Audit 29211

FY End
2022-12-31
Total Expended
$144.59M
Findings
6
Programs
30
Organization: Sutter Health and Affiliates (CA)
Year: 2022 Accepted: 2023-09-27

Organization Exclusion Status:

Checking exclusion status...

Findings

ID Ref Severity Repeat Requirement
37469 2022-001 Material Weakness - ABHN
37470 2022-001 Material Weakness - ABHN
37471 2022-001 Material Weakness - ABHN
613911 2022-001 Material Weakness - ABHN
613912 2022-001 Material Weakness - ABHN
613913 2022-001 Material Weakness - ABHN

Programs

ALN Program Spent Major Findings
97.036 Covid-19 - Disaster Grants - Public Assistance (presidentially Declared Disasters) $70.83M Yes 1
93.498 Covid-19 - Provider Relief Fund and American Rescue Plan (arp) Rural Distribution $48.90M Yes 0
93.461 Covid-19 - Hrsa Covid-19 Claims Reimbursement for the Uninsured Program and the Covid-19 Coverage Assistance Fund $1.86M - 0
93.914 Hiv Emergency Relief Project Grants $676,813 - 0
93.928 Special Projects of National Significance $638,681 - 0
93.395 Cancer Treatment Research $214,525 - 0
93.153 Coordinated Services and Access to Research for Women, Infants, Children, and Youth $210,835 - 0
93.837 Cardiovascular Diseases Research $154,677 - 0
93.939 Hiv Prevention Activities Non-Governmental Organization Based $144,476 - 0
93.686 Ending the Hiv Epidemic: A Plan for America - Ryan White Hiv/aids Program Parts A and B $126,707 - 0
93.940 Hiv Prevention Activities Health Department Based $120,023 - 0
93.846 Arthritis, Musculoskeletal and Skin Diseases Research $115,295 - 0
93.279 Drug Abuse and Addiction Research Programs $102,149 - 0
93.994 Maternal and Child Health Services Block Grant to the States $102,126 - 0
93.155 Rural Health Research Centers $77,678 - 0
93.213 Research and Training in Complementary and Integrative Health $73,569 - 0
93.866 Aging Research $71,496 - 0
93.558 Temporary Assistance for Needy Families $63,800 - 0
93.242 Mental Health Research Grants $45,781 - 0
93.121 Oral Diseases and Disorders Research $42,162 - 0
93.394 Cancer Detection and Diagnosis Research $37,356 - 0
97.036 Disaster Grants - Public Assistance (presidentially Declared Disasters) $27,535 Yes 1
93.855 Allergy and Infectious Diseases Research $27,422 - 0
93.353 21st Century Cures Act - Beau Biden Cancer Moonshot $22,922 - 0
93.393 Cancer Cause and Prevention Research $12,113 - 0
93.853 Extramural Research Programs in the Neurosciences and Neurological Disorders $11,501 - 0
93.233 National Center on Sleep Disorders Research $11,338 - 0
12.420 Military Medical Research and Development $5,497 - 0
93.847 Diabetes, Digestive, and Kidney Diseases Extramural Research $4,854 - 0
93.867 Vision Research $3,910 - 0

Contacts

Name Title Type
HRW3LUDLLCH5 Colette Boudreau Auditee
9162866928 Scott Enos Auditor
No contacts on file

Notes to SEFA

Title: Disaster Grants Public Assistance (Presidentially Declared Disasters) Accounting Policies: 1. Summary of Significant Accounting Policies: Basis of Accounting: The accompanying Schedule of Expenditures of Federal Awards (SEFA) includes the federal grant activity of Sutter Health and Affiliates and is presented on the accrual basis of accounting. The information in the SEFA is presented in accordance with the requirements of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Costs Principles, and Audit Requirements for Federal Awards (Uniform Guidance). The SEFA does not include payments received under the traditional Medicare and Medicaid reimbursement programs, as these programs are outside the scope of the Uniform Guidance. There were no donated goods and personal protective equipment received from federal sources that required recognition or disclosure in the notes to the SEFA. De Minimis Rate Used: N Rate Explanation: 2. Indirect Costs: Sutter Health and Affiliates does not use the 10 percent de minimis indirect cost rate provided for in the Uniform Guidance. 3. Disaster Grants Public Assistance (Presidentially Declared Disasters): In fiscal year 2022, Sutter Health and Affiliates received approval from State of California Governors Office of Emergency Services for six project worksheets related to the reimbursement of eligible expenditures of $55,496,733 incurred in previous fiscal years. These previous years expenditures are included in the SEFA in the current year in accordance with guidance provided by Department of Homeland Security.
