Audit 327330

FY End
2022-12-31
Total Expended
$55.39M
Findings
8
Programs
33
Organization: Inova Health System (VA)
Year: 2022 Accepted: 2024-11-05

Organization Exclusion Status:

Checking exclusion status...

Findings

ID Ref Severity Repeat Requirement
504718 2022-001 Significant Deficiency Yes ABL
504719 2022-002 Material Weakness - ABEJ
504720 2022-003 Significant Deficiency Yes P
504721 2022-004 Material Weakness - P
1081160 2022-001 Significant Deficiency Yes ABL
1081161 2022-002 Material Weakness - ABEJ
1081162 2022-003 Significant Deficiency Yes P
1081163 2022-004 Material Weakness - P

Programs

ALN Program Spent Major Findings
97.036 Disaster Grants - Public Assistance (presidentially Declared Disasters) $31.63M Yes 1
93.498 Provider Relief Fund and American Rescue Plan (arp) Rural Distribution $12.42M Yes 2
93.917 Hiv Care Formula Grants $3.05M Yes 1
12.750 Uniformed Services University Medical Research Projects $2.36M - 0
93.837 Cardiovascular Diseases Research $728,686 - 0
93.153 Coordinated Services and Access to Research for Women, Infants, Children, and Youth $630,893 - 0
93.918 Grants to Provide Outpatient Early Intervention Services with Respect to Hiv Disease $551,228 - 0
93.461 Hrsa Covid-19 Claims Reimbursement for the Uninsured Program and the Covid-19 Coverage Assistance Fund $537,317 - 0
93.939 Hiv Prevention Activities Non-Governmental Organization Based $428,237 - 0
20.RD Nhtsa Discretionary Safety Grants and Cooperative Agreements $358,219 - 0
93.350 National Center for Advancing Translational Sciences $278,879 - 0
93.145 Aids Education and Training Centers $249,634 - 0
93.RD Population Health Research Support $203,128 - 0
93.914 Hiv Emergency Relief Project Grants $168,245 - 0
93.767 Children's Health Insurance Program $166,981 - 0
93.353 21st Century Cures Act - Beau Biden Cancer Moonshot $144,695 - 0
93.103 Food and Drug Administration Research $134,239 - 0
16.575 Crime Victim Assistance $126,935 - 0
93.393 Cancer Cause and Prevention Research $102,253 - 0
93.RD Nhlbi Graft Sample and Data Collection Project $80,705 - 0
93.394 Cancer Detection and Diagnosis Research $73,677 - 0
12.420 Military Medical Research and Development $40,278 - 0
93.226 Research on Healthcare Costs, Quality and Outcomes $35,161 - 0
93.323 Epidemiology and Laboratory Capacity for Infectious Diseases (elc) $32,135 - 0
93.RD Nhlbi/inova Pulmonary Vascular Program $27,759 - 0
93.397 Cancer Centers Support Grants $21,633 - 0
93.853 Extramural Research Programs in the Neurosciences and Neurological Disorders $17,834 - 0
21.027 Coronavirus State and Local Fiscal Recovery Funds $13,427 - 0
93.847 Diabetes, Digestive, and Kidney Diseases Extramural Research $13,326 - 0
93.RD Nhlbi Pulmonary Vascular Program $7,240 - 0
93.855 Allergy and Infectious Diseases Research $5,536 - 0
93.RD Support Services for the Lampoon Protocol Ide Enrollment Sites $4,248 - 0
93.940 Hiv Prevention Activities Health Department Based $2,126 - 0

Contacts

Name Title Type
WQCEDBM284L6 Christopher Smith Auditee
7034349230 Marykate Federico Auditor
No contacts on file

Notes to SEFA

Title: Basis of Presentation Accounting Policies: The accompanying schedule of expenditures of federal awards (the “Schedule”) includes all federal grant activity of the Inova Health System (“IHS” or “System”) including federal awards passed through other agencies. The accompanying Schedule is presented using the accrual basis of accounting and 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 (Uniform Guidance). In accordance with applicable requirements, certain programs may be presented in a fiscal period based on program-specific guidance (see Note 3). Therefore, some amounts presented in the Schedule may differ from amounts presented in, or used in the preparation of, IHS’s consolidated financial statements. The preparation of the Schedule in conformity with accounting principles generally accepted in the United States of America requires management to make estimates and assumptions that affect the reported amounts in the Schedule during the reporting period. Actual results could differ from those estimates. De Minimis Rate Used: N Rate Explanation: 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 for Uniform Guidance awards. 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, IHS did not make this election and uses a negotiated indirect cost rate in the accompanying Schedule. The accompanying schedule of expenditures of federal awards (the “Schedule”) includes all federal grant activity of the Inova Health System (“IHS” or “System”) including federal awards passed through other agencies. The accompanying Schedule is presented using the accrual basis of accounting and 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 (Uniform Guidance). In accordance with applicable requirements, certain programs may be presented in a fiscal period based on program-specific guidance (see Note 3). Therefore, some amounts presented in the Schedule may differ from amounts presented in, or used in the preparation of, IHS’s consolidated financial statements. The preparation of the Schedule in conformity with accounting principles generally accepted in the United States of America requires management to make estimates and assumptions that affect the reported amounts in the Schedule during the reporting period. Actual results could differ from those estimates.
