Finding 1170433 (2022-004)

Material Weakness Repeat Finding
Requirement
E
Questioned Costs
-
Year
2022
Accepted
2026-01-23
Audit: 383596
Organization: Baltimore Medical System, Inc. (MD)
Auditor: RSM US LLP

AI Summary

  • Core Issue: Two patients received sliding fee discounts without proper income documentation, and one received an incorrect discount rate.
  • Impacted Requirements: The Organization must maintain accurate records to verify patient eligibility based on income and family size.
  • Recommended Follow-Up: Review and strengthen policies and procedures for obtaining and verifying income documentation to ensure compliance.

Finding Text

Federal Award Agency: U.S. Department of Health and Human Services Federal awards: 93.224 / 93.527 – Health Center Program Cluster Criteria: Under this selected program, eligible individuals receive a sliding fee discount on amounts owed for health center services based on family size and income levels in comparison to the federal poverty guidelines. The Organization should maintain records providing evidence that the patients included under this program are eligible. Condition: During the compliance testing of 44 sample items, there was two instances where the Organization applied a sliding fee discount to a patient who had not submitted any documents regarding their income level or family size and we could not determine whether the patient should have been included as a sliding fee patient, and one instance where the patient had properly submitted their forms, but the Organization applied the incorrect sliding fee rate. Effect: Currently, there is no known monetary impact, improper expenditure of funds or questioned costs identified. However, if the Organization does not strengthen the internal controls in regard to the eligibility determination process, there is a possible effect on the ability of the Organization to obtain additional funding under this program if ineligible patients are being treated with grant funding. Cause: There is a lack of review in regard to obtaining, retaining and approving documentation that support individual's eligibility for the program. Recommendation: We recommend that the Organization review policies, procedures and practices in place over the controls related to obtaining, retaining and reviewing proof of income support for patients. Repeat Finding: No. Views of responsible officials and planned corrective actions: See attached letter. Reportable questioned costs: None

Corrective Action Plan

Finding: Under this selected program, eligible individuals receive a sliding fee discount on amounts owed for health center services based on family size and income levels in comparison to the federal poverty guidelines. The Organization should maintain records providing evidence that the patients included under this program are eligible. During the compliance testing of 44 sample items, there was two instances where the Organization applied a sliding fee discount to a patient who had not submitted any documents regarding their income level or family size and we could not determine whether the patient should have been included as a sliding fee patient, and one instance where the patient had properly submitted their forms, but the Organization applied the incorrect sliding fee rate. Currently, there is no known monetary impact, improper expenditure of funds or questioned costs identified. However, if the Organization does not strengthen the internal controls in regard to the eligibility determination process, there is a possible effect on the ability of the Organization to obtain additional funding under this program if ineligible patients are being treated with grant funding. Views of responsible officials and planned corrective actions: Management agrees with the recommendation to review policies, procedures and practices in place over the controls related to obtaining, retaining and reviewing proof of income support for patients. • Train relevant staff on the Sliding Fee eligibility process and supporting documentation requirements. Anticipated date of completion: December 31, 2025 Contact person responsible – Tammy Grinnan, Controller and Margaret Boemmel, CFO

Categories

Eligibility Internal Control / Segregation of Duties

Other Findings in this Audit

  • 1170418 2022-002
    Material Weakness Repeat
  • 1170419 2022-002
    Material Weakness Repeat
  • 1170420 2022-002
    Material Weakness Repeat
  • 1170421 2022-002
    Material Weakness Repeat
  • 1170422 2022-002
    Material Weakness Repeat
  • 1170423 2022-002
    Material Weakness Repeat
  • 1170424 2022-003
    Material Weakness Repeat
  • 1170425 2022-003
    Material Weakness Repeat
  • 1170426 2022-003
    Material Weakness Repeat
  • 1170427 2022-003
    Material Weakness Repeat
  • 1170428 2022-003
    Material Weakness Repeat
  • 1170429 2022-003
    Material Weakness Repeat
  • 1170430 2022-004
    Material Weakness Repeat
  • 1170431 2022-004
    Material Weakness Repeat
  • 1170432 2022-004
    Material Weakness Repeat
  • 1170434 2022-005
    Material Weakness Repeat
  • 1170435 2022-005
    Material Weakness Repeat
  • 1170436 2022-005
    Material Weakness Repeat
  • 1170437 2022-005
    Material Weakness Repeat

Programs in Audit

ALN Program Name Expenditures
93.224 CONSOLIDATED HEALTH CENTERS (COMMUNITY HEALTH CENTERS, MIGRANT HEALTH CENTERS, HEALTH CARE FOR THE HOMELESS, AND PUBLIC HOUSING PRIMARY CARE) $7.39M
93.527 AFFORDABLE CARE ACT (ACA) GRANTS FOR NEW AND EXPANDED SERVICES UNDER THE HEALTH CENTER PROGRAM $4.97M
93.526 AFFORDABLE CARE ACT (ACA) GRANTS FOR CAPITAL DEVELOPMENT IN HEALTH CENTERS $1.11M
93.566 REFUGEE AND ENTRANT ASSISTANCE_STATE ADMINISTERED PROGRAMS $994,389
93.217 FAMILY PLANNING_SERVICES $83,609
93.297 TEENAGE PREGNANCY PREVENTION PROGRAM $59,789
93.800 ORGANIZED APPROACHES TO INCREASE COLORECTAL CANCER SCREENING $54,161
93.224 AFFORDABLE CARE ACT (ACA) GRANTS FOR NEW AND EXPANDED SERVICES UNDER THE HEALTH CENTER PROGRAM $42,850
93.870 MATERNAL, INFANT AND EARLY CHILDHOOD HOME VISITING GRANT $35,754
93.501 AFFORDABLE CARE ACT (ACA) GRANTS FOR SCHOOL-BASED HEALTH CENTER CAPITAL EXPENDITURES $2,488