Identification of the Federal Program:Federal Grantor: U.S. Department of Agriculture Food and Nutrition ServiceAssistance Listing No.: 10.557 ? Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)Pass-Through Entity: Indiana State Department of HealthPass-Through Award Numbers: 3610-572900-142500 (21), 3610-572900-142500 (22)Award Years: 10/1/21?9/30/22 and 10/1/22-9/30/23Criteria or Specific Requirement (including statutory, regulatory or other citation):Applicants for WIC program benefits are screened at WIC clinic sites to determine their WIC eligibility. To be certified eligible, they must meet the following eligibility criteria (7 CFR Sections 246.7(c), (d), (e), (g), and (l)):(a) Categorical ? Eligibility is restricted to pregnant, postpartum, and breast-feeding women; infants; and children up to their fifth birthday (7 CFR Sections 246.2 (definition of each category) and 246.7(c)).(b) Identity and Residency ? Except in limited circumstances, WIC applicants must be physically present for eligibility screenings and must provide proof of identity. An applicant must also meet the state agency residency requirement. Except in the case of Indian state agencies, the applicant must reside in the jurisdiction of the state. Indian state agencies may require applicants to reside within their jurisdiction.(c) Income ? An applicant must meet an income standard established by the state agency or be determined to be automatically (adjunctively) income-eligible based on documentation of his/her eligibility, or certain family members? eligibility, for the following federal programs: (1) Temporary Assistance for Needy Families, (2) Medicaid, or (3) Supplemental Nutrition Assistance Program (formerly the Food Stamp Program). State agencies may also determine an individual to be automatically income-eligible, based on documentation of his/her eligibility for certain state-administered programs.(d) Nutritional Risk ? A competent professional authority (e.g., physician, nutritionist, registered nurse, or other health professional) must determine that the applicant is at nutritional risk. While the broad guidelines for determining nutritional risk are set forth in WIC legislation and regulations, the specific allowable nutritional risk criteria are defined in WIC policy guidance, which is updated periodically. Each state agency may choose which allowable nutritional risk criteria will be used to determine eligibility.When an applicant meets all eligibility criteria, he/she is determined by WIC clinic staff to be eligible for program benefits. Certification periods are assigned to each participant based on categorical status for women, infants, and children (7 CFR Section 246.7(g)).A WIC local agency assigns each eligible person a priority classification according to the classification system described in 7 CFR Section 246.7(e)(4). A person?s priority assignment reflects the severity of his/her nutritional risk. If the local agency cannot immediately place the person on the program for lack of an available caseload slot, the person is placed on a waiting list. Caseload vacancies are filled from the waiting list in priority classification order. State agencies are expected to target program outreach and caseload management efforts toward persons at greatest nutritional risk (i.e., those in the highest priority classifications).Pregnant women are certified for the duration of their pregnancies and for up to six weeks postpartum. Breast-feeding women may be certified approximately every six months, up to one year postpartum, or until the woman ceases breast-feeding, whichever occurs first (7 CFR Section 246.7(g)(1)). Infants are certified at intervals of approximately six months, except that infants under six months of age may be certified for a period extending up to the child?s first birthday, provided the quality and accessibility of health care services are not diminished. Children are certified for six-month intervals ending with the last day of the month in which the child reaches his/her fifth birthday. State agencies also have the option to certify children for a period of one year if the state agency ensures that the child receives the required health and nutrition assessments (7 CFR Section 246.7(g)(1)). Non-breast-feeding women are certified for up to six months postpartum. All categories of participants may be certified up to the last day of the last month of the certification period (7 CFR Section 246.7(g)(1)).Condition:The Corporation screens applicants for eligibility by following the state of Indiana guidelines as provided through the INWIC system used to enter, track, and store information about applicants. Based on guidance contained in 7 CFR Section 246, states were encouraged to move to a paperless system. Specifically, federal guidance contained in 7 CFR 246.7 (i)(4) and (5)(i) outlines acceptable documentation to be included on certification forms as ?a description of the document(s) used to determine residency and identity or a copy of the document(s) used or the applicants written statement when no documentation exists,? and ?a description of the document(s) used to determine income eligibility or a copy of the document(s) in the file.? The state of Indiana has followed that guidance and does not require the Corporation to retain copies of an applicant?s proof of residence, income, etc., regarding eligibility. Therefore, we were not able to test internal controls over compliance or compliance over the eligibility compliance requirement through re-performance and have issued a qualified opinion based on the scope limitations.Cause:The Corporation follows a paperless system as supported by the state of Indiana and the U.S. Department of Agriculture. The state does not require third-party supporting documentation of eligibility determinations to be retained.Effect or potential effect:Due to the online nature of the eligibility system, the program does not have documentation available for the audit team to test compliance with the eligibility requirement. A scope limitation qualified opinion was issued for Assistance Listing 10.557, as we were unable to obtain sufficient documentation supporting the compliance of the Corporation regarding eligibility.Questioned Costs:None.Context:Federal expenditures reported in the schedule of expenditures of federal awards for Assistance Listing 10.557 totaled $1,703,252 for the year ended December 31, 2022.Identification as a repeat finding, if applicable:Yes. Prior year findings 2021-001.Recommendation:No further follow-up is required, as management of the Corporation is following the applicable guidance.Views of responsible officials:Management agrees with the finding. No changes in our current procedures are required as we are following the State requirements.