Title: Indirect Cost Rate Accounting Policies: The accompanying schedule of expenditures of federal awards (the “Schedule”) includes all federal grant activity of the Inova Health System (“IHS” or “System”) including federal awards passed through other agencies. The accompanying Schedule is presented using the accrual basis of accounting and 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 (Uniform Guidance). In accordance with applicable requirements, certain programs may be presented in a fiscal period based on program-specific guidance (see Note 3). Therefore, some amounts presented in the Schedule may differ from amounts presented in, or used in the preparation of, IHS’s consolidated financial statements. The preparation of the Schedule in conformity with accounting principles generally accepted in the United States of America requires management to make estimates and assumptions that affect the reported amounts in the Schedule during the reporting period. Actual results could differ from those estimates. De Minimis Rate Used: N Rate Explanation: 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 for Uniform Guidance awards. 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, IHS did not make this election and uses a negotiated indirect cost rate in the accompanying Schedule. 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 for Uniform Guidance awards. 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, IHS did not make this election and uses a negotiated indirect cost rate in the accompanying Schedule.
Title: COVID‑19 – Provider Relief Fund and American Rescue Plan (“ARP”) Rural Distribution Accounting Policies: The accompanying schedule of expenditures of federal awards (the “Schedule”) includes all federal grant activity of the Inova Health System (“IHS” or “System”) including federal awards passed through other agencies. The accompanying Schedule is presented using the accrual basis of accounting and 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 (Uniform Guidance). In accordance with applicable requirements, certain programs may be presented in a fiscal period based on program-specific guidance (see Note 3). Therefore, some amounts presented in the Schedule may differ from amounts presented in, or used in the preparation of, IHS’s consolidated financial statements. The preparation of the Schedule in conformity with accounting principles generally accepted in the United States of America requires management to make estimates and assumptions that affect the reported amounts in the Schedule during the reporting period. Actual results could differ from those estimates. De Minimis Rate Used: N Rate Explanation: 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 for Uniform Guidance awards. 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, IHS did not make this election and uses a negotiated indirect cost rate in the accompanying Schedule. In accordance with the U.S. Department of Health and Human Services’ requirements specific to Federal Assistance Listing Number 93.498, COVID‑19 – Provider Relief Fund and American Rescue Plan (“ARP”) Rural Distribution, the amount presented on the accompanying Schedule for the year ended December 31, 2022 for Federal Assistance Listing No. 93.498 relates to (i) Provider Relief Fund (“PRF”) payments received from January 1, 2021 through December 31, 2021 and (ii) used for PRF-eligible activity from the period January 1, 2020 through December 31, 2022. This payment receipt period and activity period and the resulting amount presented on the accompanying Schedule for the year ended December 31, 2022, reconciles to the PRF information reported to the Health Resources and Services Administration (“HRSA”) for PRF Reporting Periods 3 and 4 as follows: See the Notes to the SEFA for chart/table Health and Human Services (“HHS”) has indicated the PRF Funds should be reported according to reporting requirements of the HRSA PRF Reporting Portal (the “Portal”). Payments from HHS for PRF are assigned to ‘Payment Received Periods’ (each, a Period) based upon the date each payment from the PRF was received. Each Period has a specified Period of Availability and timing of reporting requirements. Entities report into the Portal after each Period’s deadline to use the funds (i.e., after the end of the Period of Availability). The Schedule includes $12,424,630 of PRF Funds received from HHS between January 1, 2021 through December 31, 2021. The PRF-eligible expenses attributable to Coronavirus Disease 2019 (“COVID 19”) and lost revenues incurred by IHS during the period of availability for PRF Reporting Period 3 (January 1, 2020 through June 30, 2022) and PRF Reporting Period 4 (January 1, 2020 through December 31, 2022) are in excess of the general and targeted distributions received from January 1, 2021 through December 31, 2021 and, therefore, the amounts presented in the table above and on the accompanying Schedule are limited to the amount of such distributions. IHS also received PRF payments subsequent to December 31, 2021, which are required to be reported in subsequent HRSA PRF Reporting Periods and, accordingly, pursuant to the requirements specific to Federal Assistance Listing Number 93.498, activity related to such payments is included in the accompanying Schedule.