Title: Provider Relief Fund Accounting Policies: 1. Summary of Significant Accounting Policies: Basis of Accounting: The accompanying Schedule of Expenditures of Federal Awards (SEFA) includes the federal grant activity of Sutter Health and Affiliates and is presented on the accrual basis of accounting. The information in the SEFA is presented in accordance with the requirements of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Costs Principles, and Audit Requirements for Federal Awards (Uniform Guidance). The SEFA does not include payments received under the traditional Medicare and Medicaid reimbursement programs, as these programs are outside the scope of the Uniform Guidance. There were no donated goods and personal protective equipment received from federal sources that required recognition or disclosure in the notes to the SEFA. De Minimis Rate Used: N Rate Explanation: 2. Indirect Costs: Sutter Health and Affiliates does not use the 10 percent de minimis indirect cost rate provided for in the Uniform Guidance. 4. Provider Relief Fund: The amount presented on the SEFA for Assistance Listing Number 93.498, COVID-19 - Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution (PRF Funds), is for the year ended December 31, 2022. The amount presented reconciles to the Provider Relief Fund (PRF) information reported to the Health Resources and Services Administration (HRSA) as follows: See the Notes to the SEFA for table. Health and Human Services (HHS) has indicated the PRF Funds on the SEFA be reported corresponding to reporting requirements of the HRSA PRF Reporting Portal. Payments from HHS for PRF are assigned to Payment Received Periods (each, a Period) based upon the date each payment from the PRF was received. Each Period has a specified Period of Availability and timing of reporting requirements. Entities report into the HRSA PRF Reporting Portal after each Periods deadline to use the funds (i.e., after the end of the Period of Availability). The SEFA includes $48,896,664 of PRF Funds received from HHS between January 1, 2021 through December 31, 2021. In accordance with guidance from HHS, these amounts are presented as Period 3 and Period 4. Such amount was recognized as contributions revenues in Sutter Health and Affiliates consolidated financial statements in the year ended December 31, 2021.

Finding Details

Finding 2022-001: Internal control deficiency and noncompliance over activities allowed or unallowed, allowable costs/cost principles, period of performance, and special tests and provisions related to amounts reimbursed for the project worksheet. Identification of the federal program: Assistance Listing Number 97.036: ? COVID-19 ? Disaster Grants ? Public Assistance (Presidentially Declared Disasters) ? U.S. Department of Homeland Security ? Federal award identification number: o Application title ? 549687 ? Sutter Health Materials Northern California o Application number ? PA-09-CA-4482-PW-01727(0) ? Federal award year ? January 20, 2020 to July 1, 2022 ? Pass-through entity ? California Governor?s Office of Emergency Services Criteria or specific requirement (including statutory, regulatory or other citation): Title 2, Subtitle A, Chapter II, Part 200, Subpart D, 200.303 ? Internal controls. The 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 or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). 2 CFR, Part 200, Section 200.84 ? Questioned costs states a questioned cost as either (a) which resulted from a violation or possible violation of a statute, regulation, or the terms and conditions of a Federal award, including for funds used to match Federal funds; (b) where the costs, at the time of the audit, are not supported by adequate documentation; or (c) where the costs incurred appear unreasonable and do not reflect the actions a prudent person would take in the circumstances. 2 CFR, Part 200, Section 200.403 ? Except where otherwise authorized by statute, costs must meet the following general criteria in order to be allowable under Federal awards: ? (a) Be necessary and reasonable for the performance of the Federal award and be allocable thereto under these principles ? (g) Be adequately documented The Office of Management and Budget Compliance Supplement states the Federal Emergency Management Agency (FEMA) evaluates the eligibility of all costs claimed by the applicant. Not all costs incurred as a result of the incident are eligible. Costs must be: ? Directly tied to the performance of eligible work ? Adequately documented ? Reduced by all applicable credits ? Authorized and not prohibited under federal, state, territorial, tribal, or local government laws or regulations ? Consistent with applicant?s internal policies, regulations, and procedures that apply uniformly to both federal awards and other activities of the applicant ? Necessary and reasonable to accomplish the work properly and efficiently The Office of Management and Budget Compliance Supplement states the entity is required to certify that reported costs were incurred in performance of eligible work, that the approved work was completed, that the project is in compliance with the provisions of the FEMA-State Agreement, all grant conditions were met, and that payments for that project were made