WELLSPACE HEALTH

Criteria: In accordance with 42 CFR 56.303, health centers must have a schedule of fees or payments for the provision of their health services consistent with locally prevailing rates or charges and designed to cover their reasonable costs of operation. They are also required to have a corresponding schedule of discounts applied and adjusted based on the patient’s ability to pay. The patient’s ability to pay is determined based on the official poverty guidelines, as revised annually by U.S. Department of Health and Human Services (HHS). The schedule of discounts must provide for a full discount to individuals and families with annual incomes at or below those set forth in the most recent poverty income guidelines (except that nominal fees for service may be collected from such individuals and families) and for no discount to individuals and families with annual incomes greater th…

Corrective action: Corrective Action Plan: The organization will continue with its ongoing implementation of several measures to ensure accuracy and compliance in the sliding fee process. Monthly audits will continue to be conducted to review all sliding fee application forms from the previous month for accuracy and verifying information in NextGen. Skills assessments will continue to be conducted in January and July to identify staff needing refresher training. A sliding fee wage training video has been added to Relias and will be required for all staff involved in the process, providing guidance on wage calculation. This training will be distributed twice a year. Additionally, sliding fee monthly audit…

Criteria: In accordance with OMB No. 0915-0193, the Uniform Data System (UDS) report is required to be submitted for the Health Centers Cluster program annually on a calendar year basis. In accordance with 42 CFR 56.303, health centers must have a schedule of fees or payments for the provision of their health services consistent with locally prevailing rates or charges and designed to cover their reasonable costs of operation. They are also required to have a corresponding schedule of discounts applied and adjusted based on the patient’s ability to pay. The patient’s ability to pay is determined based on the official poverty guidelines, as revised annually by U.S. Department of Health and Human Services (HHS). The schedule of discounts must provide for a full discount to individuals and families with annual incomes at or below those set forth in the most recent poverty income guidelines …

Corrective action: Corrective Action Plan: The organization will continue with its ongoing implementation of several measures to ensure accuracy and compliance in the sliding fee process. Monthly audits will continue to be conducted to review all sliding fee application forms from the previous month for accuracy and verifying information in NextGen. Skills assessments will continue to be conducted in January and July to identify staff needing refresher training. A sliding fee wage training video has been added to Relias and will be required for all staff involved in the process, providing guidance on wage calculation. This training will be distributed twice a year. Additionally, sliding fee monthly audit resul…

Criteria: The requirements for matching are contained in 2 CFR section 200.306, program legislation, Federal awarding agency regulations, and the terms and conditions of the award. The requirements for level of effort and earmarking are contained in program legislation, Federal awarding agency regulations, and the terms and conditions of the award. Per review of the award documents for Certified Community Behavioral Health Clinics Program, key staff have identified the following level of effort requirements:  Project Director at 50%  Evaluator at 50% Any changes in the key staff including level of effort, involving separation from the projects for 3 or more months, or a 25% reduction in time dedicated to the projects requires prior approval from SAMHSA. Condition: During the audit, we noted that a level of effort for the Evaluator was below the 50% required minimum by the grant agreeme…

Corrective action: Corrective Action Plan: The Organization will ensure to track minimum level of effort requirement in regard to any key staff to stay in compliance. All invoices will be reviewed by accounting management staff to ensure level of effort requirements are in compliance. Estimated completion date: June 30, 2025 Contact person: Chue Vang, Chief Financial Officer

Criteria: In accordance with OMB No. 0915-0193, the Uniform Data System (UDS) report is required to be submitted for the Health Centers Cluster program annually on a calendar year basis. In accordance with 42 CFR 56.303, health centers must have a schedule of fees or payments for the provision of their health services consistent with locally prevailing rates or charges and designed to cover their reasonable costs of operation. They are also required to have a corresponding schedule of discounts applied and adjusted based on the patient’s ability to pay. The patient’s ability to pay is determined based on the official poverty guidelines, as revised annually by U.S. Department of Health and Human Services (HHS). The schedule of discounts must provide for a full discount to individuals and families with annual incomes at or below those set forth in the most recent poverty income guidelines …

Corrective action: Corrective Action Plan: The Organization will strengthen procedures to ensure discounts for sliding fee is applied consistently and accurately. Immediately, the Organization will conduct monthly application audits. An audit of 25 sliding fee application forms completed in the month prior will be examined for accuracy, along with their supporting data. All information from these applications will be cross‐verified in NextGen. The results from the sliding fee monthly audits will be monitored and reported quarterly at the Quality Assurance and Quality Improvement meetings. This has continued to occur monthly. We will be implementing a workflow adjustment stating all Slide applications will be n…

2002-003 - Special Test and Provisions ? Sliding Fee Discounts Significant Deficiency over Internal Controls over Compliance Federal Assistance Listing Number: 93.224 Name of Federal Program or Cluster: Health Centers Program Cluster Federal Agency/Pass-Through Entity: U.S. Department of Health and Human Services Federal Award Number: H80CS12872 & H8F41209 Award Year: 2021-2022 Criteria: In accordance with OM…

Corrective action: 2022-003 Special Test and Provisions ? Sliding Fee Discounts Corrective Action Plan: WellSpace concurs with recommendations to strengthen procedures to ensure discounts for sliding fee is applied consistently and accurately. Immediately, WellSpace will conduct monthly application audits. An audit of 25 sliding fee application forms completed in the month prior will be examined for accuracy, along with their supporting data. All information from these applications will be cross-verified in NextGen. The results from the sliding fee monthly audits will be monitored and reported quarterly at the Quality Assurance and Quality Improvement meetings. Furthermore, WellSpace will continue the practice…

