Audit 24187

FY End
2022-12-31
Total Expended
$73.08M
Findings
6
Programs
45
Year: 2022 Accepted: 2023-10-01
Auditor: Forvis LLP

Organization Exclusion Status:

Checking exclusion status...

Findings

ID Ref Severity Repeat Requirement
35340 2022-004 Significant Deficiency - B
35341 2022-003 Significant Deficiency - N
35342 2022-002 Significant Deficiency - P
611782 2022-004 Significant Deficiency - B
611783 2022-003 Significant Deficiency - N
611784 2022-002 Significant Deficiency - P

Programs

ALN Program Spent Major Findings
93.498 Provider Relief Fund $28.34M Yes 1
10.766 Community Facilities Loans and Grants $16.77M Yes 1
93.399 Cancer Control $3.21M - 0
94.006 Americorps $1.81M - 0
93.350 National Center for Advancing Translational Sciences $683,873 - 0
93.859 Biomedical Research and Research Training $663,551 - 0
32.006 Covid-19 Telehealth Program $654,939 - 0
93.310 Trans-Nih Research Support $638,303 - 0
93.912 Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement $572,566 - 0
16.575 Crime Victim Assistance $432,867 - 0
93.959 Block Grants for Prevention and Treatment of Substance Abuse $412,533 - 0
93.697 Covid-19 Testing for Rural Health Clinics $322,578 - 0
93.155 Rural Health Research Centers $257,853 - 0
93.211 Telehealth Programs $222,082 - 0
93.788 Opioid Str $210,993 - 0
93.396 Cancer Biology Research $204,974 - 0
93.323 Epidemiology and Laboratory Capacity for Infectious Diseases (elc) $191,624 - 0
93.866 Aging Research $100,410 - 0
93.393 Cancer Cause and Prevention Research $80,574 - 0
10.001 Agricultural Research_basic and Applied Research $60,097 - 0
93.279 Drug Abuse and Addiction Research Programs $48,148 - 0
93.243 Substance Abuse and Mental Health Services_projects of Regional and National Significance $48,024 - 0
93.426 Improving the Health of Americans Through Prevention and Management of Diabetes and Heart Disease and Stroke $35,769 - 0
93.575 Child Care and Development Block Grant $31,975 - 0
93.394 Cancer Detection and Diagnosis Research $31,127 - 0
93.172 Human Genome Research $27,301 - 0
93.241 State Rural Hospital Flexibility Program $20,000 - 0
93.898 Cancer Prevention and Control Programs for State, Territorial and Tribal Organizations $17,024 - 0
93.262 Occupational Safety and Health Program $13,860 - 0
10.212 Small Business Innovation Research $12,500 - 0
93.301 Small Rural Hospital Improvement Grant Program $11,790 - 0
12.420 Military Medical Research and Development $11,000 - 0
47.041 Engineering $9,786 - 0
93.847 Diabetes, Digestive, and Kidney Diseases Extramural Research $8,700 - 0
93.865 Child Health and Human Development Extramural Research $6,075 - 0
93.421 Strengthening Public Health Systems and Services Through National Partnerships to Improve and Protect the Nations Health $3,406 - 0
93.307 Minority Health and Health Disparities Research $2,673 - 0
21.027 Coronavirus State and Local Fiscal Recovery Funds $2,513 Yes 0
93.435 Innovative State and Local Public Health Strategies to Prevent and Manage Diabetes and Heart Disease and Stroke- $1,166 - 0
93.853 Extramural Research Programs in the Neurosciences and Neurological Disorders $1,111 - 0
93.185 Immunization Research, Demonstration, Public Information and Education_training and Clinical Skills Improvement Projects $764 - 0
93.855 Allergy, Immunology and Transplantation Research $463 - 0
10.303 Integrated Programs $297 - 0
93.837 Cardiovascular Diseases Research $57 - 0
93.268 Immunization Cooperative Agreements $40 - 0

Contacts

Name Title Type
JCALBPNMAHF3 Janette Townsend Auditee
7557502197 Norman Mosrie Auditor
No contacts on file

Notes to SEFA

Title: Contingency Accounting Policies: The Schedule has been prepared on the accrual basis of accounting. The Schedule includes all federal and state grants, and contracts entered into by the System that had activity during the year ended December 31, 2022 and should be read in conjunction with the Systems consolidated financial statements. The information in the Schedule is presented in accordance with the requirements of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) and the State Single Audit Guidelines for Wisconsin. Negative amounts shown on the Schedule represent adjustments or credits made in the normal course of business to amounts reported as expenditures in prior years. The System and federal agencies use a facilities and administrative cost rate to charge facilities and administrative costs to individual sponsored projects. The rate is the result of a number of complex cost allocation procedures that the System uses to allocate its facilities and administrative costs to both sponsored and nonsponsored activities. The costs allocated to sponsored projects are divided by the direct costs of sponsored projects to arrive at a rate. The U.S. Department of Health and Human Services (DHHS) must approve the rate before the System can use it to charge facilities and administrative costs to federally sponsored projects. The System has elected not to use the 10% de minimis indirect cost rate allowed under Uniform Guidance.Under Uniform Guidance and State Single Audit Guidelines for Wisconsin, tests of compliance with laws and regulations related to specific program requirements are required for each federal and state award program that is considered a major program for the System. Because the Schedule presents only a selected portion of the operations of the System, it is not intended to and does not present the financial position, changes in net assets or cash flows of the System. As outlined in the April 2022 OMB Compliance Supplement, the amounts reported in the Schedule related to the Provider Relief Fund (PRF), Assistance Listing No. 93.498, are reported based upon the PRF reporting portal submission guidelines established by the Health Resource