Information on the federal program:Federal Grantor: Department of Homeland SecurityAssistance Listing No.: 97.036, COVID-19 Disaster Grants ? Public Assistance (Presidentially Declared Disasters) (FEMA)Pass-Through Entity: Indiana State Department of HealthPass-Through Award Numbers: PA-06-IN-4515-PW-00292(432), PA-05-IN-4515-PW-00396(473), PA-05-IN-4515-PW-00463(556)Award Period of Performance: 01/20/2020?03/02/2022Criteria 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).?Per the FEMA Project Worksheet Report #334659-292, under the Subgrant Conditions section, bullet point 1, ?As described in Title 2 Code of Federal Regulations (C.F.R.) ? 200.333, financial records, supporting documents, statistical records and all other non-Federal entity records pertinent to a Federal award must be retained for a period of three (3) years from the date of submission of the final expenditure report or, for Federal awards that are renewed quarterly or annually, from the date of the submission of the quarterly or annual financial report, respectively, as reported to the Federal awarding agency or pass-through entity in the case of a subrecipient.?Condition:The Corporation did not retain supporting documentation over its review and approval of FEMA federal expenditures. The inventory system that tracked personal protective equipment (PPE) and drugs was unable to be relied upon due to limitation of testing underlying application controls.The Corporation recorded FEMA expenditures based on the number of units of the PPE used during the period of performance outlined in the project worksheet. The information used to develop the federal expenditures in the schedule of expenditures of federal awards was developed from the Corporation?s inventory management system. Management did not retain supporting documentation over the information technology general controls; therefore, the information from the inventory management system cannot be relied on.Cause:Management designed a process to accumulate and review expenditures related to the FEMA; however, they did not retain supporting documentation to evidence that the internal review was sufficiently designed and operating effectively throughout the process.Management did not retain supporting documentation over the information technology general controls; therefore, the information from the inventory management system cannot be relied on.Questioned costs:None.Context:All expenditures related to FEMA were approved by the procurement department and coded to COVID-19 cost centers. The Corporation developed protocols of what expenses should be charged to the COVID-19 cost centers and communicated these protocols throughout the Corporation to ensure costs were being appropriately recorded. Management then developed a process to review the costs in the COVID-19 cost centers to determine which ones were applicable to FEMA. However, management did not maintain evidence supporting the review and approval of expenses under FEMA.The Corporation?s FEMA project worksheet included six categories of PPE which included the total invoice amount and units purchased. The Corporation then analyzed the units of PPE used for each of the six categories of PPE to support that the PPE outlined in the project worksheet was used and, therefore, properly expensed to FEMA. We selected a sample of 25 invoices across the six categories of PPE to support the invoice amount and units purchased. We then agreed the number of units used to the Corporation?s inventory management system reports for the six PPE categories. However, we could not rely on the inventory reports as were unable to test the information technology general controls over the Corporation?s inventory system in which the supplies and drugs were being accounted for.Total FEMA federal expenditures for Assistance Listing 97.036 totaled $21,034,701 for the year ended December 31, 2022.Effect or potential effect:The amounts submitted for reimbursement and the reports submitted could be inaccurate or incomplete.The units of PPE used per the inventory management reports may be inaccurate or incomplete.Identification as a repeat finding, if applicable:No.Recommendation:The Corporation should design and implement internal controls that are sufficiently precise and require supporting documentation be retained over the review and approval of the expenses.The Corporation should retain evidence of internal controls related to access and change management over the report. Management should implement a quality review process over the inventory reports.Views of Responsible Officials:The Corporation agrees with the finding and has developed a plan to correct the finding. In September 2022, the Corporation had implemented the following changes, which we believe address future internal control considerations should the program be reinstated. The below controls additionally address the need to properly maintain evidence of controls.The below procedures were added to the grant checklist which is required on all grants applied for by the Corporation?s entities. Responsible parties are required to document all procedures and sign off on these procedures. The requirements formalize reporting and data management procedures, which include proper management approval and retention of these records. The grant checklist is additionally approved by the grant applicant and Vice President or Executive Director overseeing the grant.Grant Checklist Items Initials and Date Completed CommentsDetermine required data requests in order to support this grant:? All data requests should list required data fields and constraints and must be reviewed and approved by management.? Detail sample review of the results must be performed to validate the accuracy and completeness of data and that report results meet the grant requirements.? Report access should be restricted to approved users or report results must be validated to approved constraints.Documentation of these procedures must be retained with management sign off and readily available upon request.Grants in excess of $187,500 require review by a Finance or Internal Audit representative to verify that appropriate procedures are in place for documentation of controls on reporting and data management.