Title: Noncash Federal Assistance Accounting Policies: The accompanying schedule of expenditures of federal awards (the “Schedule”) includes all federal grant activity of the Inova Health System (“IHS” or “System”) including federal awards passed through other agencies. The accompanying Schedule is presented using the accrual basis of accounting and 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 (Uniform Guidance). In accordance with applicable requirements, certain programs may be presented in a fiscal period based on program-specific guidance (see Note 3). Therefore, some amounts presented in the Schedule may differ from amounts presented in, or used in the preparation of, IHS’s consolidated financial statements. The preparation of the Schedule in conformity with accounting principles generally accepted in the United States of America requires management to make estimates and assumptions that affect the reported amounts in the Schedule during the reporting period. Actual results could differ from those estimates. De Minimis Rate Used: N Rate Explanation: 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 for Uniform Guidance awards. 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, IHS did not make this election and uses a negotiated indirect cost rate in the accompanying Schedule. IHS did not receive any noncash Federal assistance including donated personal protective equipment for the year ended December 31, 2022.
Title: Restatement Accounting Policies: The accompanying schedule of expenditures of federal awards (the “Schedule”) includes all federal grant activity of the Inova Health System (“IHS” or “System”) including federal awards passed through other agencies. The accompanying Schedule is presented using the accrual basis of accounting and 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 (Uniform Guidance). In accordance with applicable requirements, certain programs may be presented in a fiscal period based on program-specific guidance (see Note 3). Therefore, some amounts presented in the Schedule may differ from amounts presented in, or used in the preparation of, IHS’s consolidated financial statements. The preparation of the Schedule in conformity with accounting principles generally accepted in the United States of America requires management to make estimates and assumptions that affect the reported amounts in the Schedule during the reporting period. Actual results could differ from those estimates. De Minimis Rate Used: N Rate Explanation: 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 for Uniform Guidance awards. 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, IHS did not make this election and uses a negotiated indirect cost rate in the accompanying Schedule. The Schedule has been restated for the following: See the Notes to the SEFA for chart/table Expenditures for this federal program were previously omitted from the original Schedule for the fiscal year ended December 31, 2022. The original total federal expenditures reported on the Schedule were $23,754,501. The revised Schedule includes $55,385,921 of total federal expenditures.
Title: COVID-19 – Disaster Grants – Public Assistance (Presidentially Declared Disasters) (“FEMA”) Restatement Accounting Policies: The accompanying schedule of expenditures of federal awards (the “Schedule”) includes all federal grant activity of the Inova Health System (“IHS” or “System”) including federal awards passed through other agencies. The accompanying Schedule is presented using the accrual basis of accounting and 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 (Uniform Guidance). In accordance with applicable requirements, certain programs may be presented in a fiscal period based on program-specific guidance (see Note 3). Therefore, some amounts presented in the Schedule may differ from amounts presented in, or used in the preparation of, IHS’s consolidated financial statements. The preparation of the Schedule in conformity with accounting principles generally accepted in the United States of America requires management to make estimates and assumptions that affect the reported amounts in the Schedule during the reporting period. Actual results could differ from those estimates. De Minimis Rate Used: N Rate Explanation: 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 for Uniform Guidance awards. 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, IHS did not make this election and uses a negotiated indirect cost rate in the accompanying Schedule. Expenditures related to Assistance Listing Number 97.036, COVID-19 – Disaster Grants – Public Assistance (Presidentially Declared Disasters) (“FEMA”) of $31,631,420 were inappropriately omitted from the Schedule. The amount reported on the Schedule is the amount obligated in 2022. In response to the COVID-19 pandemic, the System purchased specialized medical equipment in order to treat COVID-19 patients and were claimed as reimbursement under the FEMA Public Assistance Grant Program. The COVID-19 Public Health Emergency officially ended May 11, 2023 in which, the System determined the fair market value of the purchased equipment and its residual value post the COVID-19 pandemic. As a result, the System determined a reduction of $1,278,456 to the amount obligated, which is reflected in the Schedule. There may be further adjustments to existing or future applications to account for other reductions as the Virginia Department of Emergency Management completes authorization and appropriately of the funds.