and Service Administration (HRSA). Separate reporting periods were established by HRSA based on the dates of receipt of PRF payments. Each reporting period has a specific period of availability which begins on January 1, 2020 and extends through specified deadlines, as indicated below: Payment Received Period (Payments Exceeding $10,000 in Aggregate Received), Deadline to Use Funds, Reporting Time Period Period 1 April 10, 2020 to June 30,2020, June 30, 2021, July 1, 2021 to September 30, 2021 Period 2 July 1, 2020 to December 31, 2020, December 31, 2021, January 1, 2022 to March 31, 2022, Period 3, January 1, 2021 to June 30, 2021, June 30, 2022, July 1, 2022 to September 30, 2022, Period 4, July 1, 2021 to December 31, 2021, December 31, 2022, January 1, 2023 to March 31, 2023, Period 5, January 1 2022 to June 30, 2022, June 30, 2023, July 1, 2023 to September 30, 2023, Period 6, July 1, 2022 to December 31, 2022, December 31, 2023, January 1, 2024 to March 31, 2024. The accompanying Schedule of Expenditures of Federal Awards (SEFA) includes those qualifying expenditures and lost revenues that were reported in the HRSA PRF portal for Period 3 and 4. During the years ended December 31, 2022 and 2021, the System recognized approximately $3,920,000 and $24,420,000, respectively, related to Period 3 and 4 funding. De Minimis Rate Used: N Rate Explanation: The auditee did not use the de minimis cost rate. All federal and state financial assistance programs are subject to review and audit by the grantor agencies. Such audits could lead to requests for reimbursements to the grantor agencies for costs disallowed under the terms of the programs. Management believes disallowances, if any, will not be material.
Title: Categorization of Expenditures Accounting Policies: The Schedule has been prepared on the accrual basis of accounting. The Schedule includes all federal and state grants, and contracts entered into by the System that had activity during the year ended December 31, 2022 and should be read in conjunction with the Systems consolidated financial statements. The information in the Schedule is presented in accordance with the requirements of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) and the State Single Audit Guidelines for Wisconsin. Negative amounts shown on the Schedule represent adjustments or credits made in the normal course of business to amounts reported as expenditures in prior years. The System and federal agencies use a facilities and administrative cost rate to charge facilities and administrative costs to individual sponsored projects. The rate is the result of a number of complex cost allocation procedures that the System uses to allocate its facilities and administrative costs to both sponsored and nonsponsored activities. The costs allocated to sponsored projects are divided by the direct costs of sponsored projects to arrive at a rate. The U.S. Department of Health and Human Services (DHHS) must approve the rate before the System can use it to charge facilities and administrative costs to federally sponsored projects. The System has elected not to use the 10% de minimis indirect cost rate allowed under Uniform Guidance.Under Uniform Guidance and State Single Audit Guidelines for Wisconsin, tests of compliance with laws and regulations related to specific program requirements are required for each federal and state award program that is considered a major program for the System. Because the Schedule presents only a selected portion of the operations of the System, it is not intended to and does not present the financial position, changes in net assets or cash flows of the System. As outlined in the April 2022 OMB Compliance Supplement, the amounts reported in the Schedule related to the Provider Relief Fund (PRF), Assistance Listing No. 93.498, are reported based upon the PRF reporting portal submission guidelines established by the Health Resource and Service Administration (HRSA). Separate reporting periods were established by HRSA based on the dates of receipt of PRF payments. Each reporting period has a specific period of availability which begins on January 1, 2020 and extends through specified deadlines, as indicated below: Payment Received Period (Payments Exceeding $10,000 in Aggregate Received), Deadline to Use Funds, Reporting Time Period Period 1 April 10, 2020 to June 30,2020, June 30, 2021, July 1, 2021 to September 30, 2021 Period 2 July 1, 2020 to December 31, 2020, December 31, 2021, January 1, 2022 to March 31, 2022, Period 3, January 1, 2021 to June 30, 2021, June 30, 2022, July 1, 2022 to September 30, 2022, Period 4, July 1, 2021 to December 31, 2021, December 31, 2022, January 1, 2023 to March 31, 2023, Period 5, January 1 2022 to June 30, 2022, June 30, 2023, July 1, 2023 to September 30, 2023, Period 6, July 1, 2022 to December 31, 2022, December 31, 2023, January 1, 2024 to March 31, 2024. The accompanying Schedule of Expenditures of Federal Awards (SEFA) includes those qualifying expenditures and lost revenues that were reported in the HRSA PRF portal for Period 3 and 4. During the years ended December 31, 2022 and 2021, the System recognized approximately $3,920,000 and $24,420,000, respectively, related to Period 3 and 4 funding. De Minimis Rate Used: N Rate Explanation: The auditee did not use the de minimis cost rate. The categorization of expenditures by program included in the schedule of expenditures of federal and state awards is based upon the grant documents. Changes in the categorization of expenditures occur based upon revisions to the Assistance Listing, which is issued in June and December of each year. The schedule of expenditures of federal awards for the year ended December 31, 2022 reflects Assistance Listing changes through April 2022.
