FAC Explorer

Audit 292734

FY End
2022-06-30
Total Expended
$37.47M
Findings
16
Programs
12
Organization: Alameda Health System, A Public Hospital Authority (CA)
Year: 2022 Accepted: 2024-02-28
Auditor: Moss Adams LLP

Organization Exclusion Status:

Findings

ID Ref Severity Repeat Requirement
371053 2022-001 Significant Deficiency - B
371054 2022-002 Significant Deficiency - B
371055 2022-003 Significant Deficiency Yes BH
371056 2022-004 Significant Deficiency Yes B
371057 2022-005 Significant Deficiency Yes B
371058 2022-006 Significant Deficiency Yes B
371059 2022-007 Significant Deficiency Yes BC
371060 2022-008 Significant Deficiency Yes L
947495 2022-001 Significant Deficiency - B
947496 2022-002 Significant Deficiency - B
947497 2022-003 Significant Deficiency Yes BH
947498 2022-004 Significant Deficiency Yes B
947499 2022-005 Significant Deficiency Yes B
947500 2022-006 Significant Deficiency Yes B
947501 2022-007 Significant Deficiency Yes BC
947502 2022-008 Significant Deficiency Yes L

Programs

ALN Program Spent Major Findings
93.498 Provider Relief Fund $28.97M Yes 2
93.778 Medical Assistance Program $2.87M Yes 0
16.575 Crime Victim Assistance $1.36M - 6
93.959 Block Grants for Prevention and Treatment of Substance Abuse $657,212 - 0
93.917 Hiv Care Formula Grants $480,539 - 0
17.259 Wia Youth Activities $318,000 - 0
93.918 Grants to Provide Outpatient Early Intervention Services with Respect to Hiv Disease $317,925 - 0
93.224 Consolidated Health Centers (community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) $307,511 - 0
93.279 Drug Abuse and Addiction Research Programs $229,715 Yes 0
93.153 Coordinated Services and Access to Research for Women, Infants, Children, and Youth $163,109 - 0
93.924 Ryan White Hiv/aids Dental Reimbursement and Community Based Dental Partnership Grants $108,442 - 0
93.914 Hiv Emergency Relief Project Grants $69,713 - 0

Contacts

Name Title Type
J7HXQG5NE873 Ann Metzger Auditee
5103467563 Brian Conner Auditor
No contacts on file

Notes to SEFA

Title: NOTE 1 – ORGANIZATION Accounting Policies: NOTE 3 - RELATIONSHIP TO THE BASIC FINANCIAL STATEMENTS - The information in the accompanying Schedule is presented in accordance with the requirements of the Uniform Guidance. Because the Schedule presents only a select portion of the operations of the Health System, it is not intended to and does not present the financial position, changes in net position, or cash flows of the Health System. Federal expenditures agree or can be reconciled with the amounts reported in the Health System’s basic financial statements. NOTE 2 – BASIS OF ACCOUNTING - The schedule of expenditures of federal awards (the “Schedule”) includes the federal grant activity of the Health System. All federal awards received directly from federal agencies as well as federal awards passed through other entities are included in this Schedule except for assistance related to Medical Assistance (“Medi-Cal”) and Medicare Hospital Insurance (“Medicare”) described in Note 4. The Schedule is presented using the accrual basis of accounting, which is described in Note 2 to the Health System’s basic financial statements. Expenditures reported include any property or equipment acquisitions incurred under the federal program. Under the accrual basis of accounting, expenditures are recognized when incurred, regardless of timing of cash flows. Such expenditures are recognized following the cost principles contained in the Title 2 U.S. Code of Federal Regulations (“CFR”) Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements, for Federal Awards (“Uniform Guidance”), wherein certain types of expenditures are not allowable or are limited as to reimbursement. In accordance with guidance from the U.S. Department of Health and Human Services (“HHS”), the Health System included the Reporting Period 2 and Period 3 expenditures for Provider Relief Fund and American Rescue Plan Distribution Federal Assistance Listing No. (“FALN”) 93.498 of $8,858,433 and $20,113,553, respectively, in the Schedule for the year ended June 30, 2022, to align with HHS reporting guidelines. In accordance with U.S. GAAP, the total amount of $28,971,985 of Provider Relief Fund assistance received by the Health System was recognized as revenue during the year ended June 30, 2021, and is included in beginning net assets as of and for the year ended June 30, 2022. De Minimis Rate Used: N Rate Explanation: NOTE 6 - INDIRECT COSTS - The Health System has not elected to use the 10 percent de minimus indirect cost rate allowed under the Uniform Guidance. The Health System negotiates indirect cost rates separately for each contract. Alameda Health System (the “Health System”) is a Public Hospital Authority created originally under the name of Alameda County Medical Center (the “Medical Center”) on July 1, 1998, pursuant to California Health and Safety Code Section 101850. The governance, management, administration, and control of healthcare facilities were transferred from the County of Alameda (the “County”) to the Medical Center in 1998. The Medical Center started doing business as the Health System on January 1, 2013. The Health System is reflected in the County’s comprehensive annual financial report as a discretely presented component unit. The Health System provides a continuum of acute and long-term care to residents of the County. In addition to offering general acute care, skilled nursing, and rehabilitative care, the Health System provides an adult day health center, and a trauma center. The Health System is currently staffed for 289 acute, 69 acute psychiatric, and 325 sub-acute, skilled nursing and rehab beds. The Health System is governed by a nine-member board of trustees (“Trustees”), eight members of which have been appointed by a majority vote of the Board of Supervisors of the County. Trustees are appointed for three-year terms and can be reappointed for up to three consecutive complete terms. The remaining position on the Board of Trustees is filled by a representative of the medical staff of the Health System, which is also appointed by the Board of Supervisors.
