FAC Explorer

Finding 548583 (2024-005)

Material Weakness Repeat Finding
Requirement
BE
Questioned Costs
-
Year
2024
Accepted
2025-03-31
Audit: 351922
Organization: Dartmouth-Hitchcock Health and Subsidiaries (NH)
Auditor: Pricewaterhousecoopers LLP

AI Summary

  • Core Issue: Cheshire Medical Center's Doorway program is not properly tracking patient eligibility for federal funding, leading to potential compliance violations.
  • Impacted Requirements: Key eligibility criteria, including income limits and residency status, are not consistently met or documented, risking questioned costs of $1,383,585.
  • Recommended Follow-Up: Implement internal controls to ensure eligibility tracking, maintain proper documentation, and differentiate between eligible and ineligible patients to comply with award terms.

Finding Text

Cluster: Not applicable Federal Agency: Department of Health and Human Services Award Names: Substance Use Disorder Treatment and Recovery Support Services Award Numbers: Cheshire Medical Center 2019-BDAS-05-ACCES-04, 05-95-92-920510-7040-5007, RFP-2018-BDAS-05-INTEG Assistance Listing Title: Opioid STR Assistance Listing Number: 93.788 Award Year: 2023 - 2024 Pass-through entity: New Hampshire Department of Health and Human Services Criteria: To be eligible under the Substance Use Disorder Treatment and Recovery Support Services award, a patient must 1) have income below 400% of the federal poverty level, 2) be a resident of New Hampshire or experiencing homelessness in New Hampshire, and 3) be determined positive for substance use disorder. Additionally, patient income information for all eligible patients receiving services must be updated at a minimum interval of once every four weeks. Condition: Cheshire Medical Center operates The Doorway program in Keene, NH. The Doorway connects patients positive for substance use disorder with support services and treatment, and receives a portion of its funding from the Substance Use Disorder Treatment and Recovery Support Services federal award. Through our testing of eligibility requirements for 40 patients, we noted the following: • For 2 of 40 selections, the patient exceeded the maximum income levels. • For 24 of 40 selections, income reassessments were not completed and documented at least once every four weeks. • For 2 of 40 selections, the patient was neither a resident of New Hampshire, nor experiencing homelessness in New Hampshire. • For 1 of 40 selections, an income reassessment was completed, however the eligibility conclusion reached was inaccurate. While The Doorway provides services to patients beyond those defined as eligible under the Substance Use Disorder Treatment and Recovery Support Services award, there is no differentiation between patients that are eligible or ineligible under the federal program. As a result of patients not being differentiated, time and effort incurred by personnel on the award is commingled with non-award activity. For example, a clinician’s salary is funded under the award, but she is not seeing only eligible patients. As such, any time she spent treating a patient who is not eligible would be a questioned cost under the grant. Cause: The nature and purpose of the federal program is very similar and consistent with the mission and operations of The Doorway. Management did not implement a process to differentiate the services performed and patients served in order to demonstrate compliance with award terms and conditions. Effect: The commingling of activities between federal and non-federal programs does not allow for compliance with award specific terms and conditions and with eligibility requirements to be effectively managed. Questioned Costs: We were unable to verify eligibility requirements were met for the program which had total expenditures of $1,383,585. Recommendation: We recommend that internal controls and policies be implemented to manage the eligibility requirements of the federal awards and ensure that documentation to support eligibility determinations is maintained. Further, procedures to differentiate patients eligible under the award from those determined to be ineligible, along with a mechanism to track the time and expenses associated with eligible patients should be put in place.

Corrective Action Plan

Management agrees with the finding regarding Cheshire Medical Center’s eligibility and allowable costs. Management will implement a control starting with the month ending April 30, 2025, to conduct a retrospective review of patient service revenue charges incurred during that month and allocate costs in a manner that aligns with the eligibility and income requirements of the award. Using this methodology, management will identify the eligible population and appropriately incur allowable expenses associated with the award. Management will initiate a bi-weekly process to review upcoming appointments and the most recent eligibility check on recurring patients. If, during this process, a patient is identified who requires an eligibility check based on award criteria (i.e., whichever is later: four weeks or the individual's next appointment), Management team will perform re-enrollment procedures to validate that the individual is still eligible. Leadership Responsible: John Muhlen, System Vice President of Corporate Finance Anticipated Completion Date: June 30, 2025

Categories

Eligibility Procurement, Suspension & Debarment Subrecipient Monitoring Matching / Level of Effort / Earmarking