Title: 1.Scope of Audit Pursuant to the Uniform Guidance Accounting Policies: The Schedule has been prepared on the accrual basis of accounting. The Schedule includes all federal and state grants, and contracts entered into by the System that had activity during the year ended December 31, 2022 and should be read in conjunction with the Systems consolidated financial statements. The information in the Schedule is presented in accordance with the requirements of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) and the State Single Audit Guidelines for Wisconsin. Negative amounts shown on the Schedule represent adjustments or credits made in the normal course of business to amounts reported as expenditures in prior years. The System and federal agencies use a facilities and administrative cost rate to charge facilities and administrative costs to individual sponsored projects. The rate is the result of a number of complex cost allocation procedures that the System uses to allocate its facilities and administrative costs to both sponsored and nonsponsored activities. The costs allocated to sponsored projects are divided by the direct costs of sponsored projects to arrive at a rate. The U.S. Department of Health and Human Services (DHHS) must approve the rate before the System can use it to charge facilities and administrative costs to federally sponsored projects. The System has elected not to use the 10% de minimis indirect cost rate allowed under Uniform Guidance.Under Uniform Guidance and State Single Audit Guidelines for Wisconsin, tests of compliance with laws and regulations related to specific program requirements are required for each federal and state award program that is considered a major program for the System. Because the Schedule presents only a selected portion of the operations of the System, it is not intended to and does not present the financial position, changes in net assets or cash flows of the System. As outlined in the April 2022 OMB Compliance Supplement, the amounts reported in the Schedule related to the Provider Relief Fund (PRF), Assistance Listing No. 93.498, are reported based upon the PRF reporting portal submission guidelines established by the Health Resource and Service Administration (HRSA). Separate reporting periods were established by HRSA based on the dates of receipt of PRF payments. Each reporting period has a specific period of availability which begins on January 1, 2020 and extends through specified deadlines, as indicated below: Payment Received Period (Payments Exceeding $10,000 in Aggregate Received), Deadline to Use Funds, Reporting Time Period Period 1 April 10, 2020 to June 30,2020, June 30, 2021, July 1, 2021 to September 30, 2021 Period 2 July 1, 2020 to December 31, 2020, December 31, 2021, January 1, 2022 to March 31, 2022, Period 3, January 1, 2021 to June 30, 2021, June 30, 2022, July 1, 2022 to September 30, 2022, Period 4, July 1, 2021 to December 31, 2021, December 31, 2022, January 1, 2023 to March 31, 2023, Period 5, January 1 2022 to June 30, 2022, June 30, 2023, July 1, 2023 to September 30, 2023, Period 6, July 1, 2022 to December 31, 2022, December 31, 2023, January 1, 2024 to March 31, 2024. The accompanying Schedule of Expenditures of Federal Awards (SEFA) includes those qualifying expenditures and lost revenues that were reported in the HRSA PRF portal for Period 3 and 4. During the years ended December 31, 2022 and 2021, the System recognized approximately $3,920,000 and $24,420,000, respectively, related to Period 3 and 4 funding. De Minimis Rate Used: N Rate Explanation: The auditee did not use the de minimis cost rate. All federal and state grant expenditures of Marshfield Clinic Health System, Inc. and subsidiaries (the System) are included in the scope of the audit except those awarded to Family Health Center of Marshfield, Inc., an entity sponsored by the System. The System acquired Dickinson County Healthcare System (Dickinson) in February 2022. The audit was performed in accordance with the provisions of the OMB Uniform Guidance Compliance Supplement (Compliance Supplement) and the State Single Audit Guidelines of Wisconsin. Compliance testing of all requirements, as described in the Compliance Supplement, was performed for the grant programs noted below. The Schedule of Expenditures of Federal and State Awards (the Schedule) includes all federal and state grants to the System that had activity during the year ended December 31, 2022, except those awarded to Family Health Center of Marshfield, Inc. A separate audit in accordance with OMB Uniform Guidance is completed for Family Health Center of Marshfield, Inc. In February 2022, the System became the sole corporate member of Dickinson County Healthcare System (MMC-Dickinson) through a member substitution. MMC-Dickinsons federal and state grant awards are included in the consolidated System Schedule for the year ended December 31, 2022. Prior to acquisition, MMC-Dickinson had a separate Single Audit for the year-ended December 31, 2021. Managements corrective action plans include the plans related to the prior year 2021 MMC-Dickinson Single Audit.Federal and state expenditures include all grants, contracts, and similar agreements entered into directly between the System and agencies and departments of the federal