Identification of the Federal Program:Federal Grantor: U.S. Department of Health and Human ServicesAssistance Listing No.: 93.011 ? National Organizations of State and Local OfficialsPass-Through Entity: Indiana State Department of HealthPass-Through Award Numbers: G32HS42634C6, U3SHS45317C6Award Years: G32HS42634C6: 07/31/2021-5/31/2023: U3SHS45317C6: 11/1/2021-7/31/2023Criteria 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).?Per Award Number 1 G32HS42634-01-00 and 1 U3SHS45317-01-00, Terms and Condition Section, page 3, subsection 5, ?As the grantee institution, you have the primary responsibility for developing and adhering to your organizational participant incentive policy and maintaining appropriate documentation for each participant gift card. Lastly, it is also the responsibility of the grant recipient to report all grant related costs and it is the responsibility of the sub-recipient to track and report these costs to you as the grant recipient?.Per the Corporation?s policy, section 12, ?During scheduled / clinic gift care pick up, CHW collects the following information to ensure the gift card is exchanged to the prequalified client who had received prior education: Vaccine Card (ensure 2nd or booster shot is documented), form of ID with the client?s name on it to match with vaccine card and internal spreadsheet, and internal spreadsheet for final confirmation of communication and exchange.?Condition:The Corporation screens applicants for eligibility to receive gift cards for participating in vaccine access programs. Once the applicant has met the guidelines of the program, a gift card is provided by the Corporation to the eligible participant. The Corporation expended the full balance of gift cards purchased during the fiscal year 2022 rather than the amount disbursed to eligible participants.Cause:The Corporation did not have internal controls that required the Corporation to only submit expenses for the gift cards disbursed to applicants.Effect or potential effect:The Corporation overstated program expenditures related to gift cards. Gift cards purchased were expensed on the schedule of expenditures of federal awards rather than the gift cards that have been distributed to eligible participants.Questioned Costs:$25,208Context:Gift card expenditure reported in the schedule of expenditures of federal awards for the year ended December 31, 2022, was $167,913. Total gift cards distributed to eligible participants was $142,705.Federal expenditures reported in the schedule of expenditures of federal awards for Assistance Listing 93.011 totaled $2,719,482 for the year ended December 31, 2022.Identification as a repeat finding, if applicable:No.Recommendation:The Corporation should revise its current internal controls to only record program expense for gift cards provided to eligible participants.Views of responsible officials:Management agrees with the finding. G32HS42634C6 and U3SHS45317C6 ended on May 31, 2023 and July 31, 2023, respectively, and therefore the remediation of the internal controls related to these programs is no longer applicable. However, if future programs are awarded, the Corporation will track the total gift cards purchased as a prepaid expense and expense the gift cards at the time they are distributed to eligible participants.
Identification of the Federal Program:Federal Grantor: U.S. Department of Health and Human ServicesAssistance Listing No.: 93.011 ? National Organizations of State and Local OfficialsPass-Through Entity: Indiana State Department of HealthPass-Through Award Numbers: G32HS42634C6, U3SHS45317C6Award Years: G32HS42634C6: 07/31/2021-5/31/2023: U3SHS45317C6: 11/1/2021-7/31/2023Criteria 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).?Per Award Number 1 G32HS42634-01-00 and 1 U3SHS45317-01-00, Terms and Condition Section, page 3, subsection 5, ?As the grantee institution, you have the primary responsibility for developing and adhering to your organizational participant incentive policy and maintaining appropriate documentation for each participant gift card. Lastly, it is also the responsibility of the grant recipient to report all grant related costs and it is the responsibility of the sub-recipient to track and report these costs to you as the grant recipient?.Per the Corporation?s policy, section 12, ?During scheduled / clinic gift care pick up, CHW collects the following information to ensure the gift card is exchanged to the prequalified client who had received prior education: Vaccine Card (ensure 2nd or booster shot is documented), form of ID with the client?s name on it to match with vaccine card and internal spreadsheet, and internal spreadsheet for final confirmation of communication and exchange.?Condition:The Corporation screens applicants for eligibility to receive gift cards for participating in vaccine access programs. Once the applicant has met the guidelines of the program, a gift card is provided by the Corporation to the eligible participant. The Corporation expended the full balance of gift cards purchased during the fiscal year 2022 rather than the amount disbursed to eligible participants.Cause:The Corporation did not have internal controls that required the Corporation to only submit expenses for the gift cards disbursed to applicants.Effect or potential effect:The Corporation overstated program expenditures related to gift cards. Gift cards purchased were expensed on the schedule of expenditures of federal awards rather than the gift cards that have been distributed to eligible participants.Questioned Costs:$25,208Context:Gift card expenditure reported in the schedule of expenditures of federal awards for the year ended December 31, 2022, was $167,913. Total gift cards distributed to eligible participants was $142,705.Federal expenditures reported in the schedule of expenditures of federal awards for Assistance Listing 93.011 totaled $2,719,482 for the year ended December 31, 2022.Identification as a repeat finding, if applicable:No.Recommendation:The Corporation should revise its current internal controls to only record program expense for gift cards provided to eligible participants.Views of responsible officials:Management agrees with the finding. G32HS42634C6 and U3SHS45317C6 ended on May 31, 2023 and July 31, 2023, respectively, and therefore the remediation of the internal controls related to these programs is no longer applicable. However, if future programs are awarded, the Corporation will track the total gift cards purchased as a prepaid expense and expense the gift cards at the time they are distributed to eligible participants.
