Finding 1221491 (2023-004)

Material Weakness Repeat Finding
Requirement
L
Questioned Costs
-
Year
2023
Accepted
2026-06-30
Audit: 405779
Organization: Baltimore Medical System, Inc. (MD)

AI Summary

  • Core Issue: The Organization failed to provide accurate supporting documentation for the annual UDS and FFR reports, leading to potential errors.
  • Impacted Requirements: Compliance with reporting standards under 2 CFR 200.328 and 2 CFR 200.329 is necessary for accurate financial reporting.
  • Recommended Follow-Up: Management should ensure adherence to policies for accurate report preparation and maintain supporting documentation, with a completion target of December 31, 2026.

Finding Text

Health Center Program Cluster ALN Nos. 93.224 and 93.527 U.S. Department of Health and Human Services Award No.2 H80CS00800, June 1, 2023 - May 31, 2024 Award No.5 H80CS00800, June 1, 2022 - May 31, 2023 Award No.3 H8FCS41036, April 1, 2021 - March 31, 2023 Criteria or Specific Requirement – Reporting – 2 CFR 200.328 and 2 CFR 200.329 Condition – The Organization is required to prepare and submit an annual Uniform Data System (UDS) report for each calendar year and an annual Federal Financial Report (FFR) for each grant year for the Health Center Cluster. These reports are to be prepared using accurate financial information. Cause – The Organization was unable to provide supporting documentation that agreed to the line items tested in the reports. The Organization’s practice management system was incorrectly set up to classify certain adjustments as sliding fee discounts and a manual correction was not made during the preparation of the UDS report. Effect or Potential Effect – Potential errors were made on the annual UDS and FFR reports. Questioned Cost – None Context – The annual UDS report and annual FFR were selected for testing out of total population of three reports. The sampling methodology used is not and is not intended to be statistically valid. Of the ten inputs tested, five exceptions were noted related to the annual UDS report. The FFR report tested was not accurately reported or could not be properly supported. Identification as a repeat finding, if applicable – Not a repeat finding. Recommendation – Management should follow established policies and procedures to ensure the required reports are prepared using accurate information and supporting documentation for federal grant reports are maintained. Views of responsible officials and planned corrective actions - Management agrees with the recommendation to ensure the required reports are prepared using accurate information and supporting documentation for federal grant reports are maintained. • All system generated reports will be maintained in the preparation of the UDS and FFR reports. • A report will be run out of the practice management system identifying qualified sliding fee discounts to be included in the UDS report. Anticipated date of completion: December 31, 2026 Contact person responsible – Margaret Boemmel, CFO

Corrective Action Plan

Management agrees with the recommendation to ensure the required reports are prepared using accurate information and supporting documentation for federal grant reports are maintained. • All system generated reports will be maintained in the preparation of the UDS and FFR reports. • A report will be run out of the practice management system identifying qualified sliding fee discounts to be included in the UDS report. Anticipated date of completion: December 31, 2026 Contact person responsible – Margaret Boemmel, CFO

Categories

Reporting

Other Findings in this Audit

  • 1221486 2023-003
    Material Weakness Repeat
  • 1221487 2023-003
    Material Weakness Repeat
  • 1221488 2023-003
    Material Weakness Repeat
  • 1221489 2023-004
    Material Weakness Repeat
  • 1221490 2023-004
    Material Weakness Repeat

Programs in Audit

ALN Program Name Expenditures
93.224 HEALTH CENTER PROGRAM $2.22M
93.527 GRANTS FOR NEW AND EXPANDED SERVICES UNDER THE HEALTH CENTER PROGRAM $623,170
14.218 COMMUNITY DEVELOPMENT BLOCK GRANTS/ENTITLEMENT GRANTS $341,367
93.940 VIRAL HEPATITIS PREVENTION AND CONTROL $197,485
93.268 IMMUNIZATION COOPERATIVE AGREEMENTS $95,000
93.137 COMMUNITY PROGRAMS TO IMPROVE MINORITY HEALTH $79,570
93.297 TEENAGE PREGNANCY PREVENTION PROGRAM $65,206
93.217 FAMILY PLANNING SERVICES $50,000
93.800 ORGANIZED APPROACHES TO INCREASE COLORECTAL CANCER SCREENING $48,422