Finding Details

Federal Program Information Federal Agencies: Department of Health and Human Services (“HHS”) Awards: Assistance Listing Number 93.498 COVID 19 – Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Award Periods: Period 3 – January 1, 2021 to June 30, 2022 Period 4 – June 30, 2021 to December 31, 2022 Description: Review and Approval of the expenditures included in the HRSA portal submission Type of Finding: Significant Deficiency in Internal Control Over Compliance Criteria 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.” The terms and conditions of the award require the recipient to submit reports as the secretary of HHS determines are needed to ensure compliance with conditions that are imposed on the payment, and such reports shall be in such form, with such content, as specified by the secretary of HHS in future program instructions directed to all recipients. Condition The System did not have appropriately designed internal controls in place over the COVID 19 Provider Relief Fund (“PRF”) grant awards related to the review and approval of the expenditures included in the U.S. Health Resources and Services Administration (“HRSA”) portal submission. Cause Management did not design internal controls or retain evidence of review and approval of the allowability of expenditures submitted within the HRSA portal. Effect or potential effect The expenditures included in the HRSA portal submission could be inaccurate or information reported to HRSA portal may be incomplete or inaccurate. Questioned costs None. Identification of a repeat finding This is a repeat finding and relates to prior year finding 2021-002. Context The System submitted a total of 9 reports within the HRSA portal during Period 3 and Period 4. The total PRF payments received by the System was $12,424,630. We tested 5 HRSA portal submissions that had total payments from HRSA amount to $11,977,661. Management did not retain documentation to support review and approval of the allowability of the expenditures entered in the HRSA portal. Audit procedures identified no questioned costs as it related to expenditures included within the HRSA portal submission. Recommendation Management should design internal controls related to the review of the allowability of expenditures for the HRSA portal submission to ensure that the reported amounts are accurate and retain evidence of this review. View of responsible officials Management concurs with the finding and will implement procedures to ensure that HRSA reporting reports are prepared by individuals with HRSA reporting experience and reviewed by management prior to submission.
Federal Program Information Federal Agencies: Department of Health and Human Services Pass-Through Entity: Virginia Department of Health Pass-Through Entity Number: INORWB611-GY21; INORWB611-GY22; INORPS611-FY22; INORPS611-FY23 Awards: Assistance Listing Number 93.917 HIV Care Formula Grants (Part B) Award Periods: April 1, 2021 to March 31, 2022: April 1, 2022 to March 31, 2023; July 1, 2021 to June 30, 2022; July 1, 2022 to March 31, 2023 Description: Review and Retention of Eligibility Required Documentation Type of Finding: Material Weakness in Internal Control Over Compliance Criteria 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.” Per the terms and conditions of the pass-through entity agreement between the Virginia Department of Health (the Department) and the Inova Juniper Program (IJP), IJP “is required to collect the following documentation for client eligibility: (a) Legible documentation for proof of residency in Virginia, (b) Legible documents for proof of a medical diagnosis of a HIV disease (required only once for each client), (c) Legible documentation or proof of household income no greater than 500% of the Poverty Level Guidelines, and (d) Legible documentation for proof that the client does not have insurance (including Medicaid) or other program coverage for the services that the client is seeking from the RW Part B Program. Medicaid-enrolled clients who have access to HIV medications are not eligible for VA MAP services.” (INORWB611-GY22 – Client Eligibility Section E.1, INORPS611-FY23 Section A.1). IJP “will maintain an eligibility checklist and required eligibility documentation in one place in each client file” (INORWB611-GY22 – Client Eligibility Section E.3, INORPS611-FY23 Section A.2). Further, IJP “will verify client eligibility status prior to providing services, including HIV medication services” (INORWB611-GY22 – Client Eligibility Section E.4, INORPS611-FY23 Section A.3). IJP “will not receive reimbursement by the Department for any services provided to clients whose eligibility was not current at the time of service” (INORWB611-GY22 – Client Eligibility Section E.6, INORPS611-FY23 Section A.5). The requirements within the pass-through entity agreement with the Department are consistent with those required by the original Federal awarding agency, the Department of Health and Human Services (DHHS), U.S. Health Resources and Services Administration (HRSA). Per the National Monitoring Standards for Part B included on the official HRSA website, it is the provider/subgrantee’s responsibility to “maintain client records that contain documentation of the client’s eligibility determination, including the following: Initial Eligibility Determination and Recertification Documentation Requirements: (1) HIV diagnosis (2) Proof of residency (3) Low Income (4) Uninsured or underinsured status.” HRSA aligns with the Public Service Health Act Section 2616 – Provision of Treatment (b) (1-2) which states “to be eligible to receive assistance from a State under this section an individual shall (1) have a medical diagnosis of HIV/AIDS; and (2) be a low-income individual, as defined by the State.” Per the National Monitoring Standards for Part B included on the official HRSA website, “Income made