nelson, Accounting and Financial Analysis Director Planned completion date for corrective action plan: 9/30/2024

Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Opioid Response Grants Assistance Listing Number: 93.788 Federal Award Identification Number: H79TI083278 Pass-Through Entity: Illinois Department of Human Services Pass-Through Number: 43CBC03525 Award Periods: July 1, 2022 – June 30, 2023 Criteria: A non-federal entity may charge only allowable costs incurred during the approved budget period of a federal award's period of performance and any costs incurred before the federal awarding agency or pass-through entity made the federal award that were authorized by the federal awarding agency or pass-through entity (2 CFR sections 200.308 200.309 and 200.403(h)). A period of performance may contain one or more budget periods. Condition: Costs incurred outside of the period of performance were charged to the grant. Questioned Costs: $26,230 Context: S…

Corrective action: Action taken in response to finding: The finance department has taken action in response to the circumstances which led up to this finding. We have added an accountant position to the team whose primary responsibility is to organize and invoice all grants for the organization. The additional staff person allows a more thorough and detailed review of allowable grant costs, specifically prorated payroll charges. Name(s) of the contact person(s) responsible for corrective action: Jeffrey Nelson, Accounting and Financial Analysis Director Planned completion date for corrective action plan: 9/30/2023

Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Health Center Cluster Assistance Listing Number: 93.224 & 93.527 Federal Award Identification Number: H80CS00725-21 and H80CS00725-22 Award Periods: June 1, 2022 – May 31, 2023 and June 1, 2023 – May 31, 2024 Criteria: 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 patient’s ability to pay. (42 USC 254(k)(3)(E), (F), and (G); 42 CFR sections 51c.303(e), (f), and (g); and 42 CFR sections 56.303(e), (f), and (g)). Condition: The Organization incorrectly assessed and/or applied the sliding fee discount to a patient encounter during the year. Questioned Costs: None. Context: One of forty transactions selected for testing. Cause: Unknown. Effect: Patients are not charg…

Corrective action: Action taken in response to finding: LCHC maintains an error log on its intranet. Among the various categories of errors that are tracked is an insurance information group. Errors are created by a variety of stakeholders including the billing staff, registration representative direct supervisors and the finance department’s internal auditor. One on one meetings to review errors that are pervasive with a staff person receiving errors are one of the ways LCHC strives to ensure the registration experience for each LCHC patient is consistent, thorough and accurate. These are of course preventative measures intended to maintain the integrity of the process and are not able to guarantee perfect ou…

Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Health Center Cluster Assistance Listing Number: 93.224 & 93.527 Federal Award Identification Number: H80CS00725-21 and H80CS00725-22 Award Periods: June 1, 2022 – May 31, 2023 and June 1, 2023 – May 31, 2024 Criteria: Recipients of grants from the Bureau of Primary Health Care Health Center Program are required to prepare and file the Uniform Data System (UDS) report on an annual basis. The UDS report contains various information which has been identified as key line items with the compliance supplement for the health center program cluster. Condition: The amounts reported for Table 8A, line 1, column c and Table 8A, line 3, column c within the UDS report did not agree to the supporting documentation provided by the organization. Questioned Costs: None. Context: One of the key line items within th…

Corrective action: Action taken in response to finding: Any changes made to the UDS report that are prompted from the report’s HRSA review are first made in the supporting file documentation and then carried to the final report itself. This was a human error that was not repeated for the subsequent year’s UDS report. Name(s) of the contact person(s) responsible for corrective action: Christopher Dons, Chief Financial Officer Planned completion date for corrective action plan: March 31, 2024

Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Health Center Infrastructure Support Assistance Listing Number: 93.526 Federal Award Identification Number: C8ECS43959-01 Award Periods: September 15, 2021 – September 14, 2024 Criteria: 2 CFR section 200.320 outlines the acceptable methods of procurement. Purchases below the simplified acquisition threshold, but above the micro-purchase threshold, require that price or rate quotations be obtained from an adequate number of qualified sources as determined appropriate by the non-Federal entity. Furthermore, the Organization's procurement policies require the maintaining of records sufficient to detail the history of procurement including the rationale for the method of procurement, selection of contract type, contractor selection or rejection, and the basis for the contract price Condition: The organi…

Corrective action: Action taken in response to finding: Management will create a process for creating and maintaining an approved vendor list as suggested. Name(s) of the contact person(s) responsible for corrective action: Christopher Dons, Chief Financial Officer Planned completion date for corrective action plan: September 30, 2024

Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Provider Relief Fund (PRF) Assistance Listing Number: 93.498 Federal Award Identification Number: n/a Award Periods: PRF period 4 Criteria: §200.303(a) indicates non-federal entities 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. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States or the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). Condition: The Organization did not mainta…

Corrective action: Action taken in response to finding: The finance department has taken an action in response to the circumstances which led up to this finding. We have implemented a new Accounts Payable Automation software (Bill.com) to help manage the process and documentation of all vendor payments. This software, when coupled with the newly implemented ERP (Sage Intacct), allow the finance team to systematically compile and access vendor documentation without the use of a separate, manual filing system. Name(s) of the contact person(s) responsible for …

Assistance Listing Number, Federal Agency, and Program Name - ALN 93.461 - COVID-19 Claims Reimbursement for the Uninsured Program and the COVID-19 Coverage Assistance Fund; CFDA 21.019 - Coronavirus Relief Fund Federal Award Identification Number and Year - None Pass-through Entity - N/A for 93.461; Illinois Department of Health and Human Services for 21.019 Finding Type - Material weakness Repeat Finding - No Criteria - Per 2 CFR 200.508(b), an auditee must prepare appropriate financial statements, including the schedule of expenditures of federal awards, in accordance with 200.510 - financial statements. Per 2 CFR 200.510(b), the auditee must also prepare a schedule of expenditures of federal awards for the period covered by the auditee's financial statements, which must include the total federal awards expended, as determined in accordance with 200.502 - basis for determining federal…

Corrective action: Finding Number: 2021-001 Condition: Controls in place were not adequate to ensure the schedule of federal expenditures was complete and accurate. Planned Corrective Action: LCHC controls for identifying CFDA numbers attached to federal awards were not designed with unsolicited funding from federal sources in mind. The necessary controls have been put in place. Contact person responsible for corrective action: Christopher Dons, Chief Financial Officer Anticipated Completion Date: 09/30/2021

CFDA Number, Federal Agency, and Program Name - CFDA 93.354; U.S Department of Health and Human Services; COVID-19 Public Health Emergency Response: Cooperative Agreement for Emergency Response: Public Health Crisis Response Federal Award Identification Number and Year - April 2, 2020 - October 2, 2020 Pass-through Entity- The City of Chicago, Department of Public Health Finding Type - Significant deficiency Repeat Finding - No Criteria - Per 2 CFR 200 303(a), the nonfederal entity must establish and maintain effective internal control over the federal award that provides reasonable assurance that the nonfederal entity is managing the federal award in compliance with federal statutes, regulations, and the terms and conditions of the federal award. Condition - The Organization overcharged the program by $6,970 and received reimbursement for this amount in fiscal year 2020. Questioned Co…

Corrective action: Finding Number: 2020-001 Condition: The Organization overcharged the program by $6,970 and received reimbursement for this amount in fiscal year 2020. Planned Corrective Action: Management agrees with the finding. A formula was used to allocate certain expenses as part of the contracted obligation with the City of Chicago to provide services to the City?s homeless population in response to the COVID-19 pandemic. The total value of the contract was approximately $3.1 million, but $6,970 of over-allocation was identified in the initial round of invoicing. The error was corrected and future invoices utilized the revised calculations. The finding was communicated to the responsible individuals w…