in accordance with the applicable payment provisions. Condition: During our testing over activities allowed or unallowed, allowable costs/cost principles, period of performance, and special tests and provisions, we observed management did not have effective internal controls in place to ensure expenditures reported for reimbursement in the FEMA project worksheet were actual paid expenditures. This resulted in an overstatement of the amount reimbursed by FEMA. Cause: Management did not have effective internal controls in place to ensure expenditures reported for reimbursement in the FEMA project worksheet were based on actual paid expenditures. Effect or potential effect: Management was reimbursed by FEMA for expenditures that were not based on the final paid expenditure. Questioned costs: $904,020 ? Assistance Listing Number 97.036 ? Federal award identification number: o Application title ? 549687 ? Sutter Health Materials Northern California o Application number ? PA-09-CA-4482-PW-01727(0) The questioned costs were computed by calculating the difference between the expenditures submitted to FEMA in the amount of $70,825,974 and the actual paid expenditures in the amount of $69,921,954 resulting in $904,020. Context: During our testing over activities allowed or unallowed, allowable costs/cost principles, period of performance, and special tests and provisions, we obtained a listing of expenditures submitted for reimbursement to FEMA for the tested project worksheet and observed 561,641 expenditures in the listing for a total value of $70,825,974. We selected a sample of 40 for testing over activities allowed or unallowed and allowable costs/cost principals, a sample of 80 for testing over period of performance, and 1 project worksheet for testing over all compliance requirements. There were 12 out of 120 selections where the expenditures submitted to FEMA were not based on the actual paid expenditures. Management performed an analysis of all expenditures submitted to FEMA and determined the actual paid expenditures amounted to $69,921,954 compared to the expenditures submitted to FEMA in the amount of $70,825,974 resulting in an overstatement of the amount reimbursed by FEMA of $904,020. Management?s control regarding the review of the project worksheet did not identify these expenditures that were not based on actual paid expenditures. Identification as a repeat finding, if applicable: No. Recommendation: Management should develop and implement effective internal controls to ensure expenditures reported for reimbursement in FEMA project worksheets are based on actual paid expenditures. Management should refund the questioned costs to FEMA and work with FEMA to determine the extent of additional courses of action. Management should ensure this is performed through the closeout process of the project worksheet with FEMA. Views of responsible officials: Management will develop and implement an additional layer of review in future FEMA project worksheet submissions to ensure expenditures reported for reimbursement are based on actual paid expenditures. Management will work with FEMA to refund the total overpayment of $904,020 and discuss the extent of additional courses of action. Management will ensure this is performed through the closeout process of the project worksheet with FEMA.
Finding 2022-001: Internal control deficiency and noncompliance over activities allowed or unallowed, allowable costs/cost principles, period of performance, and special tests and provisions related to amounts reimbursed for the project worksheet. Identification of the federal program: Assistance Listing Number 97.036: ? COVID-19 ? Disaster Grants ? Public Assistance (Presidentially Declared Disasters) ? U.S. Department of Homeland Security ? Federal award identification number: o Application title ? 549687 ? Sutter Health Materials Northern California o Application number ? PA-09-CA-4482-PW-01727(0) ? Federal award year ? January 20, 2020 to July 1, 2022 ? Pass-through entity ? California Governor?s Office of Emergency Services Criteria or specific requirement (including statutory, regulatory or other citation): Title 2, Subtitle A, Chapter II, Part 200, Subpart D, 200.303 ? Internal controls. The 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 or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). 2 CFR, Part 200, Section 200.84 ? Questioned costs states a questioned cost as either (a) which resulted from a violation or possible violation of a statute, regulation, or the terms and conditions of a Federal award, including for funds used to match Federal funds; (b) where the costs, at the time of the audit, are not supported by adequate documentation; or (c) where the costs incurred appear unreasonable and do not reflect the actions a prudent person would take in the circumstances. 