Information on the federal program:Federal Grantor: United States Department of Health and Human Services, Health Resources and Services Administration (HRSA)Assistance Listing No.: 93.498, Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution (PRF)Award Period of Performance: 01/01/21 ? 12/31/21Criteria 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).?The terms and conditions of the award require the recipient to submit reports to the secretary of Health and Human Services (HHS) for each reporting period to ensure compliance with conditions that are imposed on the payment, and such report shall be in such form, with such content, as specified by the secretary of HHS in program instructions directed to all recipients.Condition:Management did not have sufficiently designed internal controls over the review of lost revenue calculation to ensure that the lost revenue submitted in the HRSA PRF reporting portal was not duplicated between the General Distribution in the HRSA PRF report and the stand-alone subsidiary Targeted Distribution HRSA PRF reports.Cause:Management?s internal controls over the review and approval of the lost revenue calculation were not precise enough to identify that lost revenues transferred from the parent entities General Distribution to the subsidiaries were not duplicated in the subsidiary HRSA PRF Reports.Effect or potential effect:The lost revenues reported for the Corporation were overstated in the HRSA PRF portal for period 4.Questioned costs:None.Context:There was a total of eight HHS PRF portal submissions for reporting periods 3 and 4. We tested the eight HHS PRF portal submissions and underlying lost revenue calculations.For reporting period 4, there was one general distribution to the Beacon Health System (the Parent) and six targeted distributions for six subsidiaries. We note that the lost revenue was overstated in the HHS PRF portal for the Parent consolidated entity as it included the lost revenues reported by the individual subsidiaries for ARP funding. Total Lost Revenues for the Period of Availability (January 1, 2020 to December 31, 2022) reported in the reporting period 4 General Distribution was $127,672,973. The correct amount of lost revenue reported for reporting period 4 should have been $125,214,988.The Parent had sufficient lost revenue to cover the General Distribution; therefore, there are no questioned costs.Total PRF lost revenue on the SEFA is $14,518,741 for the year ended December 31, 2022.Identification as a repeat finding, if applicable:No.Recommendation:We recommend that management implement more robust management review internal controls to ensure accurate reporting in the HRSA PRF portal.Views of responsible officials:The Corporation agrees with the finding and noted this duplication via memorandum as part of the general submission. In the future, the Corporation will remove any individual submissions from the general submission and reconcile the general submission to the supporting documentation less these individual submissions. The Corporation does not expect to receive any further funding from the ARP or PRF and has no further reporting requirements under this grant.
Identification of the federal program:Federal Grantor: U.S. Department of Health and Human ServicesAssistance Listing No.: 93.461, COVID-19 HRSA COVID-19 Claims Reimbursement for the Uninsured Program and the COVID-19 Coverage Assistance Fund (Uninsured Program)Award Period: January 1, 2022 ? March 31, 2022Criteria or specific requirement (including statutory, regulatory or other citation):2 CFR 200.510 requires that the ?auditee must also prepare a Schedule of Expenditures of Federal Awards for the period covered by the auditee?s financial statements which must include the total Federal awards expended in accordance with Section 200.502.? These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework? issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR 200.508 Schedule of expenditures of Federal awards. ?The auditee must also prepare a schedule of expenditures of Federal awards for the period covered by the auditee?s financial statements which must include the total Federal awards expended as determined in accordance with ? 200.502.? Condition:The draft Schedule of Expenditures of Federal Awards (the Schedule) prepared by the Corporation was misstated. The expenditures were understated related to the Uninsured Program. The final Schedule was corrected for the differences identified.Cause:Management did not design internal controls to ensure appropriate accumulation of the data necessary to complete the Schedule.Effect or potential effect:Federal expenditures may be inappropriately included or excluded from the Schedule.Questioned costs:None.Context:Total Uninsured Program expenses were $682,332 for the year ended December 31, 2022.Total expenses included on the draft Schedule were $40,733,999 for the year ended December 31, 2022. Total expenses included on the final Schedule were $41,416,331 for the year ended December 31, 2022.Identification as a repeat finding:No.Recommendation:Management should assess its internal controls over the identification of federal expenditures to ensure the Schedule is complete.Views of responsible officials:The Corporation agrees with the finding and has developed a plan to correct the finding. As of August 16, 2023, the Corporation has implemented the following changes, which we believe address future internal control considerations should the program be reinstated. The below controls additionally address the need to properly maintain evidence of controls. The below wording was added to the SEFA Preparation Memo, which is used to prepare the SEFA each year.a. Grants listed on the prior year are reviewed to determine if the grant is still active or if the grant has closed out.i For grants that have closed, the ending dates of the grant are verified, and current year activity is reviewed to ensure that all activity for that grant has been properly accounted for.