government and all awards to the System by other governmental entities and not-for-profit organizations pursuant to federal grants, contracts, and similar agreements. The Schedule summarizes expenditures by the following:?Major and nonmajor federal programs?Primary federal funding agency?Direct award agreements between the System and federal granting agencies?Pass-through federal award agreements between the System and nonfederal granting agencies?Direct award agreements between the System and state granting agencies?Pass-through state award agreements between the System and nonstate granting agenciesExpenditures consist of direct costs and facilities and administrative costs. Direct costs are those that can be easily identified with an individual federally sponsored project. The salary of a principal investigator of a sponsored research project and the materials consumed by the project are examples of direct costs.Unlike direct costs, facilities and administrative costs cannot be easily identified with an individual sponsored project. Facilities and administrative costs are the costs of services and resources that benefit many sponsored projects as well as nonsponsored projects and activities. Expenses incurred for administration, library, building maintenance, and building and equipment depreciation are examples of facilities and administrative costs.There were no noncash expenditures or federally provided insurance related to the Systems federal award programs during the year ended December 31, 2022
Title: 3.Audits Performed by Other Organizations Accounting Policies: The Schedule has been prepared on the accrual basis of accounting. The Schedule includes all federal and state grants, and contracts entered into by the System that had activity during the year ended December 31, 2022 and should be read in conjunction with the Systems consolidated financial statements. The information in the Schedule is presented in accordance with the requirements of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) and the State Single Audit Guidelines for Wisconsin. Negative amounts shown on the Schedule represent adjustments or credits made in the normal course of business to amounts reported as expenditures in prior years. The System and federal agencies use a facilities and administrative cost rate to charge facilities and administrative costs to individual sponsored projects. The rate is the result of a number of complex cost allocation procedures that the System uses to allocate its facilities and administrative costs to both sponsored and nonsponsored activities. The costs allocated to sponsored projects are divided by the direct costs of sponsored projects to arrive at a rate. The U.S. Department of Health and Human Services (DHHS) must approve the rate before the System can use it to charge facilities and administrative costs to federally sponsored projects. The System has elected not to use the 10% de minimis indirect cost rate allowed under Uniform Guidance.Under Uniform Guidance and State Single Audit Guidelines for Wisconsin, tests of compliance with laws and regulations related to specific program requirements are required for each federal and state award program that is considered a major program for the System. Because the Schedule presents only a selected portion of the operations of the System, it is not intended to and does not present the financial position, changes in net assets or cash flows of the System. As outlined in the April 2022 OMB Compliance Supplement, the amounts reported in the Schedule related to the Provider Relief Fund (PRF), Assistance Listing No. 93.498, are reported based upon the PRF reporting portal submission guidelines established by the Health Resource and Service Administration (HRSA). Separate reporting periods were established by HRSA based on the dates of receipt of PRF payments. Each reporting period has a specific period of availability which begins on January 1, 2020 and extends through specified deadlines, as indicated below: Payment Received Period (Payments Exceeding $10,000 in Aggregate Received), Deadline to Use Funds, Reporting Time Period Period 1 April 10, 2020 to June 30,2020, June 30, 2021, July 1, 2021 to September 30, 2021 Period 2 July 1, 2020 to December 31, 2020, December 31, 2021, January 1, 2022 to March 31, 2022, Period 3, January 1, 2021 to June 30, 2021, June 30, 2022, July 1, 2022 to September 30, 2022, Period 4, July 1, 2021 to December 31, 2021, December 31, 2022, January 1, 2023 to March 31, 2023, Period 5, January 1 2022 to June 30, 2022, June 30, 2023, July 1, 2023 to September 30, 2023, Period 6, July 1, 2022 to December 31, 2022, December 31, 2023, January 1, 2024 to March 31, 2024. The accompanying Schedule of Expenditures of Federal Awards (SEFA) includes those qualifying expenditures and lost revenues that were reported in the HRSA PRF portal for Period 3 and 4. During the years ended December 31, 2022 and 2021, the System recognized approximately $3,920,000 and $24,420,000, respectively, related to Period 3 and 4 funding. De Minimis Rate Used: N Rate Explanation: The auditee did not use the de minimis cost rate. There were no audits of the Systems federal or state award programs performed by other organizations or grantor agencies during the year ended December 31, 2022.