2 CFR, Part 200, Section 200.403 ? Except where otherwise authorized by statute, costs must meet the following general criteria in order to be allowable under Federal awards: ? (a) Be necessary and reasonable for the performance of the Federal award and be allocable thereto under these principles ? (g) Be adequately documented The Office of Management and Budget Compliance Supplement states the Federal Emergency Management Agency (FEMA) evaluates the eligibility of all costs claimed by the applicant. Not all costs incurred as a result of the incident are eligible. Costs must be: ? Directly tied to the performance of eligible work ? Adequately documented ? Reduced by all applicable credits ? Authorized and not prohibited under federal, state, territorial, tribal, or local government laws or regulations ? Consistent with applicant?s internal policies, regulations, and procedures that apply uniformly to both federal awards and other activities of the applicant ? Necessary and reasonable to accomplish the work properly and efficiently The Office of Management and Budget Compliance Supplement states the entity is required to certify that reported costs were incurred in performance of eligible work, that the approved work was completed, that the project is in compliance with the provisions of the FEMA-State Agreement, all grant conditions were met, and that payments for that project were made in accordance with the applicable payment provisions. Condition: During our testing over activities allowed or unallowed, allowable costs/cost principles, period of performance, and special tests and provisions, we observed management did not have effective internal controls in place to ensure expenditures reported for reimbursement in the FEMA project worksheet were actual paid expenditures. This resulted in an overstatement of the amount reimbursed by FEMA. Cause: Management did not have effective internal controls in place to ensure expenditures reported for reimbursement in the FEMA project worksheet were based on actual paid expenditures. Effect or potential effect: Management was reimbursed by FEMA for expenditures that were not based on the final paid expenditure. Questioned costs: $904,020 ? Assistance Listing Number 97.036 ? Federal award identification number: o Application title ? 549687 ? Sutter Health Materials Northern California o Application number ? PA-09-CA-4482-PW-01727(0) The questioned costs were computed by calculating the difference between the expenditures submitted to FEMA in the amount of $70,825,974 and the actual paid expenditures in the amount of $69,921,954 resulting in $904,020. Context: During our testing over activities allowed or unallowed, allowable costs/cost principles, period of performance, and special tests and provisions, we obtained a listing of expenditures submitted for reimbursement to FEMA for the tested project worksheet and observed 561,641 expenditures in the listing for a total value of $70,825,974. We selected a sample of 40 for testing over activities allowed or unallowed and allowable costs/cost principals, a sample of 80 for testing over period of performance, and 1 project worksheet for testing over all compliance requirements. There were 12 out of 120 selections where the expenditures submitted to FEMA were not based on the actual paid expenditures. Management performed an analysis of all expenditures submitted to FEMA and determined the actual paid expenditures amounted to $69,921,954 compared to the expenditures submitted to FEMA in the amount of $70,825,974 resulting in an overstatement of the amount reimbursed by FEMA of $904,020. Management?s control regarding the review of the project worksheet did not identify these expenditures that were not based on actual paid expenditures. Identification as a repeat finding, if applicable: No. Recommendation: Management should develop and implement effective internal controls to ensure expenditures reported for reimbursement in FEMA project worksheets are based on actual paid expenditures. Management should refund the questioned costs to FEMA and work with FEMA to determine the extent of additional courses of action. Management should ensure this is performed through the closeout process of the project worksheet with FEMA. Views of responsible officials: Management will develop and implement an additional layer of review in future FEMA project worksheet submissions to ensure expenditures reported for reimbursement are based on actual paid expenditures. Management will work with FEMA to refund the total overpayment of $904,020 and discuss the extent of additional courses of action. Management will ensure this is performed through the closeout process of the project worksheet with FEMA.
Finding 2022-001: Internal control deficiency and noncompliance over activities allowed or unallowed, allowable costs/cost principles, period of performance, and special tests and provisions related to amounts reimbursed for the project worksheet. Identification of the federal program: Assistance Listing Number 97.036: ? COVID-19 ? Disaster Grants ? Public Assistance (Presidentially Declared Disasters) ? U.S. Department of Homeland Security ? Federal award identification number: o Application title ? 549687 ? Sutter Health Materials Northern California o Application number ? PA-09-CA-4482-PW-01727(0) ? Federal award year ? January 20, 2020 to July 1, 2022 ? Pass-through entity ? California Governor?s Office of Emergency Services Criteria or specific requirement (including statutory, regulatory or other citation): Title 2, Subtitle A, Chapter II, Part 200, Subpart D, 200.303 ? Internal controls. The 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 or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). 