Title: NOTE 4 – MEDI-CAL AND MEDICARE PROGRAMS Accounting Policies: NOTE 3 - RELATIONSHIP TO THE BASIC FINANCIAL STATEMENTS - The information in the accompanying Schedule is presented in accordance with the requirements of the Uniform Guidance. Because the Schedule presents only a select portion of the operations of the Health System, it is not intended to and does not present the financial position, changes in net position, or cash flows of the Health System. Federal expenditures agree or can be reconciled with the amounts reported in the Health System’s basic financial statements. NOTE 2 – BASIS OF ACCOUNTING - The schedule of expenditures of federal awards (the “Schedule”) includes the federal grant activity of the Health System. All federal awards received directly from federal agencies as well as federal awards passed through other entities are included in this Schedule except for assistance related to Medical Assistance (“Medi-Cal”) and Medicare Hospital Insurance (“Medicare”) described in Note 4. The Schedule is presented using the accrual basis of accounting, which is described in Note 2 to the Health System’s basic financial statements. Expenditures reported include any property or equipment acquisitions incurred under the federal program. Under the accrual basis of accounting, expenditures are recognized when incurred, regardless of timing of cash flows. Such expenditures are recognized following the cost principles contained in the Title 2 U.S. Code of Federal Regulations (“CFR”) Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements, for Federal Awards (“Uniform Guidance”), wherein certain types of expenditures are not allowable or are limited as to reimbursement. In accordance with guidance from the U.S. Department of Health and Human Services (“HHS”), the Health System included the Reporting Period 2 and Period 3 expenditures for Provider Relief Fund and American Rescue Plan Distribution Federal Assistance Listing No. (“FALN”) 93.498 of $8,858,433 and $20,113,553, respectively, in the Schedule for the year ended June 30, 2022, to align with HHS reporting guidelines. In accordance with U.S. GAAP, the total amount of $28,971,985 of Provider Relief Fund assistance received by the Health System was recognized as revenue during the year ended June 30, 2021, and is included in beginning net assets as of and for the year ended June 30, 2022. De Minimis Rate Used: N Rate Explanation: NOTE 6 - INDIRECT COSTS - The Health System has not elected to use the 10 percent de minimus indirect cost rate allowed under the Uniform Guidance. The Health System negotiates indirect cost rates separately for each contract. Direct Medi-Cal and Medicare expenditures are excluded from the Schedule. These expenses represent fees for services and are not included in the Schedule or in determining major programs. The Health System provides Medi-Cal and Medicare services through its facilities. The Health System participates in the California Medi-Cal Administrative Activities (“MAA”) program, which offers reimbursement under the federal Medical Assistance Program (FALN 93.778) for a portion of the costs related to specific, approved activities that are necessary for the proper and efficient administration of the Medi-Cal program.