Title: 5.Loans Outstanding Accounting Policies: The Schedule has been prepared on the accrual basis of accounting. The Schedule includes all federal and state grants, and contracts entered into by the System that had activity during the year ended December 31, 2022 and should be read in conjunction with the Systems consolidated financial statements. The information in the Schedule is presented in accordance with the requirements of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) and the State Single Audit Guidelines for Wisconsin. Negative amounts shown on the Schedule represent adjustments or credits made in the normal course of business to amounts reported as expenditures in prior years. The System and federal agencies use a facilities and administrative cost rate to charge facilities and administrative costs to individual sponsored projects. The rate is the result of a number of complex cost allocation procedures that the System uses to allocate its facilities and administrative costs to both sponsored and nonsponsored activities. The costs allocated to sponsored projects are divided by the direct costs of sponsored projects to arrive at a rate. The U.S. Department of Health and Human Services (DHHS) must approve the rate before the System can use it to charge facilities and administrative costs to federally sponsored projects. The System has elected not to use the 10% de minimis indirect cost rate allowed under Uniform Guidance.Under Uniform Guidance and State Single Audit Guidelines for Wisconsin, tests of compliance with laws and regulations related to specific program requirements are required for each federal and state award program that is considered a major program for the System. Because the Schedule presents only a selected portion of the operations of the System, it is not intended to and does not present the financial position, changes in net assets or cash flows of the System. As outlined in the April 2022 OMB Compliance Supplement, the amounts reported in the Schedule related to the Provider Relief Fund (PRF), Assistance Listing No. 93.498, are reported based upon the PRF reporting portal submission guidelines established by the Health Resource and Service Administration (HRSA). Separate reporting periods were established by HRSA based on the dates of receipt of PRF payments. Each reporting period has a specific period of availability which begins on January 1, 2020 and extends through specified deadlines, as indicated below: Payment Received Period (Payments Exceeding $10,000 in Aggregate Received), Deadline to Use Funds, Reporting Time Period Period 1 April 10, 2020 to June 30,2020, June 30, 2021, July 1, 2021 to September 30, 2021 Period 2 July 1, 2020 to December 31, 2020, December 31, 2021, January 1, 2022 to March 31, 2022, Period 3, January 1, 2021 to June 30, 2021, June 30, 2022, July 1, 2022 to September 30, 2022, Period 4, July 1, 2021 to December 31, 2021, December 31, 2022, January 1, 2023 to March 31, 2023, Period 5, January 1 2022 to June 30, 2022, June 30, 2023, July 1, 2023 to September 30, 2023, Period 6, July 1, 2022 to December 31, 2022, December 31, 2023, January 1, 2024 to March 31, 2024. The accompanying Schedule of Expenditures of Federal Awards (SEFA) includes those qualifying expenditures and lost revenues that were reported in the HRSA PRF portal for Period 3 and 4. During the years ended December 31, 2022 and 2021, the System recognized approximately $3,920,000 and $24,420,000, respectively, related to Period 3 and 4 funding. De Minimis Rate Used: N Rate Explanation: The auditee did not use the de minimis cost rate. A subsidiary with a loan under the Community Facilities Loans and Grant program was acquired by the System on February 1, 2022. Expenditures relating to this program are reported in the Schedule at the balance as of February 1, 2022 plus advances made from February 1, 2022 through December 31, 2022. The outstanding balance at December 31, 2022 was $16,287,116.