from charges to RWHAP Part B clients or to insurance companies for services performed is considered program income.” Condition The System did not have appropriately designed internal controls in place to ensure that the documentation is obtained and reviewed to verify eligibility prior to providing services. Cause IJP has policies and procedures in place to obtain the eligibility documents from all clients and retain in their files. IJP’s policies and procedures specify that an eligibility worker will meet with each client for an initial screening to verify residency, income, insurance status, and HIV status. The eligibility worker is required to meet with the client to update the required eligibility screening and include the required documentation in the client file. Additionally, at each subsequent visit, the receptionist questions each client as to whether there have been any changes in their income or insurance status. If there are changes to the client’s eligibility status, another visit is scheduled with the eligibility worker. Management identified that these policies and procedures were not followed during the year due to lack of oversight and related under performance from various eligibility workers employed during the year.  Effect or potential effect Eligibility workers did not obtain and/or retain the required documentation related to the eligibility screening for certain clients. Services continued to be provided and related costs were reimbursed by DHHS. Based on the terms and conditions of the pass-through agreement with DHHS, the clients whose eligibility was not current at the time of service would not be considered eligible and any reimbursed cost would represent unallowable costs. Furthermore, program income represents income made from charges to RW Part B eligible clients or to insurance companies for services performed. Program income was recognized on services and charges for clients whose eligibility was not current at the time of service. For clients that received services in 2022, IJP recognized $332,344 of program income during the year. Questioned costs Indeterminable. Identification of a repeat finding This is not a repeat finding. Context During our audit, we selected a sample of 60 clients for testing and noted the following 3 exceptions: • There was no evidence of documentation obtained to prove that the client did not have insurance (including Medicaid) or other program coverage for the services provided for one client. • There was no evidence of documentation obtained to prove that the client did not have household income no greater than 500% of the Poverty Level Guidelines for one client. • The documentation for support proof that the client did not have household income no greater than 500% of the Poverty Level Guidelines was retained; however, for one client, the support indicated that they exceeded the Poverty Level Guidelines and services were provided. IJP has not completed a full review of all clients that could be impacted by the exceptions above. Further, IJP does not track reimbursed costs at the individual client level. As such, the costs associated with this finding are indeterminable. Recommendation IJP’s existing policies and procedures are in line with the requirements of the pass-through agreement with DHHS; however, IJP should continue to evaluate whether appropriate oversight is performed to ensure that these policies and procedures are being followed with regard to eligibility verification including maintaining the requirement documentation for all clients. View of responsible officials Management concurs with the finding and will implement procedures to ensure that the appropriate oversight is performed with regard to eligibility.
Federal Program Information Federal Agencies: Department of Health and Human Services Awards: Assistance Listing Number 93.498 COVID 19 – Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Award Periods: Period 3 – January 1, 2021 to June 30, 2022; Period 4 – June 30, 2021 to December 31, 2022 Description: Preparation of Schedule of Expenditures of Federal Awards Type of Finding: Significant Deficiency in Internal Control Over Compliance   Criteria 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 The System did not have appropriately designed internal controls in place to determine the correct amount of COVID 19 Provider Relief Fund (PRF) grant awards on the Schedule of Expenditures of Federal Awards (the Schedule) for the year ended December 31, 2022. Cause The Schedule for the year ended December 31, 2022 continued to include a number of COVID 19 programs. These programs did not follow the historical grant process and therefore, various individuals in the System were involved and responsible for monitoring the terms and conditions of the federal awards and reporting of the federal expenditures. Management did not design internal controls to accurately report expenditures within the Schedule. Effect or potential effect The reporting and verification of the completeness and accuracy of the expenditures included in the Schedule is not sufficient. Questioned costs None. Identification of a repeat finding This is a repeat finding and relates to prior year finding 2021-001.   Context We identified that the Schedule for the PRF grant awards did not include rural distributions of $1,483,532. Management reconciled the Schedule to the payments received as well as to the HHS Tracking Accountability in Government Grants System (TAGGS) database, which inappropriately excluded the rural distributions. Management subsequently corrected the amount and the federal expenditures reported on the Schedule include the rural distributions. Recommendation The System’s policy and procedures should be designed to ensure accurate reporting as required by the Uniform Guidance. View of responsible officials There is no disagreement with the audit finding.