Title: NOTE 5 – SUBRECIPIENTS Accounting Policies: NOTE 3 - RELATIONSHIP TO THE BASIC FINANCIAL STATEMENTS - The information in the accompanying Schedule is presented in accordance with the requirements of the Uniform Guidance. Because the Schedule presents only a select portion of the operations of the Health System, it is not intended to and does not present the financial position, changes in net position, or cash flows of the Health System. Federal expenditures agree or can be reconciled with the amounts reported in the Health System’s basic financial statements. NOTE 2 – BASIS OF ACCOUNTING - The schedule of expenditures of federal awards (the “Schedule”) includes the federal grant activity of the Health System. All federal awards received directly from federal agencies as well as federal awards passed through other entities are included in this Schedule except for assistance related to Medical Assistance (“Medi-Cal”) and Medicare Hospital Insurance (“Medicare”) described in Note 4. The Schedule is presented using the accrual basis of accounting, which is described in Note 2 to the Health System’s basic financial statements. Expenditures reported include any property or equipment acquisitions incurred under the federal program. Under the accrual basis of accounting, expenditures are recognized when incurred, regardless of timing of cash flows. Such expenditures are recognized following the cost principles contained in the Title 2 U.S. Code of Federal Regulations (“CFR”) Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements, for Federal Awards (“Uniform Guidance”), wherein certain types of expenditures are not allowable or are limited as to reimbursement. In accordance with guidance from the U.S. Department of Health and Human Services (“HHS”), the Health System included the Reporting Period 2 and Period 3 expenditures for Provider Relief Fund and American Rescue Plan Distribution Federal Assistance Listing No. (“FALN”) 93.498 of $8,858,433 and $20,113,553, respectively, in the Schedule for the year ended June 30, 2022, to align with HHS reporting guidelines. In accordance with U.S. GAAP, the total amount of $28,971,985 of Provider Relief Fund assistance received by the Health System was recognized as revenue during the year ended June 30, 2021, and is included in beginning net assets as of and for the year ended June 30, 2022. De Minimis Rate Used: N Rate Explanation: NOTE 6 - INDIRECT COSTS - The Health System has not elected to use the 10 percent de minimus indirect cost rate allowed under the Uniform Guidance. The Health System negotiates indirect cost rates separately for each contract. The Health System did not provide federal awards to subrecipients during the year ended June 30, 2022.
Title: NOTE 7 - CRIME VICTIM ASSISTANCE PROGRAM Accounting Policies: NOTE 3 - RELATIONSHIP TO THE BASIC FINANCIAL STATEMENTS - The information in the accompanying Schedule is presented in accordance with the requirements of the Uniform Guidance. Because the Schedule presents only a select portion of the operations of the Health System, it is not intended to and does not present the financial position, changes in net position, or cash flows of the Health System. Federal expenditures agree or can be reconciled with the amounts reported in the Health System’s basic financial statements. NOTE 2 – BASIS OF ACCOUNTING - The schedule of expenditures of federal awards (the “Schedule”) includes the federal grant activity of the Health System. All federal awards received directly from federal agencies as well as federal awards passed through other entities are included in this Schedule except for assistance related to Medical Assistance (“Medi-Cal”) and Medicare Hospital Insurance (“Medicare”) described in Note 4. The Schedule is presented using the accrual basis of accounting, which is described in Note 2 to the Health System’s basic financial statements. Expenditures reported include any property or equipment acquisitions incurred under the federal program. Under the accrual basis of accounting, expenditures are recognized when incurred, regardless of timing of cash flows. Such expenditures are recognized following the cost principles contained in the Title 2 U.S. Code of Federal Regulations (“CFR”) Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements, for Federal Awards (“Uniform Guidance”), wherein certain types of expenditures are not allowable or are limited as to reimbursement. In accordance with guidance from the U.S. Department of Health and Human Services (“HHS”), the Health System included the Reporting Period 2 and Period 3 expenditures for Provider Relief Fund and American Rescue Plan Distribution Federal Assistance Listing No. (“FALN”) 93.498 of $8,858,433 and $20,113,553, respectively, in the Schedule for the year ended June 30, 2022, to align with HHS reporting guidelines. In accordance with U.S. GAAP, the total amount of $28,971,985 of Provider Relief Fund assistance received by the Health System was recognized as revenue during the year ended June 30, 2021, and is included in beginning net assets as of and for the year ended June 30, 2022. De Minimis Rate Used: N Rate Explanation: NOTE 6 - INDIRECT COSTS - The Health System has not elected to use the 10 percent de minimus indirect cost rate allowed under the Uniform Guidance. The Health System negotiates indirect cost rates separately for each contract. The Health System has the following programs presented in the Schedule under Federal Assistance Listing No.16.575. Program Description: 1) Rape Crisis Program, Contract Number - RC20 36 1146, and Federal Expenditures of $157,697; 2) Rape Crisis Program, Contract Number - RC21 37 1146, and Federal Expenditures of $293,672; 3) Sexual Assault Response Team Program, Contract Number - XS20 03 1146, and Federal Expenditures of $44,602; 4) Sexual Assault Response Team Program, Contract Number - XS21 04 1146, and Federal Expenditures of $38,281; 5) Domestic Violence Housing First Program, Contract Number - XD20 03 1146, and Federal Expenditures of $521,907; 6) Specialized Emergency Housing Program, Contract Number - KE20 03 1146, and Federal Expenditures of $78,551; 7) Specialized Emergency Housing Program, Contract Number - KE21 04 1146, and Federal Expenditures of $225,378; and 8) Total Federal Expenditures of $1,360,088.