Title: 7.Settlement of State of Wisconsin Department of Health Services (DHS) Cos Accounting Policies: The Schedule has been prepared on the accrual basis of accounting. The Schedule includes all federal and state grants, and contracts entered into by the System that had activity during the year ended December 31, 2022 and should be read in conjunction with the Systems consolidated financial statements. The information in the Schedule is presented in accordance with the requirements of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) and the State Single Audit Guidelines for Wisconsin. Negative amounts shown on the Schedule represent adjustments or credits made in the normal course of business to amounts reported as expenditures in prior years. The System and federal agencies use a facilities and administrative cost rate to charge facilities and administrative costs to individual sponsored projects. The rate is the result of a number of complex cost allocation procedures that the System uses to allocate its facilities and administrative costs to both sponsored and nonsponsored activities. The costs allocated to sponsored projects are divided by the direct costs of sponsored projects to arrive at a rate. The U.S. Department of Health and Human Services (DHHS) must approve the rate before the System can use it to charge facilities and administrative costs to federally sponsored projects. The System has elected not to use the 10% de minimis indirect cost rate allowed under Uniform Guidance.Under Uniform Guidance and State Single Audit Guidelines for Wisconsin, tests of compliance with laws and regulations related to specific program requirements are required for each federal and state award program that is considered a major program for the System. Because the Schedule presents only a selected portion of the operations of the System, it is not intended to and does not present the financial position, changes in net assets or cash flows of the System. As outlined in the April 2022 OMB Compliance Supplement, the amounts reported in the Schedule related to the Provider Relief Fund (PRF), Assistance Listing No. 93.498, are reported based upon the PRF reporting portal submission guidelines established by the Health Resource and Service Administration (HRSA). Separate reporting periods were established by HRSA based on the dates of receipt of PRF payments. Each reporting period has a specific period of availability which begins on January 1, 2020 and extends through specified deadlines, as indicated below: Payment Received Period (Payments Exceeding $10,000 in Aggregate Received), Deadline to Use Funds, Reporting Time Period Period 1 April 10, 2020 to June 30,2020, June 30, 2021, July 1, 2021 to September 30, 2021 Period 2 July 1, 2020 to December 31, 2020, December 31, 2021, January 1, 2022 to March 31, 2022, Period 3, January 1, 2021 to June 30, 2021, June 30, 2022, July 1, 2022 to September 30, 2022, Period 4, July 1, 2021 to December 31, 2021, December 31, 2022, January 1, 2023 to March 31, 2023, Period 5, January 1 2022 to June 30, 2022, June 30, 2023, July 1, 2023 to September 30, 2023, Period 6, July 1, 2022 to December 31, 2022, December 31, 2023, January 1, 2024 to March 31, 2024. The accompanying Schedule of Expenditures of Federal Awards (SEFA) includes those qualifying expenditures and lost revenues that were reported in the HRSA PRF portal for Period 3 and 4. During the years ended December 31, 2022 and 2021, the System recognized approximately $3,920,000 and $24,420,000, respectively, related to Period 3 and 4 funding. De Minimis Rate Used: N Rate Explanation: The auditee did not use the de minimis cost rate. The Systems settlement of DHS cost reimbursement awards presented for the year ended December 31, 2022 are summarized below. Certain awards summarized below may not agree to the amounts in the Schedule based on the difference of timing of reporting to DHS and the recognition of expenses on the Schedule. The indirect costs represent facilities and administrative costs allocated to the program based on a predetermined indirect cost rate negotiated with the U.S. Department of Health and Human Services. Community Aids System Reporting (CARS) ProfileAward TitleAward AmountAward PeriodPeriod of award within audit periodExpenditures reported to CARS for paymentSalary and wagesOther expensesIndirect costsTotal allowable costs128-010Congenital Disorders Program$37,5467/1/21-6/30/221/1/22-6/30/22$12,927$10,755$-$2,172$12,927128-010Congenital Disorders Program$37,5467/1/22-6/30/237/1/22-12/31/2212,55710,464-2,09312,557128-011Congenital Disorders Program$136,7247/1/21-6/30/221/1/22-6/30/2249,605-41,5258,08049,605128-011Congenital Disorders Program$136,7257/1/22-6/30/237/1/22-12/31/2255,819-46,5169,30355,819157-010WWWP$86,4477/1/21-6/30/221/1/22-6/30/2216,39316,33558-16,393157-120WWWP$11,3707/1/21-6/30/221/1/22-6/30/22630630--630531-282Alliance for Wisconsin$256,3459/30/21-9/29/221/1/22-9/29/22206,43318,154162,92825,351206,433533-016Alliance for Wisconsin Youth$337,8387/1/21-6/30/221/1/22-6/30/22324,602131,259139,66553,678324,602533-016Alliance for Wisconsin Youth $231,8387/1/22-6/30/237/1/22-12/31/2287,93164,9498,32714,65587,931$766,887$252,546$399,019$115,332$766,887

Finding Details

Finding 2022-004 ? Allowable Costs U.S. Department of Health and Human Services COVID-19 ? Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Assistance Listing # 93.498 Significant Deficiency and Allowable Costs Noncompliance Criteria: 2 CFR 200.303 requires that a 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. 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 and the ?Internal Control Integrated Framework,? issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). Condition: During our testing of compliance and internal controls over allowability of costs and reporting of expenditures, it was determined that internal controls over reporting are not designed to prevent and detect errors in expenditures being reported on the Department of Health Resources and Services Administration (HRSA) portal (the Portal). Consequently, we noted approximately $246,000 of ineligible expenditures related to physician compensation were submitted on the Portal for period 4 due to errors in the PRF Grants Reported Payroll Costs reports. Cause: Lack of effectively designed and implemented internal controls over allowability of expenditures and reporting of expenditures in the Portal for period 4. Effect: Without the proper implementation of an effectively designed system of internal controls, the internal control system cannot be relied upon to effectively prevent or detect noncompliance. Questioned costs: $246,000. Context: Our testing noted approximately $246,000 of ineligible expenditures for physician compensation out of a total of approximately $336,000 in physician compensation out of a total of approximately $5,440,000 in expenditures that were reported on the Portal for period 4. Our sample was not intended to be statistically valid. Repeat finding from prior year: No Recommendation: Effective supervisory review internal controls over reporting should be implemented to ensure expenditures submitted in the Portal meet the criteria established in the terms and conditions. Views of responsible officials and planned corrective actions: Management agrees with this finding. Please refer to pages 64 and 65 for the Corrective Action Plan.