Federal Program Information Federal Agencies: United States Department of Homeland Security Awards: Assistance Listing Number 97.036 – COVID-19 – Disaster Grants - Public Assistance (Presidentially Declared Disasters) Award Periods: January 20, 2020 – May 11, 2023 Description: Preparation of Schedule of Expenditures of Federal Awards Type of Finding: Material Weakness in Internal Control Over Compliance Criteria The Uniform Guidance 2 CFR section 200.303 states, “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 Uniform Guidance 2 CFR section 200.510 states, “(b) Schedule of expenditures of Federal awards. The auditee must also prepare the Schedule 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 Basis for determining Federal awards expended.” Condition The System omitted the obligated expenditures related to the Assistance Listing Number 97.036 – COVID-19 – Disaster Grants - Public Assistance (Presidentially Declared Disasters) (“FEMA”) in the Schedule. Cause The System misinterpreted the FEMA Public Assistance Grant Program guidance for reporting Assistance Listing 97.036 expenditures in the Schedule, which is based on when (1) FEMA has approved (i.e., obligated) the non-federal entity’s project worksheet (PW), and (2) the non-federal entity has incurred the eligible expenditures. The System interpreted the date the PW is approved (i.e., obligated) as the date the Virginia Department of Emergency Management will authorize disbursement and appropriate of the funds from the Department of Planning and Budget rather than the date FEMA obligated the PW. Effect or potential effect The Schedule prepared by the System was misstated but was subsequently corrected. A misstated Schedule could result in the improper selection of federal award major programs or an incorrect percentage of coverage being calculated resulting in a restatement of a previously issued Uniform Guidance report. Questioned costs None. Identification of a repeat finding This is not a repeat finding. Context Expenditures for Assistance Listing 97.036 of $31,631,420 were excluded from the Schedule. These expenditures related to PWs obligated in 2022 and expenditures incurred in previous fiscal years and consequently should have been recorded in the 2022 Schedule. Recommendation The System should update its policies and procedures and internal controls, specifically the process to accumulate and report FEMA expenditures of federal awards to be in accordance with the FEMA Schedule requirements outlined above. View of responsible officials The System agrees with the comment and has developed a plan to correct the finding.
Federal Program Information Federal Agencies: Department of Health and Human Services (“HHS”) Awards: Assistance Listing Number 93.498 COVID 19 – Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Award Periods: Period 3 – January 1, 2021 to June 30, 2022 Period 4 – June 30, 2021 to December 31, 2022 Description: Review and Approval of the expenditures included in the HRSA portal submission Type of Finding: Significant Deficiency in Internal Control Over Compliance Criteria 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.” The terms and conditions of the award require the recipient to submit reports as the secretary of HHS determines are needed to ensure compliance with conditions that are imposed on the payment, and such reports shall be in such form, with such content, as specified by the secretary of HHS in future program instructions directed to all recipients. Condition The System did not have appropriately designed internal controls in place over the COVID 19 Provider Relief Fund (“PRF”) grant awards related to the review and approval of the expenditures included in the U.S. Health Resources and Services Administration (“HRSA”) portal submission. Cause Management did not design internal controls or retain evidence of review and approval of the allowability of expenditures submitted within the HRSA portal. Effect or potential effect The expenditures included in the HRSA portal submission could be inaccurate or information reported to HRSA portal may be incomplete or inaccurate. Questioned costs None. Identification of a repeat finding This is a repeat finding and relates to prior year finding 2021-002. Context The System submitted a total of 9 reports within the HRSA portal during Period 3 and Period 4. The total PRF payments received by the System was $12,424,630. We tested 5 HRSA portal submissions that had total payments from HRSA amount to $11,977,661. Management did not retain documentation to support review and approval of the allowability of the expenditures entered in the HRSA portal. Audit procedures identified no questioned costs as it related to expenditures included within the HRSA portal submission. Recommendation Management should design internal controls related to the review of the allowability of expenditures for the HRSA portal submission to ensure that the reported amounts are accurate and retain evidence of this review. View of responsible officials Management concurs with the finding and will implement procedures to ensure that HRSA reporting reports are prepared by individuals with HRSA reporting experience and reviewed by management prior to submission.