Finding Details

Finding 2022-001
Finding Number 2022-001: Payrate Approval Letters (Significant Deficiency over Internal Control and Instances of Noncompliance over Major Federal Program – Allowable costs/Cost Principles) FALN Number 93.498 Provider Relief Fund Criteria: 2022 Compliance Supplement and 2 CFR 200.303(a) stated that the non-Federal entity must 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 terms and conditions of the federal award. Condition/Context: As a result of our audit procedures, we noted management did not retain 15 of 20 COVID-related leave approval forms for payroll expenditures tested. Repeat Finding from Prior Year(s): No Cause and Effect: The Health System did not have proper controls in place to ensure retention of COVID-related leave forms to support payroll leave expensed, which could lead to unauthorized payroll leave expenses being charged to the program. Questioned Cost: None Recommendation: We recommend management implement policies and procedures to ensure that approval of leave forms are retained to support related expenditures. Views of Responsible Officials and Planned Corrective Action: Management agrees with finding. The Health System will review and modify policies and procedures over the program to ensure management implements policies, procedures, and processes to make sure that leave approval forms are retained and are prepared and reviewed by separate individuals with evidence of review documented.
Finding 2022-002
Finding Number 2022-002: Approval of Non-Payroll Expenditures (Significant Deficiency over Internal Control and Instances of Noncompliance over Major Federal Program – Allowable costs/Cost Principles) FALN Number 93.498 Provider Relief Fund Criteria: 2022 Compliance Supplement and 2 CFR 200.303(a) stated that the non-Federal entity must 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 terms and conditions of the federal award. Condition/Context: As a result of our audit procedures, we noted 16 of 40 samples of nonpayroll expenditures tested that the Health System did not have internal controls in place to ensure expenditures charged to the program have documentation of management’s review/approval. Repeat Finding from Prior Year(s): No Cause and Effect: The Health System did not have proper controls in place to ensure all invoices are reviewed and approved by management prior to disbursements, which could lead to noncompliance with program requirements. Questioned Cost: None Recommendation: We recommend management implement policies and procedures to ensure all invoices are reviewed and approved prior to disbursements. Views of Responsible Officials and Planned Corrective Action: Management agrees with finding. The Health System will review and modify policies and procedures for non-payroll expenditures to ensure management’s review/approval is documented.
Finding 2022-003
Finding Number 2022-003: Costs Incurred Outside Period of Performance (Significant Deficiency over Internal Control and Instances of Noncompliance – Period of Performance; Allowable Costs/Cost Principles) FALN Number 16.575 U.S. Department of Justice, Office of Victims of Crime – Crime Victim Assistance Criteria: 2022 Compliance Supplement and 2 CFR 200.403(h) stated that a non-federal entity may charge only allowable costs incurred during the approved budget period of a federal award’s period of performance. Condition/Context: As a result of our audit procedures to evaluate the summary schedule of prior audit findings, we noted 1 sample where $788 of payroll expenditure incurred was charged to the program based on the pay date instead of the pay period incurred. Repeat Finding from Prior Year(s): Yes, Finding Number 2021-001 Cause and Effect: The Health System did not have proper controls in place to ensure only costs incurred in the period of performance were charged to the program, which resulted in costs outside of period of performance being charged to the program. Questioned Cost: None Recommendation: We recommend management review policies and procedures of the program to ensure the costs incurred are appropriately charged based on the contracts’ performance periods. Views of Responsible Officials and Planned Corrective Action: Management agrees with finding. The Health System will review and modify policies and procedures over the program to ensure management implements policies, procedures, and processes to make sure that the costs incurred are appropriately charged based on the contracts’ performance periods.