Finding 2022-003 ? Special Tests Reserve Deposits Department of Agriculture Community Facilities Loans and Grants Cluster Assistance Listing #10.766 Significant Deficiency and Special Tests Noncompliance Criteria: The Loan Resolution Security Agreement (LRSA) requires that a deposit in the amount of $200,000 should be funded to the debt service reserve account on each anniversary of the closing date of the related loan (October 2021). Appropriate internal controls over the debt service reserve account including timely bank account reconciliations are important to ensuring compliance with the LRSA requirements. Condition: Inadequate controls exist over monitoring compliance with the debt service reserve account requirements. Additionally, documentation was not maintained of the supervisory review of the debt service account bank reconciliations. Cause: The System acquired MMC-Dickinson during 2022 and has not yet fully implemented existing System internal controls to the new subsidiary. Effect: The annual debt service reserve deposit due in October 2022 was not made until February 2023. Furthermore, no documentation was maintained of supervisor review of the debt service reserve bank account monthly reconciliations. Questioned costs: None reported. Context: The annual $200,000 deposit that was due in October 2022 was not made in a timely manner until February 2023. Repeat finding from prior year: No Recommendation: We recommend that management implement appropriate controls over the debt service reserve fund to ensure compliance with LRSA requirements including timely deposits. Controls should include timely debt service reserve bank account reconciliations with documented supervisory review of bank reconciliations for compliance with debt service reserve requirements. Views of responsible officials and planned corrective actions: Management agrees with this finding. Please refer to pages 64 and 65 for the Corrective Action Plan.
Finding 2022-002 - Preparation of the Schedule of Expenditures of Federal Awards Department of Treasury COVID-19 - Coronavirus State and Local Fiscal Recovery Funds Assistance Listing #21.027 Significant Deficiency Criteria: Title 2 Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) requires the System to prepare a schedule of expenditures of federal awards (Schedule). 2 CFR 200.303(a) establishes that the auditee must establish and maintain effective internal control over the federal award in compliance with federal statutes, regulations, and conditions of the federal award. Condition: Inadequate controls exist over the preparation of the Schedule specific to expenditure activity for the MMC- Dickinson subsidiary that was acquired in 2022 to allow for the timely completion of a complete and accurate Schedule. Consequently, certain MMC Dickinson expenditures were erroneously omitted from the preliminary Schedule. Cause: The System acquired MMC-Dickinson during 2022 and has not yet fully implemented existing System internal controls to the new subsidiary. Effect: Management identified additional MMC-Dickinson expenditures that were added to the Schedule late in the audit process. Questioned costs: None reported. Context: Approximately $480,000 of expenditures in relations to total expenditures of approximately $800,000 under assistance listing number 21.027 COVID-19 Coronavirus State and Local Fiscal Recovery Funds for the year-ended December 31, 2022, were originally omitted from the preliminary Schedule. Additionally, approximately $665,000 in expenditures from other programs was originally omitted from the preliminary Schedule and approximately $345,000 of expenditures were removed from the preliminary Schedule. These changes were not identified in a timely manner resulting in delays in completing the System Single Audit. Repeat finding from prior year: Not for the System but Yes, for 2021 Single Audit of MMC-Dickinson See prior year finding 2021-003. Recommendation: We recommend that management enhance its controls over the Schedule to ensure they include MMC-Dickinson and future acquisition to ensure timely accurate completion of the Schedule. Views of responsible officials and planned corrective actions: Management agrees with this finding. Please refer to pages 64 and 65 for the Corrective Action Plan
Finding 2022-004 ? Allowable Costs U.S. Department of Health and Human Services COVID-19 ? Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Assistance Listing # 93.498 Significant Deficiency and Allowable Costs Noncompliance Criteria: 2 CFR 200.303 requires that a 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. 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 and the ?Internal Control Integrated Framework,? issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). Condition: During our testing of compliance and internal controls over allowability of costs and reporting of expenditures, it was determined that internal controls over reporting are not designed to prevent and detect errors in expenditures being reported on the Department of Health Resources and Services Administration (HRSA) portal (the Portal). Consequently, we noted approximately $246,000 of ineligible expenditures related to physician compensation were submitted on the Portal for period 4 due to errors in the PRF Grants Reported Payroll Costs reports. Cause: Lack of effectively designed and implemented internal controls over allowability of expenditures and reporting of expenditures in the Portal for period 4. Effect: Without the proper implementation of an effectively designed system of internal controls, the internal control system cannot be relied upon to effectively prevent or detect noncompliance. Questioned costs: $246,000. Context: Our testing noted approximately $246,000 of ineligible expenditures for physician compensation out of a total of approximately $336,000 in physician compensation out of a total of approximately $5,440,000 in expenditures that were reported on the Portal for period 4. Our sample was not intended to be statistically valid. Repeat finding from prior year: No Recommendation: Effective supervisory review internal controls over reporting should be implemented to ensure expenditures submitted in the Portal meet the criteria established in the terms and conditions. Views of responsible officials and planned corrective actions: Management agrees with this finding. Please refer to pages 64 and 65 for the Corrective Action Plan.
