Audit 323256

FY End
2023-12-31
Total Expended
$98.82M
Findings
2
Programs
41
Organization: Montefiore Health System, Inc. (NY)
Year: 2023 Accepted: 2024-09-30

Organization Exclusion Status:

Checking exclusion status...

Findings

ID Ref Severity Repeat Requirement
501019 2023-001 Significant Deficiency - ABCH
1077461 2023-001 Significant Deficiency - ABCH

Programs

ALN Program Spent Major Findings
10.557 Wic Special Supplemental Nutrition Program for Women, Infants, and Children $30.30M Yes 1
97.036 Covid-19 Disaster Grants - Public Assistance (presidentially Declared Disasters) $28.86M Yes 0
93.558 Temporary Assistance for Needy Families $5.24M - 0
93.086 Healthy Marriage Promotion and Responsible Fatherhood Grants $2.85M - 0
93.153 Coordinated Services and Access to Research for Women, Infants, Children, and Youth $1.75M - 0
93.262 Occupational Safety and Health Program $1.58M - 0
93.778 Medical Assistance Program $1.52M - 0
93.378 Integrated Care for Kids Model $1.43M - 0
10.561 State Administrative Matching Grants for the Supplemental Nutrition Assistance Program $1.43M - 0
93.087 Enhance Safety of Children Affected by Substance Abuse $1.31M - 0
93.918 Grants to Provide Outpatient Early Intervention Services with Respect to Hiv Disease $965,763 - 0
93.268 Immunization Cooperative Agreements $920,023 - 0
84.268 Federal Direct Student Loans $569,215 - 0
93.505 Affordable Care Act (aca) Maternal, Infant, and Early Childhood Home Visiting Program $461,017 - 0
93.686 Ending the Hiv Epidemic: A Plan for America — Ryan White Hiv/aids Program Parts A and B $412,095 - 0
93.527 Affordable Care Act (aca) Grants for New and Expanded Services Under the Health Center Program $359,390 - 0
93.395 Cancer Treatment Research $355,039 - 0
93.958 Block Grants for Community Mental Health Services $348,731 - 0
93.224 Health Center Program (community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) $347,170 - 0
93.732 Mental and Behavioral Health Education and Training Grants $318,007 - 0
93.924 Ryan White Hiv/aids Dental Reimbursement and Community Based Dental Partnership Grants $298,835 - 0
93.939 Hiv Prevention Activities Non-Governmental Organization Based $298,009 - 0
93.137 Community Programs to Improve Minority Health Grant Program $286,177 - 0
93.940 Hiv Prevention Activities Health Department Based $268,309 - 0
93.959 Block Grants for Prevention and Treatment of Substance Abuse $263,955 - 0
93.994 Maternal and Child Health Services Block Grant to the States $240,276 - 0
84.063 Federal Pell Grant Program $151,726 - 0
10.331 Food Insecurity Nutrition Incentive Grants Program $146,846 - 0
93.870 Maternal, Infant and Early Childhood Home Visiting Grant $98,666 - 0
93.889 Covid-19 National Bioterrorism Hospital Preparedness Program $92,500 - 0
93.243 Substance Abuse and Mental Health Services_projects of Regional and National Significance $79,805 - 0
93.526 Grants for Capital Development in Health Centers $69,679 - 0
93.976 Primary Care Medicine and Dentistry Clinician Educator Career Development Awards $66,045 - 0
93.365 Sickle Cell Treatment Demonstration Program $60,000 - 0
93.399 Cancer Control $50,000 - 0
84.425 Education Stabilization Fund $41,247 - 0
84.007 Federal Supplemental Educational Opportunity Grants $17,190 - 0
93.080 Blood Disorder Program: Prevention, Surveillance, and Research $12,506 - 0
16.588 Violence Against Women Formula Grants $9,450 - 0
93.110 Maternal and Child Health Federal Consolidated Programs $4,588 - 0
93.393 Cancer Cause and Prevention Research $4,000 - 0