2021-002 ? ELIGIBILITY Federal Program: Consolidated Health Centers and Affordable Care Act (ACA) Grants for New and Expanded Services under the Health Center Prog. (Health Center Cluster) Federal Agency: U.S. Department of Health and Human Services Assistance Listing Number: 93.224 Grant Award Number and Year: H80CS12872-11-04, 3/1/2020 ? 2/28/2021; H8CCS34240-01-00, 3/15/2020 ? 3/14/2021; H8DCS35770-01-00, 4/1/2020 ? 3/31/2021; H8ECS38672-01-00, 5/1/2020 ? 4/30/2021; H80CS12872-12-00, 3/1/2021 ? 2/28/2022; Criteria: The Consolidated Health Centers and Affordable Care Act (ACA) Grants for New and Expanded Services under the Health Center Programs (Health Center Cluster) requires health centers to prepare and apply a sliding fee discount schedule so that the amounts owed for health care center services by eligible patients are adjusted (discounted) based on the patient?s ability to pay. …

Corrective action: 2021-002 ? ELIGIBILITY Brenda Shipp, Chief Operating & Compliance Officer Organization?s Corrective Action Plan: The Organization has updated its sliding fee application and a staff acknowledgement line was added. Prior to roll out, training was provided to the staff which included a Q&A. A training video was done as well as a FAQ for staff reference. In addition, two boot camps were performed to review registration packet completion and included a system walkthrough explaining where the information on the forms are inputted into the system and the retention requirements have been reviewed. The training also included insurance training on the types of insurance and an in-depth explanation of…

2021-003 ? ELIGIBILITY Federal Program: Medical Assistance Program (Medicaid Cluster) Federal Agency: U.S. Department of Health and Human Services Assistance Listing Number: 93.778 Grant Award Number and Year: 7206000-19-017 A3, 7/1/2020 ? 6/30/2021; 4121, 6/1/2019 ? 6/30/2021; 7207500-18/21-290, 7/11/2017 ? 12/31/2020; Criteria: The Medical Assistance Program (Medicaid Cluster) requires health centers to verify that patients receiving matching funds from the federal government meet certain eligibility requirements. The objective is to help provide medical assistance to residents whose incomes and resources are insufficient to meet the costs of necessary medical services. Additionally, entities receiving federal funding are required by 2 CFR ?200.334 to retain supporting documents and all other non-Federal entity records pertinent to a Federal award for a period of three years from date …

Corrective action: 2021-003 ? ELIGIBILITY Christie Gonzales, Chief Program Officer Organization?s Corrective Action Plan: The Organization has updated its policy to ensure that staff (either administrative or billing staff depending on location) run Medi-Cal eligibility on the 1st of every month, for every patient, no matter their documented funding source to ensure the Organization is not billing an alternative funding source for patients that have active Medi-Cal. The printed Medi-Cal eligibility then gets placed in the patient file to document the monthly checks. The Organization has added Medi-Cal eligibility to not just the file review checklist, but also the monthly Medi-Cal eligibility as well. Previous…

2020-001 ? ELIGIBILITY Federal Program: Consolidated Health Centers and Affordable Care Act (ACA) Grants for New and Expanded Services under the Health Center Prog. (Health Center Cluster) Federal Agency: U.S. Department of Health and Human Services CFDA Number: 93.224 Grant Award Number and Year: H80CS12872-10-00, 3/1/2019 ? 2/29/2020; H80CS12872-11-04, 3/1/2020 ? 2/28/2021; Criteria: The Consolidated Health Centers and Affordable Care Act (ACA) Grants for New and Expanded Services under the Health Center Programs (Health Center Cluster) requires health centers to prepare and apply a sliding fee discount schedule so that the amounts owed for health care center services by eligible patients are adjusted (discounted) based on the patient?s ability to pay. An effective internal control system over compliance with this requirement provides reasonable assurance for the safeguarding …

Corrective action: 2020-001 - ELIGIBILITY Brenda Shipp, Chief Operations Officer Corrective Action: Recognizing that WellSpace Health could be more deliberate and accurate in the processes used to determine eligibility for Sliding Fee discounts, the application form and policy has been updated to provide a more definitive process to both accurately collect the information and to monitor it on a more consistent basis. Given the audit both internally and externally, we recognize the necessity of on-going tracers to ensure that we are providing the necessary guidance and direction to employees on a consistent basis. All frontline employees are in the process of being retrained and will be given follow-up training…

2019-001 ? ELIGIBILITY Federal Program: Consolidated Health Centers and Affordable Care Act (ACA) Grants for New and Expanded Services under the Health Center Prog. (Health Center Cluster) Federal Agency: U.S. Department of Health and Human Services CFDA Number: 93.224 Grant Award Number and Year: H80CS12872-09-00, 3/1/2018 ? 2/29/2019; H80CS12872-10-00, 3/1/2019 ? 2/29/2020; Criteria: The Consolidated Health Centers and Affordable Care Act (ACA) Grants for New and Expanded Services under the Health Center Programs (Health Center Cluster) requires health centers to prepare and apply a sliding fee discount schedule so that the amounts owed for health care center services by eligible patients are adjusted (discounted) based on the patient?s ability to pay. An effective internal control system over compliance with this requirement provides reasonable assurance for the safeguarding of assets…

Corrective action: 2019-001 - ELIGIBILITY Brenda Shipp, Chief Operations Officer Corrective Action: The Organization will immediately review its policies and procedures with all pertinent employees to ensure compliance of both internal and external policies as they relate appropriate fee discounts for patients. All pertinent employees will receive new training and review of patient application process and appropriate documentation. Employees will be required to sign acknowledgement verifying they understand the process for administering sliding fee discounts to eligible patients. Random audits of patient charts will be conducted monthly to ensure all policies are adhered to and that appropriate fee discounts a…