Identification of the Federal Program:Federal Grantor: U.S. Department of Agriculture Food and Nutrition ServiceAssistance Listing No.: 10.557 ? Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)Pass-Through Entity: Indiana State Department of HealthPass-Through Award Numbers: 3610-572900-142500 (21), 3610-572900-142500 (22)Award Years: 10/1/21?9/30/22 and 10/1/22-9/30/23Criteria or Specific Requirement (including statutory, regulatory or other citation):Applicants for WIC program benefits are screened at WIC clinic sites to determine their WIC eligibility. To be certified eligible, they must meet the following eligibility criteria (7 CFR Sections 246.7(c), (d), (e), (g), and (l)):(a) Categorical ? Eligibility is restricted to pregnant, postpartum, and breast-feeding women; infants; and children up to their fifth birthday (7 CFR Sections 246.2 (definition of each category) and 246.7(c)).(b) Identity and Residency ? Except in limited circumstances, WIC applicants must be physically present for eligibility screenings and must provide proof of identity. An applicant must also meet the state agency residency requirement. Except in the case of Indian state agencies, the applicant must reside in the jurisdiction of the state. Indian state agencies may require applicants to reside within their jurisdiction.(c) Income ? An applicant must meet an income standard established by the state agency or be determined to be automatically (adjunctively) income-eligible based on documentation of his/her eligibility, or certain family members? eligibility, for the following federal programs: (1) Temporary Assistance for Needy Families, (2) Medicaid, or (3) Supplemental Nutrition Assistance Program (formerly the Food Stamp Program). State agencies may also determine an individual to be automatically income-eligible, based on documentation of his/her eligibility for certain state-administered programs.(d) Nutritional Risk ? A competent professional authority (e.g., physician, nutritionist, registered nurse, or other health professional) must determine that the applicant is at nutritional risk. While the broad guidelines for determining nutritional risk are set forth in WIC legislation and regulations, the specific allowable nutritional risk criteria are defined in WIC policy guidance, which is updated periodically. Each state agency may choose which allowable nutritional risk criteria will be used to determine eligibility.When an applicant meets all eligibility criteria, he/she is determined by WIC clinic staff to be eligible for program benefits. Certification periods are assigned to each participant based on categorical status for women, infants, and children (7 CFR Section 246.7(g)).A WIC local agency assigns each eligible person a priority classification according to the classification system described in 7 CFR Section 246.7(e)(4). A person?s priority assignment reflects the severity of his/her nutritional risk. If the local agency cannot immediately place the person on the program for lack of an available caseload slot, the person is placed on a waiting list. Caseload vacancies are filled from the waiting list in priority classification order. State agencies are expected to target program outreach and caseload management efforts toward persons at greatest nutritional risk (i.e., those in the highest priority classifications).Pregnant women are certified for the duration of their pregnancies and for up to six weeks postpartum. Breast-feeding women may be certified approximately every six months, up to one year postpartum, or until the woman ceases breast-feeding, whichever occurs first (7 CFR Section 246.7(g)(1)). Infants are certified at intervals of approximately six months, except that infants under six months of age may be certified for a period extending up to the child?s first birthday, provided the quality and accessibility of health care services are not diminished. Children are certified for six-month intervals ending with the last day of the month in which the child reaches his/her fifth birthday. State agencies also have the option to certify children for a period of one year if the state agency ensures that the child receives the required health and nutrition assessments (7 CFR Section 246.7(g)(1)). Non-breast-feeding women are certified for up to six months postpartum. All categories of participants may be certified up to the last day of the last month of the certification period (7 CFR Section 246.7(g)(1)).Condition:The Corporation screens applicants for eligibility by following the state of Indiana guidelines as provided through the INWIC system used to enter, track, and store information about applicants. Based on guidance contained in 7 CFR Section 246, states were encouraged to move to a paperless system. Specifically, federal guidance contained in 7 CFR 246.7 (i)(4) and (5)(i) outlines acceptable documentation to be included on certification forms as ?a description of the document(s) used to determine residency and identity or a copy of the document(s) used or the applicants written statement when no documentation exists,? and ?a description of the document(s) used to determine income eligibility or a copy of the document(s) in the file.? The state of Indiana has followed that guidance and does not require the Corporation to retain copies of an applicant?s proof of residence, income, etc., regarding eligibility. Therefore, we were not able to test internal controls over compliance or compliance over the eligibility compliance requirement through re-performance and have issued a qualified opinion based on the scope limitations.Cause:The Corporation follows a paperless system as supported by the state of Indiana and the U.S. Department of Agriculture. The state does not require third-party supporting documentation of eligibility determinations to be retained.Effect or potential effect:Due to the online nature of the eligibility system, the program does not have documentation available for the audit team to test compliance with the eligibility requirement. A scope limitation qualified opinion was issued for Assistance Listing 10.557, as we were unable to obtain sufficient documentation supporting the compliance of the Corporation regarding eligibility.Questioned Costs:None.Context:Federal expenditures reported in the schedule of expenditures of federal awards for Assistance Listing 10.557 totaled $1,703,252 for the year ended December 31, 2022.Identification as a repeat finding, if applicable:Yes. Prior year findings 2021-001.Recommendation:No further follow-up is required, as management of the Corporation is following the applicable guidance.Views of responsible officials:Management agrees with the finding. No changes in our current procedures are required as we are following the State requirements.