2 CFR, Part 200, Section 200.84 ? Questioned costs states a questioned cost as either (a) which resulted from a violation or possible violation of a statute, regulation, or the terms and conditions of a Federal award, including for funds used to match Federal funds; (b) where the costs, at the time of the audit, are not supported by adequate documentation; or (c) where the costs incurred appear unreasonable and do not reflect the actions a prudent person would take in the circumstances. 2 CFR, Part 200, Section 200.403 ? Except where otherwise authorized by statute, costs must meet the following general criteria in order to be allowable under Federal awards: ? (a) Be necessary and reasonable for the performance of the Federal award and be allocable thereto under these principles ? (g) Be adequately documented The Office of Management and Budget Compliance Supplement states the Federal Emergency Management Agency (FEMA) evaluates the eligibility of all costs claimed by the applicant. Not all costs incurred as a result of the incident are eligible. Costs must be: ? Directly tied to the performance of eligible work ? Adequately documented ? Reduced by all applicable credits ? Authorized and not prohibited under federal, state, territorial, tribal, or local government laws or regulations ? Consistent with applicant?s internal policies, regulations, and procedures that apply uniformly to both federal awards and other activities of the applicant ? Necessary and reasonable to accomplish the work properly and efficiently The Office of Management and Budget Compliance Supplement states the entity is required to certify that reported costs were incurred in performance of eligible work, that the approved work was completed, that the project is in compliance with the provisions of the FEMA-State Agreement, all grant conditions were met, and that payments for that project were made in accordance with the applicable payment provisions. Condition: During our testing over activities allowed or unallowed, allowable costs/cost principles, period of performance, and special tests and provisions, we observed management did not have effective internal controls in place to ensure expenditures reported for reimbursement in the FEMA project worksheet were actual paid expenditures. This resulted in an overstatement of the amount reimbursed by FEMA. Cause: Management did not have effective internal controls in place to ensure expenditures reported for reimbursement in the FEMA project worksheet were based on actual paid expenditures. Effect or potential effect: Management was reimbursed by FEMA for expenditures that were not based on the final paid expenditure. Questioned costs: $904,020 ? Assistance Listing Number 97.036 ? Federal award identification number: o Application title ? 549687 ? Sutter Health Materials Northern California o Application number ? PA-09-CA-4482-PW-01727(0) The questioned costs were computed by calculating the difference between the expenditures submitted to FEMA in the amount of $70,825,974 and the actual paid expenditures in the amount of $69,921,954 resulting in $904,020. Context: During our testing over activities allowed or unallowed, allowable costs/cost principles, period of performance, and special tests and provisions, we obtained a listing of expenditures submitted for reimbursement to FEMA for the tested project worksheet and observed 561,641 expenditures in the listing for a total value of $70,825,974. We selected a sample of 40 for testing over activities allowed or unallowed and allowable costs/cost principals, a sample of 80 for testing over period of performance, and 1 project worksheet for testing over all compliance requirements. There were 12 out of 120 selections where the expenditures submitted to FEMA were not based on the actual paid expenditures. Management performed an analysis of all expenditures submitted to FEMA and determined the actual paid expenditures amounted to $69,921,954 compared to the expenditures submitted to FEMA in the amount of $70,825,974 resulting in an overstatement of the amount reimbursed by FEMA of $904,020. Management?s control regarding the review of the project worksheet did not identify these expenditures that were not based on actual paid expenditures. Identification as a repeat finding, if applicable: No. Recommendation: Management should develop and implement effective internal controls to ensure expenditures reported for reimbursement in FEMA project worksheets are based on actual paid expenditures. Management should refund the questioned costs to FEMA and work with FEMA to determine the extent of additional courses of action. Management should ensure this is performed through the closeout process of the project worksheet with FEMA. Views of responsible officials: Management will develop and implement an additional layer of review in future FEMA project worksheet submissions to ensure expenditures reported for reimbursement are based on actual paid expenditures. Management will work with FEMA to refund the total overpayment of $904,020 and discuss the extent of additional courses of action. Management will ensure this is performed through the closeout process of the project worksheet with FEMA.