Contacts

Name Title Type
FP1VD1HU5HV7 Kristopher Von Steenburg Auditee
9143498462 Megan Byrne Auditor
No contacts on file

Notes to SEFA

Title: 1. Basis of Presentation Accounting Policies: The accompanying schedule of expenditures of federal awards (the Schedule) includes the federal grant activity of Montefiore Health System, Inc. and its controlled organizations (the Health System) for the year ended December 31, 2023 and is presented on the accrual basis of accounting. The information in the Schedule is presented in accordance with the requirements of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (the Uniform Guidance) other applicable requirements. Therefore, some amounts presented in the Schedule may differ from amounts presented in, or used in the preparation of, the Health System’s consolidated financial statements. For purposes of the Schedule, federal awards include any assistance provided by a federal agency directly or indirectly in the form of grants, contracts, cooperative agreements, loan and loan guarantees, or other non-cash assistance. Direct and indirect costs are charged to awards in accordance with cost principles contained in the United States Department of Health and Human Services Cost Principles for Hospitals at 45 CFR Part 75 Appendix IX and 45 CFR Part 74 Appendix E, as applicable. Under these cost principles, certain types of expenditures are not allowable or are limited as to reimbursement. The Uniform Guidance provides for a 10% de minimis indirect cost rate election; however, the Health System did not make this election and uses a negotiated indirect cost rate. De Minimis Rate Used: N Rate Explanation: The auditee did not use the de minimis cost rate. The accompanying schedule of expenditures of federal awards (the Schedule) includes the federal grant activity of Montefiore Health System, Inc. and its controlled organizations (the Health System) for the year ended December 31, 2023 and is presented on the accrual basis of accounting. The information in the Schedule is presented in accordance with the requirements of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (the Uniform Guidance) other applicable requirements. Therefore, some amounts presented in the Schedule may differ from amounts presented in, or used in the preparation of, the Health System’s consolidated financial statements. For purposes of the Schedule, federal awards include any assistance provided by a federal agency directly or indirectly in the form of grants, contracts, cooperative agreements, loan and loan guarantees, or other non-cash assistance. Direct and indirect costs are charged to awards in accordance with cost principles contained in the United States Department of Health and Human Services Cost Principles for Hospitals at 45 CFR Part 75 Appendix IX and 45 CFR Part 74 Appendix E, as applicable. Under these cost principles, certain types of expenditures are not allowable or are limited as to reimbursement. The Uniform Guidance provides for a 10% de minimis indirect cost rate election; however, the Health System did not make this election and uses a negotiated indirect cost rate.
Title: 2. Food and Nutrition Awards Accounting Policies: The accompanying schedule of expenditures of federal awards (the Schedule) includes the federal grant activity of Montefiore Health System, Inc. and its controlled organizations (the Health System) for the year ended December 31, 2023 and is presented on the accrual basis of accounting. The information in the Schedule is presented in accordance with the requirements of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (the Uniform Guidance) other applicable requirements. Therefore, some amounts presented in the Schedule may differ from amounts presented in, or used in the preparation of, the Health System’s consolidated financial statements. For purposes of the Schedule, federal awards include any assistance provided by a federal agency directly or indirectly in the form of grants, contracts, cooperative agreements, loan and loan guarantees, or other non-cash assistance. Direct and indirect costs are charged to awards in accordance with cost principles contained in the United States Department of Health and Human Services Cost Principles for Hospitals at 45 CFR Part 75 Appendix IX and 45 CFR Part 74 Appendix E, as applicable. Under these cost principles, certain types of expenditures are not allowable or are limited as to reimbursement. The Uniform Guidance provides for a 10% de minimis indirect cost rate election; however, the Health System did not make this election and uses a negotiated indirect cost rate. De Minimis Rate Used: N Rate Explanation: The auditee did not use the de minimis cost rate. During the year ended December 31, 2023, the Health System participated in the New York State Department of Health WIC Special Supplemental Nutrition Program for Women, Infants and Children (WIC) through the receipt and distribution of food vouchers. The U.S. Department of Agriculture has determined that such WIC food vouchers are considered “property in lieu of money” and, therefore, should be reported as