Information on the federal program:Federal Grantor: Department of Homeland SecurityAssistance Listing No.: 97.036, COVID-19 Disaster Grants ? Public Assistance (Presidentially Declared Disasters) (FEMA)Pass-Through Entity: Indiana State Department of HealthPass-Through Award Numbers: PA-06-IN-4515-PW-00292(432), PA-05-IN-4515-PW-00396(473), PA-05-IN-4515-PW-00463(556)Award Period of Performance: 01/20/2020?03/02/2022Criteria 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).?Per the FEMA Project Worksheet Report #334659-292, under the Subgrant Conditions section, bullet point 1, ?As described in Title 2 Code of Federal Regulations (C.F.R.) ? 200.333, financial records, supporting documents, statistical records and all other non-Federal entity records pertinent to a Federal award must be retained for a period of three (3) years from the date of submission of the final expenditure report or, for Federal awards that are renewed quarterly or annually, from the date of the submission of the quarterly or annual financial report, respectively, as reported to the Federal awarding agency or pass-through entity in the case of a subrecipient.?Condition:The Corporation did not retain supporting documentation over its review and approval of FEMA federal expenditures. The inventory system that tracked personal protective equipment (PPE) and drugs was unable to be relied upon due to limitation of testing underlying application controls.The Corporation recorded FEMA expenditures based on the number of units of the PPE used during the period of performance outlined in the project worksheet. The information used to develop the federal expenditures in the schedule of expenditures of federal awards was developed from the Corporation?s inventory management system. Management did not retain supporting documentation over the information technology general controls; therefore, the information from the inventory management system cannot be relied on.Cause:Management designed a process to accumulate and review expenditures related to the FEMA; however, they did not retain supporting documentation to evidence that the internal review was sufficiently designed and operating effectively throughout the process.Management did not retain supporting documentation over the information technology general controls; therefore, the information from the inventory management system cannot be relied on.Questioned costs:None.Context:All expenditures related to FEMA were approved by the procurement department and coded to COVID-19 cost centers. The Corporation developed protocols of what expenses should be charged to the COVID-19 cost centers and communicated these protocols throughout the Corporation to ensure costs were being appropriately recorded. Management then developed a process to review the costs in the COVID-19 cost centers to determine which ones were applicable to FEMA. However, management did not maintain evidence supporting the review and approval of expenses under FEMA.The Corporation?s FEMA project worksheet included six categories of PPE which included the total invoice amount and units purchased. The Corporation then analyzed the units of PPE used for each of the six categories of PPE to support that the PPE outlined in the project worksheet was used and, therefore, properly expensed to FEMA. We selected a sample of 25 invoices across the six categories of PPE to support the invoice amount and units purchased. We then agreed the number of units used to the Corporation?s inventory management system reports for the six PPE categories. However, we could not rely on the inventory reports as were unable to test the information technology general controls over the Corporation?s inventory system in which the supplies and drugs were being accounted for.Total FEMA federal expenditures for Assistance Listing 97.036 totaled $21,034,701 for the year ended December 31, 2022.Effect or potential effect:The amounts submitted for reimbursement and the reports submitted could be inaccurate or incomplete.The units of PPE used per the inventory management reports may be inaccurate or incomplete.Identification as a repeat finding, if applicable:No.Recommendation:The Corporation should design and implement internal controls that are sufficiently precise and require supporting documentation be retained over the review and approval of the expenses.The Corporation should retain evidence of internal controls related to access and change management over the report. Management should implement a quality review process over the inventory reports.Views of Responsible Officials:The Corporation agrees with the finding and has developed a plan to correct the finding. In September 2022, the Corporation had implemented the following changes, which we believe address future internal control considerations should the program be reinstated. The below controls additionally address the need to properly maintain evidence of controls.The below procedures were added to the grant checklist which is required on all grants applied for by the Corporation?s entities. Responsible parties are required to document all procedures and sign off on these procedures. The requirements formalize reporting and data management procedures, which include proper management approval and retention of these records. The grant checklist is additionally approved by the grant applicant and Vice President or Executive Director overseeing the grant.Grant Checklist Items Initials and Date Completed CommentsDetermine required data requests in order to support this grant:? All data requests should list required data fields and constraints and must be reviewed and approved by management.? Detail sample review of the results must be performed to validate the accuracy and completeness of data and that report results meet the grant requirements.? Report access should be restricted to approved users or report results must be validated to approved constraints.Documentation of these procedures must be retained with management sign off and readily available upon request.Grants in excess of $187,500 require review by a Finance or Internal Audit representative to verify that appropriate procedures are in place for documentation of controls on reporting and data management.