Finding 2022-001: Internal control deficiency and noncompliance over activities allowed or unallowed, allowable costs/cost principles, period of performance, and special tests and provisions related to amounts reimbursed for the project worksheet. Identification of the federal program: Assistance Listing Number 97.036: ? COVID-19 ? Disaster Grants ? Public Assistance (Presidentially Declared Disasters) ? U.S. Department of Homeland Security ? Federal award identification number: o Application title ? 549687 ? Sutter Health Materials Northern California o Application number ? PA-09-CA-4482-PW-01727(0) ? Federal award year ? January 20, 2020 to July 1, 2022 ? Pass-through entity ? California Governor?s Office of Emergency Services Criteria or specific requirement (including statutory, regulatory or other citation): Title 2, Subtitle A, Chapter II, Part 200, Subpart D, 200.303 ? Internal controls. The 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 or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). 2 CFR, Part 200, Section 200.84 ? Questioned costs states a questioned cost as either (a) which resulted from a violation or possible violation of a statute, regulation, or the terms and conditions of a Federal award, including for funds used to match Federal funds; (b) where the costs, at the time of the audit, are not supported by adequate documentation; or (c) where the costs incurred appear unreasonable and do not reflect the actions a prudent person would take in the circumstances. 2 CFR, Part 200, Section 200.403 ? Except where otherwise authorized by statute, costs must meet the following general criteria in order to be allowable under Federal awards: ? (a) Be necessary and reasonable for the performance of the Federal award and be allocable thereto under these principles ? (g) Be adequately documented The Office of Management and Budget Compliance Supplement states the Federal Emergency Management Agency (FEMA) evaluates the eligibility of all costs claimed by the applicant. Not all costs incurred as a result of the incident are eligible. Costs must be: ? Directly tied to the performance of eligible work ? Adequately documented ? Reduced by all applicable credits ? Authorized and not prohibited under federal, state, territorial, tribal, or local government laws or regulations ? Consistent with applicant?s internal policies, regulations, and procedures that apply uniformly to both federal awards and other activities of the applicant ? Necessary and reasonable to accomplish the work properly and efficiently The Office of Management and Budget Compliance Supplement states the entity is required to certify that reported costs were incurred in performance of eligible work, that the approved work was completed, that the project is in compliance with the provisions of the FEMA-State Agreement, all grant conditions were met, and that payments for that project were made in accordance with the applicable payment provisions. Condition: During our testing over activities allowed or unallowed, allowable costs/cost principles, period of performance, and special tests and provisions, we observed management did not have effective internal controls in place to ensure expenditures reported for reimbursement in the FEMA project worksheet were actual paid expenditures. This resulted in an overstatement of the amount reimbursed by FEMA. Cause: Management did not have effective internal controls in place to ensure expenditures reported for reimbursement in the FEMA project worksheet were based on actual paid expenditures. Effect or potential effect: Management was reimbursed by FEMA for expenditures that were not based on the final paid expenditure. Questioned costs: $904,020 ? Assistance Listing Number 97.036 ? Federal award identification number: o Application title ? 549687 ? Sutter Health Materials Northern California o Application number ? PA-09-CA-4482-PW-01727(0) The questioned costs were computed by calculating the difference between the expenditures submitted to FEMA in the amount of $70,825,974 and the actual paid expenditures in the amount of $69,921,954 resulting in $904,020. Context: During our testing over activities allowed or unallowed, allowable costs/cost principles, period of performance, and special tests and provisions, we obtained a listing of expenditures submitted for reimbursement to FEMA for the tested project worksheet and observed 561,641 expenditures in the listing for a total value of $70,825,974. We selected a sample of 40 for testing over activities allowed or unallowed and allowable costs/cost principals, a sample of 80 for testing over period of performance, and 1 project worksheet for testing over all compliance requirements. There were 12 out of 120 selections where the expenditures submitted to FEMA were not based on the actual paid expenditures. Management performed an analysis of all expenditures submitted to FEMA and determined the actual paid expenditures amounted to $69,921,954 compared to the expenditures submitted to FEMA in the amount of $70,825,974 resulting in an overstatement of the amount reimbursed by FEMA of $904,020. Management?s control regarding the review of the project worksheet did not identify these expenditures that were not based on actual paid expenditures. Identification as a repeat finding, if applicable: No. Recommendation: Management should develop and implement effective internal controls to ensure expenditures reported for reimbursement in FEMA project worksheets are based on actual paid expenditures. Management should refund the questioned costs to FEMA and work with FEMA to determine the extent of additional courses of action. Management should ensure this is performed through the closeout process of the project worksheet with FEMA. Views of responsible officials: Management will develop and implement an additional layer of review in future FEMA project worksheet submissions to ensure expenditures reported for reimbursement are based on actual paid expenditures. Management will work with FEMA to refund the total overpayment of $904,020 and discuss the extent of additional courses of action. Management will ensure this is performed through the closeout process of the project worksheet with FEMA.