Federal Program Information Federal Agencies: Department of Health and Human Services Pass-Through Entity: Virginia Department of Health Pass-Through Entity Number: INORWB611-GY21; INORWB611-GY22; INORPS611-FY22; INORPS611-FY23 Awards: Assistance Listing Number 93.917 HIV Care Formula Grants (Part B) Award Periods: April 1, 2021 to March 31, 2022: April 1, 2022 to March 31, 2023; July 1, 2021 to June 30, 2022; July 1, 2022 to March 31, 2023 Description: Review and Retention of Eligibility Required Documentation Type of Finding: Material Weakness in Internal Control Over Compliance Criteria 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.” Per the terms and conditions of the pass-through entity agreement between the Virginia Department of Health (the Department) and the Inova Juniper Program (IJP), IJP “is required to collect the following documentation for client eligibility: (a) Legible documentation for proof of residency in Virginia, (b) Legible documents for proof of a medical diagnosis of a HIV disease (required only once for each client), (c) Legible documentation or proof of household income no greater than 500% of the Poverty Level Guidelines, and (d) Legible documentation for proof that the client does not have insurance (including Medicaid) or other program coverage for the services that the client is seeking from the RW Part B Program. Medicaid-enrolled clients who have access to HIV medications are not eligible for VA MAP services.” (INORWB611-GY22 – Client Eligibility Section E.1, INORPS611-FY23 Section A.1). IJP “will maintain an eligibility checklist and required eligibility documentation in one place in each client file” (INORWB611-GY22 – Client Eligibility Section E.3, INORPS611-FY23 Section A.2). Further, IJP “will verify client eligibility status prior to providing services, including HIV medication services” (INORWB611-GY22 – Client Eligibility Section E.4, INORPS611-FY23 Section A.3). IJP “will not receive reimbursement by the Department for any services provided to clients whose eligibility was not current at the time of service” (INORWB611-GY22 – Client Eligibility Section E.6, INORPS611-FY23 Section A.5). The requirements within the pass-through entity agreement with the Department are consistent with those required by the original Federal awarding agency, the Department of Health and Human Services (DHHS), U.S. Health Resources and Services Administration (HRSA). Per the National Monitoring Standards for Part B included on the official HRSA website, it is the provider/subgrantee’s responsibility to “maintain client records that contain documentation of the client’s eligibility determination, including the following: Initial Eligibility Determination and Recertification Documentation Requirements: (1) HIV diagnosis (2) Proof of residency (3) Low Income (4) Uninsured or underinsured status.” HRSA aligns with the Public Service Health Act Section 2616 – Provision of Treatment (b) (1-2) which states “to be eligible to receive assistance from a State under this section an individual shall (1) have a medical diagnosis of HIV/AIDS; and (2) be a low-income individual, as defined by the State.” Per the National Monitoring Standards for Part B included on the official HRSA website, “Income made from charges to RWHAP Part B clients or to insurance companies for services performed is considered program income.” Condition The System did not have appropriately designed internal controls in place to ensure that the documentation is obtained and reviewed to verify eligibility prior to providing services. Cause IJP has policies and procedures in place to obtain the eligibility documents from all clients and retain in their files. IJP’s policies and procedures specify that an eligibility worker will meet with each client for an initial screening to verify residency, income, insurance status, and HIV status. The eligibility worker is required to meet with the client to update the required eligibility screening and include the required documentation in the client file. Additionally, at each subsequent visit, the receptionist questions each client as to whether there have been any changes in their income or insurance status. If there are changes to the client’s eligibility status, another visit is scheduled with the eligibility worker. Management identified that these policies and procedures were not followed during the year due to lack of oversight and related under performance from various eligibility workers employed during the year.  Effect or potential effect Eligibility workers did not obtain and/or retain the required documentation related to the eligibility screening for certain clients. Services continued to be provided and related costs were reimbursed by DHHS. Based on the terms and conditions of the pass-through agreement with DHHS, the clients whose eligibility was not current at the time of service would not be considered eligible and any reimbursed cost would represent unallowable costs. Furthermore, program income represents income made from charges to RW Part B eligible clients or to insurance companies for services performed. Program income was recognized on services and charges for clients whose eligibility was not current at the time of service. For clients that received services in 2022, IJP recognized $332,344 of program income during the year. Questioned costs Indeterminable. Identification of a repeat finding This is not a repeat finding. Context During our audit, we selected a sample of 60 clients for testing and noted the following 3 exceptions: • There was no evidence of documentation obtained to prove that the client did not have insurance (including Medicaid) or other program coverage for the services provided for one client. • There was no evidence of documentation obtained to prove that the client did not have household income no greater than 500% of the Poverty Level Guidelines for one client. • The documentation for support proof that the client did not have household income no greater than 500% of the Poverty Level Guidelines was retained; however, for one client, the support indicated that they exceeded the Poverty Level Guidelines and services were provided. IJP has not completed a full review of all clients that could be impacted by the exceptions above. Further, IJP does not track reimbursed costs at the individual client level. As such, the costs associated with this finding are indeterminable. Recommendation IJP’s existing policies and procedures are in line with the requirements of the pass-through agreement with DHHS; however, IJP should continue to evaluate whether appropriate oversight is performed to ensure that these policies and procedures are being followed with regard to eligibility verification including maintaining the requirement documentation for all clients. View of responsible officials Management concurs with the finding and will implement procedures to ensure that the appropriate oversight is performed with regard to eligibility.