federal awards received by the Health System. Federal expenditures under the WIC program are as follows: Assistance Listing No. For the Year Ended December 31, 2023 United States Department of Agriculture: WIC Special Supplemental Nutrition Program for Women, Infants and Children: Pass-through New York State Department of Health 10.557 $ 30,295,069 The total amount reported as federal awards above, represents the value of food checks redeemed and administrative costs in the amount of $5,896,238, for the year ended December 31, 2023. As state funds are commingled with the federal funds received by New York State, percentages (83.8% for administrative costs and 100% for the value of checks redeemed for Federal fiscal year ended 2023) were applied to determine the total amount of federal funds to be reported above. These percentages were supplied by the New York State Department of Health.
Title: 3. COVID-19 – Disaster Grants – Public Assistance (Presidentially Declared Disasters) Accounting Policies: The accompanying schedule of expenditures of federal awards (the Schedule) includes the federal grant activity of Montefiore Health System, Inc. and its controlled organizations (the Health System) for the year ended December 31, 2023 and is presented on the accrual basis of accounting. The information in the Schedule is presented in accordance with the requirements of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (the Uniform Guidance) other applicable requirements. Therefore, some amounts presented in the Schedule may differ from amounts presented in, or used in the preparation of, the Health System’s consolidated financial statements. For purposes of the Schedule, federal awards include any assistance provided by a federal agency directly or indirectly in the form of grants, contracts, cooperative agreements, loan and loan guarantees, or other non-cash assistance. Direct and indirect costs are charged to awards in accordance with cost principles contained in the United States Department of Health and Human Services Cost Principles for Hospitals at 45 CFR Part 75 Appendix IX and 45 CFR Part 74 Appendix E, as applicable. Under these cost principles, certain types of expenditures are not allowable or are limited as to reimbursement. The Uniform Guidance provides for a 10% de minimis indirect cost rate election; however, the Health System did not make this election and uses a negotiated indirect cost rate. De Minimis Rate Used: N Rate Explanation: The auditee did not use the de minimis cost rate. The Health System incurred certain expenditures related to the COVID-19 pandemic which are eligible for reimbursement from the Federal Emergency Management Agency (FEMA) Disaster Grants – Public Assistance (Presidentially Declared Disasters) (Assistance Listing No. 97.036). In 2023, FEMA approved $28,858,434 of eligible expenditures that were incurred in prior years. This amount has been included in the accompanying Schedule for the year ended December 31, 2023 in accordance with the guidance specific to Assistance Listing No. 97.036.
Title: 4. Loan Program Accounting Policies: The accompanying schedule of expenditures of federal awards (the Schedule) includes the federal grant activity of Montefiore Health System, Inc. and its controlled organizations (the Health System) for the year ended December 31, 2023 and is presented on the accrual basis of accounting. The information in the Schedule is presented in accordance with the requirements of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (the Uniform Guidance) other applicable requirements. Therefore, some amounts presented in the Schedule may differ from amounts presented in, or used in the preparation of, the Health System’s consolidated financial statements. For purposes of the Schedule, federal awards include any assistance provided by a federal agency directly or indirectly in the form of grants, contracts, cooperative agreements, loan and loan guarantees, or other non-cash assistance. Direct and indirect costs are charged to awards in accordance with cost principles contained in the United States Department of Health and Human Services Cost Principles for Hospitals at 45 CFR Part 75 Appendix IX and 45 CFR Part 74 Appendix E, as applicable. Under these cost principles, certain types of expenditures are not allowable or are limited as to reimbursement. The Uniform Guidance provides for a 10% de minimis indirect cost rate election; however, the Health System did not make this election and uses a negotiated indirect cost rate. De Minimis Rate Used: N Rate Explanation: The auditee did not use the de minimis cost rate. During the year ended December 31, 2023, the Health System processed $883,055 in new loans under the Federal Direct Student Loans Program (Assistance Listing No. 84.268). Since this program is administered by outside financial institutions, new loans made in the year ended December 31, 2023 relating to this program are considered current period federal expenditures, whereas the outstanding balances are not. The new loans made in the year ended December 31, 2023 are reported in the Schedule.