Finding 2022-001: Internal control deficiency and noncompliance over activities allowed or unallowed, allowable costs/cost principles, period of performance, and special tests and provisions related to amounts reimbursed for the project worksheet. Identification of the federal program: Assistance Listing Number 97.036: ? COVID-19 ? Disaster Grants ? Public Assistance (Presidentially Declared Disasters) ? U.S. Department of Homeland Security ? Federal award identification number: o Application title ? 549687 ? Sutter Health Materials Northern California o Application number ? PA-09-CA-4482-PW-01727(0) ? Federal award year ? January 20, 2020 to July 1, 2022 ? Pass-through entity ? California Governor?s Office of Emergency Services Criteria or specific requirement (including statutory, regulatory or other citation): Title 2, Subtitle A, Chapter II, Part 200, Subpart D, 200.303 ? Internal controls. The 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 or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). 2 CFR, Part 200, Section 200.84 ? Questioned costs states a questioned cost as either (a) which resulted from a violation or possible violation of a statute, regulation, or the terms and conditions of a Federal award, including for funds used to match Federal funds; (b) where the costs, at the time of the audit, are not supported by adequate documentation; or (c) where the costs incurred appear unreasonable and do not reflect the actions a prudent person would take in the circumstances. 2 CFR, Part 200, Section 200.403 ? Except where otherwise authorized by statute, costs must meet the following general criteria in order to be allowable under Federal awards: ? (a) Be necessary and reasonable for the performance of the Federal award and be allocable thereto under these principles ? (g) Be adequately documented The Office of Management and Budget Compliance Supplement states the Federal Emergency Management Agency (FEMA) evaluates the eligibility of all costs claimed by the applicant. Not all costs incurred as a result of the incident are eligible. Costs must be: ? Directly tied to the performance of eligible work ? Adequately documented ? Reduced by all applicable credits ? Authorized and not prohibited under federal, state, territorial, tribal, or local government laws or regulations ? Consistent with applicant?s internal policies, regulations, and procedures that apply uniformly to both federal awards and other activities of the applicant ? Necessary and reasonable to accomplish the work properly and efficiently The Office of Management and Budget Compliance Supplement states the entity is required to certify that reported costs were incurred in performance of eligible work, that the approved work was completed, that the project is in compliance with the provisions of the FEMA-State Agreement, all grant conditions were met, and that payments for that project were made in accordance with the applicable payment provisions. Condition: During our testing over activities allowed or unallowed, allowable costs/cost principles, period of performance, and special tests and provisions, we observed management did not have effective internal controls in place to ensure expenditures reported for reimbursement in the FEMA project worksheet were actual paid expenditures. This resulted in an overstatement of the amount reimbursed by FEMA. Cause: Management did not have effective internal controls in place to ensure expenditures reported for reimbursement in the FEMA project worksheet were based on actual paid expenditures. Effect or potential effect: Management was reimbursed by FEMA for expenditures that were not based on the final paid expenditure. Questioned costs: $904,020 ? Assistance Listing Number 97.036 ? Federal award identification number: o Application title ? 549687 ? Sutter Health Materials Northern California o Application number ? PA-09-CA-4482-PW-01727(0) The questioned costs were computed by calculating the difference between the expenditures submitted to FEMA in the amount of $70,825,974 and the actual paid expenditures in the amount of $69,921,954 resulting in $904,020. Context: During our testing over activities allowed or unallowed, allowable costs/cost principles, period of performance, and special tests and provisions, we obtained a listing of expenditures submitted for reimbursement to FEMA for the tested project worksheet and observed 561,641 expenditures in the listing for a total value of $70,825,974. We selected a sample of 40 for testing over activities allowed or unallowed and allowable costs/cost principals, a sample of 80 for testing over period of performance, and 1 project worksheet for testing over all compliance requirements. There were 12 out of 120 selections where the expenditures submitted to FEMA were not based on the actual paid expenditures. Management performed an analysis of all expenditures submitted to FEMA and determined the actual paid expenditures amounted to $69,921,954 compared to the expenditures submitted to FEMA in the amount of $70,825,974 resulting in an overstatement of the amount reimbursed by FEMA of $904,020. Management?s control regarding the review of the project worksheet did not identify these expenditures that were not based on actual paid expenditures. Identification as a repeat finding, if applicable: No. Recommendation: Management should develop and implement effective internal controls to ensure expenditures reported for reimbursement in FEMA project worksheets are based on actual paid expenditures. Management should refund the questioned costs to FEMA and work with FEMA to determine the extent of additional courses of action. Management should ensure this is performed through the closeout process of the project worksheet with FEMA. Views of responsible officials: Management will develop and implement an additional layer of review in future FEMA project worksheet submissions to ensure expenditures reported for reimbursement are based on actual paid expenditures. Management will work with FEMA to refund the total overpayment of $904,020 and discuss the extent of additional courses of action. Management will ensure this is performed through the closeout process of the project worksheet with FEMA.