Federal Program Information Federal Agencies: Department of Health and Human Services Awards: Assistance Listing Number 93.498 COVID 19 – Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Award Periods: Period 3 – January 1, 2021 to June 30, 2022; Period 4 – June 30, 2021 to December 31, 2022 Description: Preparation of Schedule of Expenditures of Federal Awards Type of Finding: Significant Deficiency in Internal Control Over Compliance   Criteria 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 The System did not have appropriately designed internal controls in place to determine the correct amount of COVID 19 Provider Relief Fund (PRF) grant awards on the Schedule of Expenditures of Federal Awards (the Schedule) for the year ended December 31, 2022. Cause The Schedule for the year ended December 31, 2022 continued to include a number of COVID 19 programs. These programs did not follow the historical grant process and therefore, various individuals in the System were involved and responsible for monitoring the terms and conditions of the federal awards and reporting of the federal expenditures. Management did not design internal controls to accurately report expenditures within the Schedule. Effect or potential effect The reporting and verification of the completeness and accuracy of the expenditures included in the Schedule is not sufficient. Questioned costs None. Identification of a repeat finding This is a repeat finding and relates to prior year finding 2021-001.   Context We identified that the Schedule for the PRF grant awards did not include rural distributions of $1,483,532. Management reconciled the Schedule to the payments received as well as to the HHS Tracking Accountability in Government Grants System (TAGGS) database, which inappropriately excluded the rural distributions. Management subsequently corrected the amount and the federal expenditures reported on the Schedule include the rural distributions. Recommendation The System’s policy and procedures should be designed to ensure accurate reporting as required by the Uniform Guidance. View of responsible officials There is no disagreement with the audit finding.
Federal Program Information Federal Agencies: United States Department of Homeland Security Awards: Assistance Listing Number 97.036 – COVID-19 – Disaster Grants - Public Assistance (Presidentially Declared Disasters) Award Periods: January 20, 2020 – May 11, 2023 Description: Preparation of Schedule of Expenditures of Federal Awards Type of Finding: Material Weakness in Internal Control Over Compliance Criteria The Uniform Guidance 2 CFR section 200.303 states, “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 Uniform Guidance 2 CFR section 200.510 states, “(b) Schedule of expenditures of Federal awards. The auditee must also prepare the Schedule 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 Basis for determining Federal awards expended.” Condition The System omitted the obligated expenditures related to the Assistance Listing Number 97.036 – COVID-19 – Disaster Grants - Public Assistance (Presidentially Declared Disasters) (“FEMA”) in the Schedule. Cause The System misinterpreted the FEMA Public Assistance Grant Program guidance for reporting Assistance Listing 97.036 expenditures in the Schedule, which is based on when (1) FEMA has approved (i.e., obligated) the non-federal entity’s project worksheet (PW), and (2) the non-federal entity has incurred the eligible expenditures. The System interpreted the date the PW is approved (i.e., obligated) as the date the Virginia Department of Emergency Management will authorize disbursement and appropriate of the funds from the Department of Planning and Budget rather than the date FEMA obligated the PW. Effect or potential effect The Schedule prepared by the System was misstated but was subsequently corrected. A misstated Schedule could result in the improper selection of federal award major programs or an incorrect percentage of coverage being calculated resulting in a restatement of a previously issued Uniform Guidance report. Questioned costs None. Identification of a repeat finding This is not a repeat finding. Context Expenditures for Assistance Listing 97.036 of $31,631,420 were excluded from the Schedule. These expenditures related to PWs obligated in 2022 and expenditures incurred in previous fiscal years and consequently should have been recorded in the 2022 Schedule. Recommendation The System should update its policies and procedures and internal controls, specifically the process to accumulate and report FEMA expenditures of federal awards to be in accordance with the FEMA Schedule requirements outlined above. View of responsible officials The System agrees with the comment and has developed a plan to correct the finding.