Finding 2022-004
Finding Number 2022-004: Duplicate Charges (Significant Deficiency over Internal Control and Instances of Noncompliance – Allowable Costs/Cost Principles) FALN Number 16.575 U.S. Department of Justice, Office of Victims of Crime – Crime Victim Assistance Criteria: 2022 Compliance Supplement and 2 CFR 200.303(a) stated that the non-Federal entity must 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 terms and conditions of the federal award. Condition/Context: As a result of our audit procedures to evaluate the summary schedule of prior audit findings, we noted 1 sample of a $4,855 non-payroll expenditure had been duplicated on invoices remitted to the grantor. Repeat Finding from Prior Year(s): Yes, Finding Number 2021-002 Cause and Effect: The Health System did not have proper controls in place to prevent duplicate transactions from being entered into the system and charged to the program, which resulted in duplicate costs being charged to the program. Questioned Cost: None Recommendation: We recommend management implement policies and procedures to prevent duplicate transactions from being charged to the program. Views of Responsible Officials and Planned Corrective Action: Management agrees with finding. The Health System will review and modify policies and procedures over the program to ensure management implements policies, procedures, and processes to prevent duplicate transactions from being charged to the program.
Finding 2022-005
Finding Number 2022-005: Gift Card Tracking (Significant Deficiency over Internal Control and Instance of Noncompliance – Allowable Costs/Cost Principles) FALN Number 16.575 U.S. Department of Justice, Office of Victims of Crime – Crime Victim Assistance Criteria: 2022 Compliance Supplement and 2 CFR 200.303(a) stated that the non-Federal entity must 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 terms and conditions of the federal award. Condition/Context: As a result of our audit procedures to evaluate the summary schedule of prior audit findings, we noted 1 sample of a $5,008 gift card purchase with multiple gift cards was not tracked with an inventory system to allow for the expenditure to the grantor to be invoiced after gift cards are distributed. We also noted the Health System did not have policies and procedures related to gift card tracking. Repeat Finding from Prior Year(s): Yes, Finding Number 2021-003 Cause and Effect: The Health System did not have proper controls in place to ensure proper tracking of the gift cards, which could lead to noncompliance with program compliance requirements. Questioned Cost: None Recommendation: We recommend management implement policies and procedures to ensure proper tracking of gift card distributions for victims of crime. Views of Responsible Officials and Planned Corrective Action: Management agrees with finding. The Health System will review and modify policies and procedures over the program to ensure management implements policies, procedures, and processes to properly track the distribution of gift cards for victims of crime.
Finding 2022-006
Finding Number 2022-006: Charges Not Specified in Grant Contracts (Significant Deficiency over Internal Control and Instances of Noncompliance – Allowable Costs/Cost Principles) FALN Number 16.575 U.S. Department of Justice, Office of Victims of Crime – Crime Victim Assistance Criteria: 2022 Compliance Supplement and 2 CFR 200.303(a) stated that the non-Federal entity must 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 terms and conditions of the federal award. Condition/Context: As a result of our audit procedures to evaluate the summary schedule of prior audit findings, we noted 1 sample of a $4,265 non-payroll expenditure for purchased service that was not outlined in the grant contract. Repeat Finding from Prior Year(s): Yes, Finding Number 2021-004 Cause and Effect: The Health System did not have proper controls in place to ensure expenditures being charged to the program are specifically identified in the grant contract. In addition, the Health System did not have proper controls in place to ensure all invoices are reviewed and approved by management prior to disbursements. The results could lead to noncompliance with compliance requirements of the program. Questioned Cost: None Recommendation: We recommend management implement policies and procedures to ensure expenditures charged to the program are in accordance with the grant contracts and that all invoices are reviewed and approved prior to disbursements. Views of Responsible Officials and Planned Corrective Action: Management agrees with finding. The Health System will review and modify policies and procedures over the program to ensure management implement policies, procedures, and processes to make sure that expenditures are charged to the program in accordance with the grant contracts and that all invoices are reviewed and approved prior to disbursements.
