Audit 307226

Finding 2023-001 – Internal Control Deficiency Over Activities Allowed or Unallowed and Activities Allowed/Allowable Costs Identification of the federal program: Federal Grantor: Department of Homeland Security; Federal Emergency Management Agency (FEMA) Assistance Listing No.: 97.036, Disaster Grants – Public Assistance (Presidentially Declared Disasters) Award Period of Performance: January 20, 2020 – May 11, 2023 Criteria or Specific Requirement (including statutory, regulatory, or other citation): Section 200.303 of the Uniform Guidance states the following regarding internal control: “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). Condition: Management did not consistently retain documentation evidencing the performance of controls to ensure allowable COVID-19 expenses were charged to the program. Cause: Pomona Valley Hospital Medical Center did not consistently retain documentation to evidence the performance of internal controls over the expenses charged to the federal program. Effect or potential effect: There is no consistent documentation to support the performance of internal controls for costs charged to the federal program. Questioned Costs: $0 Section III – Federal Award Findings and Questioned Costs (continued) Finding 2023-001 – Internal Control Deficiency Over Activities Allowed or Unallowed and Activities Allowed/Allowable Costs (continued) Context: We selected 40 expenses for testing totaling $1,731,616. Of the 40 expenses, 9 of the expenses totaling $34,338 did not have evidence of review of the expense to document allowability of the expenditure under the program. Total FEMA expenditures for Assistance Listing 97.036 were $36,803,773. Identification as a repeat finding, if applicable: The finding is not a repeat finding. Recommendation: Pomona Valley Hospital Medical Center should refine its process and retain documentation for every expenditure to evidence that management reviewed expenses charged to the federal program to ensure the cost is allowable. View of Responsible Officials: The Hospital agrees with the finding and will implement procedures to ensure all documentation evidencing review is retained.

Finding 2023-001 – Internal Control Deficiency Over Activities Allowed or Unallowed and Activities Allowed/Allowable Costs Identification of the federal program: Federal Grantor: Department of Homeland Security; Federal Emergency Management Agency (FEMA) Assistance Listing No.: 97.036, Disaster Grants – Public Assistance (Presidentially Declared Disasters) Award Period of Performance: January 20, 2020 – May 11, 2023 Criteria or Specific Requirement (including statutory, regulatory, or other citation): Section 200.303 of the Uniform Guidance states the following regarding internal control: “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). Condition: Management did not consistently retain documentation evidencing the performance of controls to ensure allowable COVID-19 expenses were charged to the program. Cause: Pomona Valley Hospital Medical Center did not consistently retain documentation to evidence the performance of internal controls over the expenses charged to the federal program. Effect or potential effect: There is no consistent documentation to support the performance of internal controls for costs charged to the federal program. Questioned Costs: $0 Section III – Federal Award Findings and Questioned Costs (continued) Finding 2023-001 – Internal Control Deficiency Over Activities Allowed or Unallowed and Activities Allowed/Allowable Costs (continued) Context: We selected 40 expenses for testing totaling $1,731,616. Of the 40 expenses, 9 of the expenses totaling $34,338 did not have evidence of review of the expense to document allowability of the expenditure under the program. Total FEMA expenditures for Assistance Listing 97.036 were $36,803,773. Identification as a repeat finding, if applicable: The finding is not a repeat finding. Recommendation: Pomona Valley Hospital Medical Center should refine its process and retain documentation for every expenditure to evidence that management reviewed expenses charged to the federal program to ensure the cost is allowable. View of Responsible Officials: The Hospital agrees with the finding and will implement procedures to ensure all documentation evidencing review is retained.