Other Findings in this Audit

Programs in Audit

ALN Program Name Expenditures
93.498 Provider Relief Fund and American Rescue Plan (arp) Rural Distribution $3.19M
17.720 Disability Employment Policy Development $1.05M
93.969 Pphf Geriatric Education Centers $914,313
17.268 H-1b Job Training Grants $840,402
93.087 Enhance Safety of Children Affected by Substance Abuse $787,352
93.788 Opioid Str $744,673
93.800 Organized Approaches to Increase Colorectal Cancer Screening $686,821
93.069 Public Health Emergency Preparedness $653,662
93.186 National Research Service Award in Primary Care Medicine $625,462
93.307 Minority Health and Health Disparities Research $570,661
93.846 Arthritis, Musculoskeletal and Skin Diseases Research $463,310
93.153 Coordinated Services and Access to Research for Women, Infants, Children, and Youth $400,226
93.958 Block Grants for Community Mental Health Services $376,504
97.036 Disaster Grants - Public Assistance (presidentially Declared Disasters) $357,751
93.213 Research and Training in Complementary and Integrative Health $326,712
93.391 Activities to Support State, Tribal, Local and Territorial (stlt) Health Department Response to Public Health Or Healthcare Crises $306,282
93.918 Grants to Provide Outpatient Early Intervention Services with Respect to Hiv Disease $304,399
12.007 Military Health Services Research (mhsr) $298,107
93.870 Maternal, Infant and Early Childhood Home Visiting Grant $289,668
21.027 Coronavirus State and Local Fiscal Recovery Funds $280,206
93.155 Rural Health Research Centers $251,842
93.493 Congressional Directives $250,000
93.850 Improving Epilepsy Programs, Services, and Outcomes Through National Partnerships $246,198
93.127 Emergency Medical Services for Children $230,377
93.U01 Greater Monadnock Regional Public Health Network Services $203,244
93.778 Medical Assistance Program $191,314
93.323 Epidemiology and Laboratory Capacity for Infectious Diseases (elc) $187,836
93.243 Substance Abuse and Mental Health Services Projects of Regional and National Significance $179,865
93.398 Cancer Research Manpower $169,631
93.077 Family Smoking Prevention and Tobacco Control Act Regulatory Research $161,812
93.135 Centers for Research and Demonstration for Health Promotion and Disease Prevention $153,744
93.268 Immunization Cooperative Agreements $136,332
93.478 Preventing Maternal Deaths: Supporting Maternal Mortality Review Committees $128,779
93.991 Preventive Health and Health Services Block Grant $93,359
93.113 Environmental Health $89,605
93.397 Cancer Centers Support Grants $81,393
93.912 Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement $77,997
93.145 Hiv-Related Training and Technical Assistance $71,324
93.847 Diabetes, Digestive, and Kidney Diseases Extramural Research $67,536
20.600 State and Community Highway Safety $64,733
93.043 Special Programs for the Aging, Title Iii, Part D, Disease Prevention and Health Promotion Services $62,240
93.353 21st Century Cures Act - Beau Biden Cancer Moonshot $56,164
93.879 Medical Library Assistance $51,265
93.310 Trans-Nih Research Support $49,873
93.276 Drug-Free Communities Support Program Grants $47,859
16.758 Improving the Investigation and Prosecution of Child Abuse and the Regional and Local Children's Advocacy Centers $45,013
93.838 Lung Diseases Research $34,859
93.837 Cardiovascular Diseases Research $34,234
93.395 Cancer Treatment Research $31,703
93.865 Child Health and Human Development Extramural Research $31,495
93.224 Health Center Program (community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) $28,750
93.393 Cancer Cause and Prevention Research $26,804
12.599 Congressionally Directed Assistance $24,472
93.080 Blood Disorder Program: Prevention, Surveillance, and Research $24,342
93.061 Innovations in Applied Public Health Research $23,015
93.433 Acl National Institute on Disability, Independent Living, and Rehabilitation Research $22,499
93.110 Maternal and Child Health Federal Consolidated Programs $20,464
93.136 Injury Prevention and Control Research and State and Community Based Programs $20,433
93.866 Aging Research $19,950
93.855 Allergy and Infectious Diseases Research $19,733
93.173 Research Related to Deafness and Communication Disorders $15,838
93.350 National Center for Advancing Translational Sciences $15,412
93.732 Mental and Behavioral Health Education and Training Grants $14,365
10.558 Child and Adult Care Food Program $13,446
93.301 Small Rural Hospital Improvement Grant Program $13,312
93.859 Biomedical Research and Research Training $12,883
93.867 Vision Research $11,697
93.853 Extramural Research Programs in the Neurosciences and Neurological Disorders $11,466
93.989 International Research and Research Training $10,571
93.059 Training in General, Pediatric, and Public Health Dentistry $9,261
93.959 Block Grants for Prevention and Treatment of Substance Abuse $8,768
93.121 Oral Diseases and Disorders Research $8,016
93.396 Cancer Biology Research $7,389
93.286 Discovery and Applied Research for Technological Innovations to Improve Human Health $6,273
93.226 Research on Healthcare Costs, Quality and Outcomes $4,077
12.420 Military Medical Research and Development $3,743
10.902 Soil and Water Conservation $3,478
93.761 Evidence-Based Falls Prevention Programs Financed Solely by Prevention and Public Health Funds (pphf) $2,525
93.394 Cancer Detection and Diagnosis Research $1,389
93.242 Mental Health Research Grants $1,230
93.279 Drug Use and Addiction Research Programs $1,055