Finding 2022-007
Finding Number 2022-007: Costs Incurred & Paid Prior to Reimbursements (Significant Deficiency over Internal Control and Instance of Noncompliance – Cash Management; Period of Performance) FALN 16.575 U.S. Department of Justice, Office of Victims of Crime – Crime Victim Assistance Criteria: 2022 Compliance Supplement stated that program costs must be paid by non-federal entity funds before submitting a payment request (2 CFR section 200.305(b)(3)) (i.e., the non-federal entity must disburse funds for program purposes before requesting payment from the federal awarding agency or pass-through entity). In addition, a non-federal entity may charge only allowable costs incurred during the approved budget period of a federal award’s period of performance. Condition/Context: As a result of our audit procedures to evaluate the summary schedule of prior audit findings, we noted 1 sample of $2,500 nonpayroll expenditures that was submitted for reimbursement prior to the expenditure being incurred. In addition, the cost incurred was outside of the period of performance ended 9/30/2021. Repeat Finding from Prior Year(s): Yes, Finding Number 2021-005 Cause and Effect: The Health System did not have proper controls in place to ensure expenditures are incurred and paid for prior to reimbursements, and that expenditures are incurred within the period of performance of the contract, which resulted in noncompliance with the compliance requirements of the program. Questioned Cost: None Recommendation: We recommend management implement policies and procedures to ensure funds are disbursed for expenditures incurred prior to reimbursement requests, and that expenditures are incurred within the contract’s performance period. Views of Responsible Officials and Planned Corrective Action: Management agrees with finding. The Health System will review and modify policies and procedures over the program to ensure management implements policies, procedures, and processes to make sure that funds are disbursed for incurred expenditures prior to reimbursement requests.
Finding 2022-008
Finding Number 2022-008: Reporting (Significant Deficiency over Internal Control and Instances of Noncompliance – Reporting) FALN Number 16.575 U.S. Department of Justice, Office of Victims of Crime – Crime Victim Assistance Criteria: 2022 Compliance Supplement and 2 CFR 200.303(a) stated that the non-Federal entity must 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 terms and conditions of the federal award. Condition/Context: As a result of our audit procedures to evaluate the summary schedule of prior audit findings, we noted 1 sample of untimely financial reporting submitting to the grantor. The financial report was for the quarter ended 3/31/2022 with a due date of 30 days after the reporting period; however, the report was submitted on 6/13/2022. We also noted 1 sample of performance report for the quarter ended 12/31/2021 that did not have clear evidence of preparer and reviewer of the report. Repeat Finding from Prior Year(s): Yes, Finding Number 2021-006 Cause and Effect: The Health System did not have proper controls in place to ensure the performance reports are prepared and reviewed by separate individuals with evidence of review documented and retained, which could lead to inaccurate information being reported. In addition, the Health System did not have proper controls in place to ensure financial reports are submitted timely with underlying support properly documented, which resulted in untimely reporting filing. Questioned Cost: None Recommendation: We recommend management implement policies and procedures to ensure performance reports are prepared and reviewed by separate individuals with evidence of review documented and that financial reports are submitted timely with underlying support properly documented. Views of Responsible Officials and Planned Corrective Action: Management agrees with finding. The Health System will review and modify policies and procedures over the program to ensure management implement policies and procedures to ensure performance reports are prepared and reviewed by separate individuals with evidence of review documented and that financial reports are submitted timely.
Finding 2022-001
Finding Number 2022-001: Payrate Approval Letters (Significant Deficiency over Internal Control and Instances of Noncompliance over Major Federal Program – Allowable costs/Cost Principles) FALN Number 93.498 Provider Relief Fund Criteria: 2022 Compliance Supplement and 2 CFR 200.303(a) stated that the non-Federal entity must 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 terms and conditions of the federal award. Condition/Context: As a result of our audit procedures, we noted management did not retain 15 of 20 COVID-related leave approval forms for payroll expenditures tested. Repeat Finding from Prior Year(s): No Cause and Effect: The Health System did not have proper controls in place to ensure retention of COVID-related leave forms to support payroll leave expensed, which could lead to unauthorized payroll leave expenses being charged to the program. Questioned Cost: None Recommendation: We recommend management implement policies and procedures to ensure that approval of leave forms are retained to support related expenditures. Views of Responsible Officials and Planned Corrective Action: Management agrees with finding. The Health System will review and modify policies and procedures over the program to ensure management implements policies, procedures, and processes to make sure that leave approval forms are retained and are prepared and reviewed by separate individuals with evidence of review documented.
Finding 2022-002
Finding Number 2022-002: Approval of Non-Payroll Expenditures (Significant Deficiency over Internal Control and Instances of Noncompliance over Major Federal Program – Allowable costs/Cost Principles) FALN Number 93.498 Provider Relief Fund Criteria: 2022 Compliance Supplement and 2 CFR 200.303(a) stated that the non-Federal entity must 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 terms and conditions of the federal award. Condition/Context: As a result of our audit procedures, we noted 16 of 40 samples of nonpayroll expenditures tested that the Health System did not have internal controls in place to ensure expenditures charged to the program have documentation of management’s review/approval. Repeat Finding from Prior Year(s): No Cause and Effect: The Health System did not have proper controls in place to ensure all invoices are reviewed and approved by management prior to disbursements, which could lead to noncompliance with program requirements. Questioned Cost: None Recommendation: We recommend management implement policies and procedures to ensure all invoices are reviewed and approved prior to disbursements. Views of Responsible Officials and Planned Corrective Action: Management agrees with finding. The Health System will review and modify policies and procedures for non-payroll expenditures to ensure management’s review/approval is documented.