Identification of the Federal Program:Federal Grantor: U.S. Department of Health and Human ServicesAssistance Listing No.: 93.011 ? National Organizations of State and Local OfficialsPass-Through Entity: Indiana State Department of HealthPass-Through Award Numbers: G32HS42634C6, U3SHS45317C6Award Years: G32HS42634C6: 07/31/2021-5/31/2023: U3SHS45317C6: 11/1/2021-7/31/2023Criteria 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).?Per Award Number 1 G32HS42634-01-00 and 1 U3SHS45317-01-00, Terms and Condition Section, page 3, subsection 5, ?As the grantee institution, you have the primary responsibility for developing and adhering to your organizational participant incentive policy and maintaining appropriate documentation for each participant gift card. Lastly, it is also the responsibility of the grant recipient to report all grant related costs and it is the responsibility of the sub-recipient to track and report these costs to you as the grant recipient?.Per the Corporation?s policy, section 12, ?During scheduled / clinic gift care pick up, CHW collects the following information to ensure the gift card is exchanged to the prequalified client who had received prior education: Vaccine Card (ensure 2nd or booster shot is documented), form of ID with the client?s name on it to match with vaccine card and internal spreadsheet, and internal spreadsheet for final confirmation of communication and exchange.?Condition:The Corporation screens applicants for eligibility to receive gift cards for participating in vaccine access programs. Once the applicant has met the guidelines of the program, a gift card is provided by the Corporation to the eligible participant. The Corporation expended the full balance of gift cards purchased during the fiscal year 2022 rather than the amount disbursed to eligible participants.Cause:The Corporation did not have internal controls that required the Corporation to only submit expenses for the gift cards disbursed to applicants.Effect or potential effect:The Corporation overstated program expenditures related to gift cards. Gift cards purchased were expensed on the schedule of expenditures of federal awards rather than the gift cards that have been distributed to eligible participants.Questioned Costs:$25,208Context:Gift card expenditure reported in the schedule of expenditures of federal awards for the year ended December 31, 2022, was $167,913. Total gift cards distributed to eligible participants was $142,705.Federal expenditures reported in the schedule of expenditures of federal awards for Assistance Listing 93.011 totaled $2,719,482 for the year ended December 31, 2022.Identification as a repeat finding, if applicable:No.Recommendation:The Corporation should revise its current internal controls to only record program expense for gift cards provided to eligible participants.Views of responsible officials:Management agrees with the finding. G32HS42634C6 and U3SHS45317C6 ended on May 31, 2023 and July 31, 2023, respectively, and therefore the remediation of the internal controls related to these programs is no longer applicable. However, if future programs are awarded, the Corporation will track the total gift cards purchased as a prepaid expense and expense the gift cards at the time they are distributed to eligible participants.
Identification of the Federal Program:Federal Grantor: U.S. Department of Health and Human ServicesAssistance Listing No.: 93.011 ? National Organizations of State and Local OfficialsPass-Through Entity: Indiana State Department of HealthPass-Through Award Numbers: G32HS42634C6, U3SHS45317C6Award Years: G32HS42634C6: 07/31/2021-5/31/2023: U3SHS45317C6: 11/1/2021-7/31/2023Criteria 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).?Per Award Number 1 G32HS42634-01-00 and 1 U3SHS45317-01-00, Terms and Condition Section, page 3, subsection 5, ?As the grantee institution, you have the primary responsibility for developing and adhering to your organizational participant incentive policy and maintaining appropriate documentation for each participant gift card. Lastly, it is also the responsibility of the grant recipient to report all grant related costs and it is the responsibility of the sub-recipient to track and report these costs to you as the grant recipient?.Per the Corporation?s policy, section 12, ?During scheduled / clinic gift care pick up, CHW collects the following information to ensure the gift card is exchanged to the prequalified client who had received prior education: Vaccine Card (ensure 2nd or booster shot is documented), form of ID with the client?s name on it to match with vaccine card and internal spreadsheet, and internal spreadsheet for final confirmation of communication and exchange.?Condition:The Corporation screens applicants for eligibility to receive gift cards for participating in vaccine access programs. Once the applicant has met the guidelines of the program, a gift card is provided by the Corporation to the eligible participant. The Corporation expended the full balance of gift cards purchased during the fiscal year 2022 rather than the amount disbursed to eligible participants.Cause:The Corporation did not have internal controls that required the Corporation to only submit expenses for the gift cards disbursed to applicants.Effect or potential effect:The Corporation overstated program expenditures related to gift cards. Gift cards purchased were expensed on the schedule of expenditures of federal awards rather than the gift cards that have been distributed to eligible participants.Questioned Costs:$25,208Context:Gift card expenditure reported in the schedule of expenditures of federal awards for the year ended December 31, 2022, was $167,913. Total gift cards distributed to eligible participants was $142,705.Federal expenditures reported in the schedule of expenditures of federal awards for Assistance Listing 93.011 totaled $2,719,482 for the year ended December 31, 2022.Identification as a repeat finding, if applicable:No.Recommendation:The Corporation should revise its current internal controls to only record program expense for gift cards provided to eligible participants.Views of responsible officials:Management agrees with the finding. G32HS42634C6 and U3SHS45317C6 ended on May 31, 2023 and July 31, 2023, respectively, and therefore the remediation of the internal controls related to these programs is no longer applicable. However, if future programs are awarded, the Corporation will track the total gift cards purchased as a prepaid expense and expense the gift cards at the time they are distributed to eligible participants.