Finding 2022-003 ? Special Tests Reserve Deposits Department of Agriculture Community Facilities Loans and Grants Cluster Assistance Listing #10.766 Significant Deficiency and Special Tests Noncompliance Criteria: The Loan Resolution Security Agreement (LRSA) requires that a deposit in the amount of $200,000 should be funded to the debt service reserve account on each anniversary of the closing date of the related loan (October 2021). Appropriate internal controls over the debt service reserve account including timely bank account reconciliations are important to ensuring compliance with the LRSA requirements. Condition: Inadequate controls exist over monitoring compliance with the debt service reserve account requirements. Additionally, documentation was not maintained of the supervisory review of the debt service account bank reconciliations. Cause: The System acquired MMC-Dickinson during 2022 and has not yet fully implemented existing System internal controls to the new subsidiary. Effect: The annual debt service reserve deposit due in October 2022 was not made until February 2023. Furthermore, no documentation was maintained of supervisor review of the debt service reserve bank account monthly reconciliations. Questioned costs: None reported. Context: The annual $200,000 deposit that was due in October 2022 was not made in a timely manner until February 2023. Repeat finding from prior year: No Recommendation: We recommend that management implement appropriate controls over the debt service reserve fund to ensure compliance with LRSA requirements including timely deposits. Controls should include timely debt service reserve bank account reconciliations with documented supervisory review of bank reconciliations for compliance with debt service reserve requirements. Views of responsible officials and planned corrective actions: Management agrees with this finding. Please refer to pages 64 and 65 for the Corrective Action Plan.
Finding 2022-002 - Preparation of the Schedule of Expenditures of Federal Awards Department of Treasury COVID-19 - Coronavirus State and Local Fiscal Recovery Funds Assistance Listing #21.027 Significant Deficiency Criteria: Title 2 Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) requires the System to prepare a schedule of expenditures of federal awards (Schedule). 2 CFR 200.303(a) establishes that the auditee must establish and maintain effective internal control over the federal award in compliance with federal statutes, regulations, and conditions of the federal award. Condition: Inadequate controls exist over the preparation of the Schedule specific to expenditure activity for the MMC- Dickinson subsidiary that was acquired in 2022 to allow for the timely completion of a complete and accurate Schedule. Consequently, certain MMC Dickinson expenditures were erroneously omitted from the preliminary Schedule. Cause: The System acquired MMC-Dickinson during 2022 and has not yet fully implemented existing System internal controls to the new subsidiary. Effect: Management identified additional MMC-Dickinson expenditures that were added to the Schedule late in the audit process. Questioned costs: None reported. Context: Approximately $480,000 of expenditures in relations to total expenditures of approximately $800,000 under assistance listing number 21.027 COVID-19 Coronavirus State and Local Fiscal Recovery Funds for the year-ended December 31, 2022, were originally omitted from the preliminary Schedule. Additionally, approximately $665,000 in expenditures from other programs was originally omitted from the preliminary Schedule and approximately $345,000 of expenditures were removed from the preliminary Schedule. These changes were not identified in a timely manner resulting in delays in completing the System Single Audit. Repeat finding from prior year: Not for the System but Yes, for 2021 Single Audit of MMC-Dickinson See prior year finding 2021-003. Recommendation: We recommend that management enhance its controls over the Schedule to ensure they include MMC-Dickinson and future acquisition to ensure timely accurate completion of the Schedule. Views of responsible officials and planned corrective actions: Management agrees with this finding. Please refer to pages 64 and 65 for the Corrective Action Plan