Finding Details

Finding 2023-001 – A. Activities Allowed or Unallowed, B. Allowable Costs/Cost Principles, C. Cash Management, H. Period of Performance Information on the Federal Program: Grantor: United States Department of Agriculture Program Name: Special Supplemental Nutrition Program for Women, Infant, and Children Assistance Listing Number: 10.557 Criteria or Specific Requirement: In accordance with Title 2 U.S. Code of Federal Regulations, Part 200.303, Internal controls, “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.” Condition: Management was unable to provide evidence of a control being consistently performed to address the risk that the Health System may seek reimbursement for expenditures that are either out of contract period or are for non-permissible costs under the applicable contracts. Cause: As a result of multiple control owners, there is inconsistency in the steps performed as part of the control and evidence was unavailable to support the effective operation of management’s review control. Effect or Potential Effect: As a result of inconsistent review of vouchers submitted to the applicable agency, the Health System could include non-permissible, or out of period expenditures, when seeking reimbursement. Questioned Costs: Not applicable. Context: For each of the contracts that are in affect for the period under audit, the Health System submits a monthly voucher request to the local agency for reimbursement of eligible expenditures. Each of these submissions is to be reviewed by a person knowledgeable of the program. In testing this review control, evidence to support the effective operation of this control could not be provided for 16 of the 35 occurrences. Identification as a repeat finding: This finding is not a repeat finding from the prior year. Recommendation: The Health System should improve its process to standardize the review of program vouchers, including retention of evidence supporting the performance of the control. View of responsible officials: Management concurred with the audit finding and has implemented a standardized review and approval process that will be performed prior to monthly vouchers being submitted for reimbursement, including verification of allowability of expenditures and that all expenditures were incurred in the proper period. Evidence of the monthly review and approval will be retained.
Finding 2023-001 – A. Activities Allowed or Unallowed, B. Allowable Costs/Cost Principles, C. Cash Management, H. Period of Performance Information on the Federal Program: Grantor: United States Department of Agriculture Program Name: Special Supplemental Nutrition Program for Women, Infant, and Children Assistance Listing Number: 10.557 Criteria or Specific Requirement: In accordance with Title 2 U.S. Code of Federal Regulations, Part 200.303, Internal controls, “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.” Condition: Management was unable to provide evidence of a control being consistently performed to address the risk that the Health System may seek reimbursement for expenditures that are either out of contract period or are for non-permissible costs under the applicable contracts. Cause: As a result of multiple control owners, there is inconsistency in the steps performed as part of the control and evidence was unavailable to support the effective operation of management’s review control. Effect or Potential Effect: As a result of inconsistent review of vouchers submitted to the applicable agency, the Health System could include non-permissible, or out of period expenditures, when seeking reimbursement. Questioned Costs: Not applicable. Context: For each of the contracts that are in affect for the period under audit, the Health System submits a monthly voucher request to the local agency for reimbursement of eligible expenditures. Each of these submissions is to be reviewed by a person knowledgeable of the program. In testing this review control, evidence to support the effective operation of this control could not be provided for 16 of the 35 occurrences. Identification as a repeat finding: This finding is not a repeat finding from the prior year. Recommendation: The Health System should improve its process to standardize the review of program vouchers, including retention of evidence supporting the performance of the control. View of responsible officials: Management concurred with the audit finding and has implemented a standardized review and approval process that will be performed prior to monthly vouchers being submitted for reimbursement, including verification of allowability of expenditures and that all expenditures were incurred in the proper period. Evidence of the monthly review and approval will be retained.