Information on the federal program:Federal Grantor: United States Department of Health and Human Services, Health Resources and Services Administration (HRSA)Assistance Listing No.: 93.498, Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution (PRF)Award Period of Performance: 01/01/21 ? 12/31/21Criteria 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).?The terms and conditions of the award require the recipient to submit reports to the secretary of Health and Human Services (HHS) for each reporting period to ensure compliance with conditions that are imposed on the payment, and such report shall be in such form, with such content, as specified by the secretary of HHS in program instructions directed to all recipients.Condition:Management did not have sufficiently designed internal controls over the review of lost revenue calculation to ensure that the lost revenue submitted in the HRSA PRF reporting portal was not duplicated between the General Distribution in the HRSA PRF report and the stand-alone subsidiary Targeted Distribution HRSA PRF reports.Cause:Management?s internal controls over the review and approval of the lost revenue calculation were not precise enough to identify that lost revenues transferred from the parent entities General Distribution to the subsidiaries were not duplicated in the subsidiary HRSA PRF Reports.Effect or potential effect:The lost revenues reported for the Corporation were overstated in the HRSA PRF portal for period 4.Questioned costs:None.Context:There was a total of eight HHS PRF portal submissions for reporting periods 3 and 4. We tested the eight HHS PRF portal submissions and underlying lost revenue calculations.For reporting period 4, there was one general distribution to the Beacon Health System (the Parent) and six targeted distributions for six subsidiaries. We note that the lost revenue was overstated in the HHS PRF portal for the Parent consolidated entity as it included the lost revenues reported by the individual subsidiaries for ARP funding. Total Lost Revenues for the Period of Availability (January 1, 2020 to December 31, 2022) reported in the reporting period 4 General Distribution was $127,672,973. The correct amount of lost revenue reported for reporting period 4 should have been $125,214,988.The Parent had sufficient lost revenue to cover the General Distribution; therefore, there are no questioned costs.Total PRF lost revenue on the SEFA is $14,518,741 for the year ended December 31, 2022.Identification as a repeat finding, if applicable:No.Recommendation:We recommend that management implement more robust management review internal controls to ensure accurate reporting in the HRSA PRF portal.Views of responsible officials:The Corporation agrees with the finding and noted this duplication via memorandum as part of the general submission. In the future, the Corporation will remove any individual submissions from the general submission and reconcile the general submission to the supporting documentation less these individual submissions. The Corporation does not expect to receive any further funding from the ARP or PRF and has no further reporting requirements under this grant.
Identification of the federal program:Federal Grantor: U.S. Department of Health and Human ServicesAssistance Listing No.: 93.461, COVID-19 HRSA COVID-19 Claims Reimbursement for the Uninsured Program and the COVID-19 Coverage Assistance Fund (Uninsured Program)Award Period: January 1, 2022 ? March 31, 2022Criteria or specific requirement (including statutory, regulatory or other citation):2 CFR 200.510 requires that the ?auditee must also prepare a Schedule of Expenditures of Federal Awards for the period covered by the auditee?s financial statements which must include the total Federal awards expended in accordance with Section 200.502.? These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework? issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR 200.508 Schedule of expenditures of Federal awards. ?The auditee must also prepare a schedule of expenditures of Federal awards for the period covered by the auditee?s financial statements which must include the total Federal awards expended as determined in accordance with ? 200.502.? Condition:The draft Schedule of Expenditures of Federal Awards (the Schedule) prepared by the Corporation was misstated. The expenditures were understated related to the Uninsured Program. The final Schedule was corrected for the differences identified.Cause:Management did not design internal controls to ensure appropriate accumulation of the data necessary to complete the Schedule.Effect or potential effect:Federal expenditures may be inappropriately included or excluded from the Schedule.Questioned costs:None.Context:Total Uninsured Program expenses were $682,332 for the year ended December 31, 2022.Total expenses included on the draft Schedule were $40,733,999 for the year ended December 31, 2022. Total expenses included on the final Schedule were $41,416,331 for the year ended December 31, 2022.Identification as a repeat finding:No.Recommendation:Management should assess its internal controls over the identification of federal expenditures to ensure the Schedule is complete.Views of responsible officials:The Corporation agrees with the finding and has developed a plan to correct the finding. As of August 16, 2023, the Corporation has implemented the following changes, which we believe address future internal control considerations should the program be reinstated. The below controls additionally address the need to properly maintain evidence of controls. The below wording was added to the SEFA Preparation Memo, which is used to prepare the SEFA each year.a. Grants listed on the prior year are reviewed to determine if the grant is still active or if the grant has closed out.i For grants that have closed, the ending dates of the grant are verified, and current year activity is reviewed to ensure that all activity for that grant has been properly accounted for.