Finding 2022-001: Internal control deficiency and noncompliance over activities allowed or unallowed, allowable costs/cost principles, period of performance, and special tests and provisions related to amounts reimbursed for the project worksheet. Identification of the federal program: Assistance Listing Number 97.036: ? COVID-19 ? Disaster Grants ? Public Assistance (Presidentially Declared Disasters) ? U.S. Department of Homeland Security ? Federal award identification number: o Application title ? 549687 ? Sutter Health Materials Northern California o Application number ? PA-09-CA-4482-PW-01727(0) ? Federal award year ? January 20, 2020 to July 1, 2022 ? Pass-through entity ? California Governor?s Office of Emergency Services Criteria or specific requirement (including statutory, regulatory or other citation): Title 2, Subtitle A, Chapter II, Part 200, Subpart D, 200.303 ? Internal controls. The 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 or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). 2 CFR, Part 200, Section 200.84 ? Questioned costs states a questioned cost as either (a) which resulted from a violation or possible violation of a statute, regulation, or the terms and conditions of a Federal award, including for funds used to match Federal funds; (b) where the costs, at the time of the audit, are not supported by adequate documentation; or (c) where the costs incurred appear unreasonable and do not reflect the actions a prudent person would take in the circumstances. 2 CFR, Part 200, Section 200.403 ? Except where otherwise authorized by statute, costs must meet the following general criteria in order to be allowable under Federal awards: ? (a) Be necessary and reasonable for the performance of the Federal award and be allocable thereto under these principles ? (g) Be adequately documented The Office of Management and Budget Compliance Supplement states the Federal Emergency Management Agency (FEMA) evaluates the eligibility of all costs claimed by the applicant. Not all costs incurred as a result of the incident are eligible. Costs must be: ? Directly tied to the performance of eligible work ? Adequately documented ? Reduced by all applicable credits ? Authorized and not prohibited under federal, state, territorial, tribal, or local government laws or regulations ? Consistent with applicant?s internal policies, regulations, and procedures that apply uniformly to both federal awards and other activities of the applicant ? Necessary and reasonable to accomplish the work properly and efficiently The Office of Management and Budget Compliance Supplement states the entity is required to certify that reported costs were incurred in performance of eligible work, that the approved work was completed, that the project is in compliance with the provisions of the FEMA-State Agreement, all grant conditions were met, and that payments for that project were made in accordance with the applicable payment provisions. Condition: During our testing over activities allowed or unallowed, allowable costs/cost principles, period of performance, and special tests and provisions, we observed management did not have effective internal controls in place to ensure expenditures reported for reimbursement in the FEMA project worksheet were actual paid expenditures. This resulted in an overstatement of the amount reimbursed by FEMA. Cause: Management did not have effective internal controls in place to ensure expenditures reported for reimbursement in the FEMA project worksheet were based on actual paid expenditures. Effect or potential effect: Management was reimbursed by FEMA for expenditures that were not based on the final paid expenditure. Questioned costs: $904,020 ? Assistance Listing Number 97.036 ? Federal award identification number: o Application title ? 549687 ? Sutter Health Materials Northern California o Application number ? PA-09-CA-4482-PW-01727(0) The questioned costs were computed by calculating the difference between the expenditures submitted to FEMA in the amount of $70,825,974 and the actual paid expenditures in the amount of $69,921,954 resulting in $904,020. Context: During our testing over activities allowed or unallowed, allowable costs/cost principles, period of performance, and special tests and provisions, we obtained a listing of expenditures submitted for reimbursement to FEMA for the tested project worksheet and observed 561,641 expenditures in the listing for a total value of $70,825,974. We selected a sample of 40 for testing over activities allowed or unallowed and allowable costs/cost principals, a sample of 80 for testing over period of performance, and 1 project worksheet for testing over all compliance requirements. There were 12 out of 120 selections where the expenditures submitted to FEMA were not based on the actual paid expenditures. Management performed an analysis of all expenditures submitted to FEMA and determined the actual paid expenditures amounted to $69,921,954 compared to the expenditures submitted to FEMA in the amount of $70,825,974 resulting in an overstatement of the amount reimbursed by FEMA of $904,020. Management?s control regarding the review of the project worksheet did not identify these expenditures that were not based on actual paid expenditures. Identification as a repeat finding, if applicable: No. Recommendation: Management should develop and implement effective internal controls to ensure expenditures reported for reimbursement in FEMA project worksheets are based on actual paid expenditures. Management should refund the questioned costs to FEMA and work with FEMA to determine the extent of additional courses of action. Management should ensure this is performed through the closeout process of the project worksheet with FEMA. Views of responsible officials: Management will develop and implement an additional layer of review in future FEMA project worksheet submissions to ensure expenditures reported for reimbursement are based on actual paid expenditures. Management will work with FEMA to refund the total overpayment of $904,020 and discuss the extent of additional courses of action. Management will ensure this is performed through the closeout process of the project worksheet with FEMA.