Finding 2022-003
Finding Number 2022-003: Costs Incurred Outside Period of Performance (Significant Deficiency over Internal Control and Instances of Noncompliance – Period of Performance; Allowable Costs/Cost Principles) FALN Number 16.575 U.S. Department of Justice, Office of Victims of Crime – Crime Victim Assistance Criteria: 2022 Compliance Supplement and 2 CFR 200.403(h) stated that a non-federal entity may charge only allowable costs incurred during the approved budget period of a federal award’s period of performance. Condition/Context: As a result of our audit procedures to evaluate the summary schedule of prior audit findings, we noted 1 sample where $788 of payroll expenditure incurred was charged to the program based on the pay date instead of the pay period incurred. Repeat Finding from Prior Year(s): Yes, Finding Number 2021-001 Cause and Effect: The Health System did not have proper controls in place to ensure only costs incurred in the period of performance were charged to the program, which resulted in costs outside of period of performance being charged to the program. Questioned Cost: None Recommendation: We recommend management review policies and procedures of the program to ensure the costs incurred are appropriately charged based on the contracts’ performance periods. Views of Responsible Officials and Planned Corrective Action: Management agrees with finding. The Health System will review and modify policies and procedures over the program to ensure management implements policies, procedures, and processes to make sure that the costs incurred are appropriately charged based on the contracts’ performance periods.
Finding 2022-004
Finding Number 2022-004: Duplicate Charges (Significant Deficiency over Internal Control and Instances of Noncompliance – Allowable Costs/Cost Principles) FALN Number 16.575 U.S. Department of Justice, Office of Victims of Crime – Crime Victim Assistance Criteria: 2022 Compliance Supplement and 2 CFR 200.303(a) stated that the non-Federal entity must 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 terms and conditions of the federal award. Condition/Context: As a result of our audit procedures to evaluate the summary schedule of prior audit findings, we noted 1 sample of a $4,855 non-payroll expenditure had been duplicated on invoices remitted to the grantor. Repeat Finding from Prior Year(s): Yes, Finding Number 2021-002 Cause and Effect: The Health System did not have proper controls in place to prevent duplicate transactions from being entered into the system and charged to the program, which resulted in duplicate costs being charged to the program. Questioned Cost: None Recommendation: We recommend management implement policies and procedures to prevent duplicate transactions from being charged to the program. Views of Responsible Officials and Planned Corrective Action: Management agrees with finding. The Health System will review and modify policies and procedures over the program to ensure management implements policies, procedures, and processes to prevent duplicate transactions from being charged to the program.
Finding 2022-005
Finding Number 2022-005: Gift Card Tracking (Significant Deficiency over Internal Control and Instance of Noncompliance – Allowable Costs/Cost Principles) FALN Number 16.575 U.S. Department of Justice, Office of Victims of Crime – Crime Victim Assistance Criteria: 2022 Compliance Supplement and 2 CFR 200.303(a) stated that the non-Federal entity must 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 terms and conditions of the federal award. Condition/Context: As a result of our audit procedures to evaluate the summary schedule of prior audit findings, we noted 1 sample of a $5,008 gift card purchase with multiple gift cards was not tracked with an inventory system to allow for the expenditure to the grantor to be invoiced after gift cards are distributed. We also noted the Health System did not have policies and procedures related to gift card tracking. Repeat Finding from Prior Year(s): Yes, Finding Number 2021-003 Cause and Effect: The Health System did not have proper controls in place to ensure proper tracking of the gift cards, which could lead to noncompliance with program compliance requirements. Questioned Cost: None Recommendation: We recommend management implement policies and procedures to ensure proper tracking of gift card distributions for victims of crime. Views of Responsible Officials and Planned Corrective Action: Management agrees with finding. The Health System will review and modify policies and procedures over the program to ensure management implements policies, procedures, and processes to properly track the distribution of gift cards for victims of crime.
Finding 2022-006
Finding Number 2022-006: Charges Not Specified in Grant Contracts (Significant Deficiency over Internal Control and Instances of Noncompliance – Allowable Costs/Cost Principles) FALN Number 16.575 U.S. Department of Justice, Office of Victims of Crime – Crime Victim Assistance Criteria: 2022 Compliance Supplement and 2 CFR 200.303(a) stated that the non-Federal entity must 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 terms and conditions of the federal award. Condition/Context: As a result of our audit procedures to evaluate the summary schedule of prior audit findings, we noted 1 sample of a $4,265 non-payroll expenditure for purchased service that was not outlined in the grant contract. Repeat Finding from Prior Year(s): Yes, Finding Number 2021-004 Cause and Effect: The Health System did not have proper controls in place to ensure expenditures being charged to the program are specifically identified in the grant contract. In addition, the Health System did not have proper controls in place to ensure all invoices are reviewed and approved by management prior to disbursements. The results could lead to noncompliance with compliance requirements of the program. Questioned Cost: None Recommendation: We recommend management implement policies and procedures to ensure expenditures charged to the program are in accordance with the grant contracts and that all invoices are reviewed and approved prior to disbursements. Views of Responsible Officials and Planned Corrective Action: Management agrees with finding. The Health System will review and modify policies and procedures over the program to ensure management implement policies, procedures, and processes to make sure that expenditures are charged to the program in accordance with the grant contracts and that all invoices are reviewed and approved prior to disbursements.
Finding 2022-007
Finding Number 2022-007: Costs Incurred & Paid Prior to Reimbursements (Significant Deficiency over Internal Control and Instance of Noncompliance – Cash Management; Period of Performance) FALN 16.575 U.S. Department of Justice, Office of Victims of Crime – Crime Victim Assistance Criteria: 2022 Compliance Supplement stated that program costs must be paid by non-federal entity funds before submitting a payment request (2 CFR section 200.305(b)(3)) (i.e., the non-federal entity must disburse funds for program purposes before requesting payment from the federal awarding agency or pass-through entity). In addition, a non-federal entity may charge only allowable costs incurred during the approved budget period of a federal award’s period of performance. Condition/Context: As a result of our audit procedures to evaluate the summary schedule of prior audit findings, we noted 1 sample of $2,500 nonpayroll expenditures that was submitted for reimbursement prior to the expenditure being incurred. In addition, the cost incurred was outside of the period of performance ended 9/30/2021. Repeat Finding from Prior Year(s): Yes, Finding Number 2021-005 Cause and Effect: The Health System did not have proper controls in place to ensure expenditures are incurred and paid for prior to reimbursements, and that expenditures are incurred within the period of performance of the contract, which resulted in noncompliance with the compliance requirements of the program. Questioned Cost: None Recommendation: We recommend management implement policies and procedures to ensure funds are disbursed for expenditures incurred prior to reimbursement requests, and that expenditures are incurred within the contract’s performance period. Views of Responsible Officials and Planned Corrective Action: Management agrees with finding. The Health System will review and modify policies and procedures over the program to ensure management implements policies, procedures, and processes to make sure that funds are disbursed for incurred expenditures prior to reimbursement requests.
Finding 2022-008
Finding Number 2022-008: Reporting (Significant Deficiency over Internal Control and Instances of Noncompliance – Reporting) FALN Number 16.575 U.S. Department of Justice, Office of Victims of Crime – Crime Victim Assistance Criteria: 2022 Compliance Supplement and 2 CFR 200.303(a) stated that the non-Federal entity must 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 terms and conditions of the federal award. Condition/Context: As a result of our audit procedures to evaluate the summary schedule of prior audit findings, we noted 1 sample of untimely financial reporting submitting to the grantor. The financial report was for the quarter ended 3/31/2022 with a due date of 30 days after the reporting period; however, the report was submitted on 6/13/2022. We also noted 1 sample of performance report for the quarter ended 12/31/2021 that did not have clear evidence of preparer and reviewer of the report. Repeat Finding from Prior Year(s): Yes, Finding Number 2021-006 Cause and Effect: The Health System did not have proper controls in place to ensure the performance reports are prepared and reviewed by separate individuals with evidence of review documented and retained, which could lead to inaccurate information being reported. In addition, the Health System did not have proper controls in place to ensure financial reports are submitted timely with underlying support properly documented, which resulted in untimely reporting filing. Questioned Cost: None Recommendation: We recommend management implement policies and procedures to ensure performance reports are prepared and reviewed by separate individuals with evidence of review documented and that financial reports are submitted timely with underlying support properly documented. Views of Responsible Officials and Planned Corrective Action: Management agrees with finding. The Health System will review and modify policies and procedures over the program to ensure management implement policies and procedures to ensure performance reports are prepared and reviewed by separate individuals with evidence of review documented and that financial reports are submitted timely.