FAC Explorer

Audit 351637

FY End
2024-06-30
Total Expended
$60.45M
Findings
12
Programs
72
Organization: Trinity Health (MI)
Year: 2024 Accepted: 2025-03-31
Auditor: Deloitte & Touche LLP

Organization Exclusion Status:

Findings

ID Ref Severity Repeat Requirement
547400 2024-001 Significant Deficiency - N
547401 2024-002 Significant Deficiency - G
547402 2024-002 Significant Deficiency - G
547403 2024-002 Significant Deficiency - G
547404 2024-002 Significant Deficiency - G
547405 2024-002 Significant Deficiency - G
1123842 2024-001 Significant Deficiency - N
1123843 2024-002 Significant Deficiency - G
1123844 2024-002 Significant Deficiency - G
1123845 2024-002 Significant Deficiency - G
1123846 2024-002 Significant Deficiency - G
1123847 2024-002 Significant Deficiency - G

Programs

ALN Program Spent Major Findings
93.399 Cancer Control $3.10M - 0
84.268 Federal Direct Student Loans $1.75M - 0
93.988 Cooperative Agreements for Diabetes Control Programs $1.57M - 0
93.696 Certified Community Behavioral Health Clinic Expansion Grants $1.32M - 0
21.027 Coronavirus State and Local Fiscal Recovery Funds $786,031 Yes 0
93.074 Hospital Preparedness Program (hpp) and Public Health Emergency Preparedness (phep) Aligned Cooperative Agreements $501,297 - 0
93.917 Hiv Care Formula Grants $474,311 - 0
84.063 Federal Pell Grant Program $470,293 - 0
93.918 Grants to Provide Outpatient Early Intervention Services with Respect to Hiv Disease $465,179 - 0
93.150 Projects for Assistance in Transition From Homelessness (path) $391,256 - 0
97.036 Disaster Grants - Public Assistance (presidentially Declared Disasters) $346,044 - 0
93.969 Pphf Geriatric Education Centers $319,685 - 0
93.261 Scaling the National Diabetes Prevention Program to Priority Populations $291,421 - 0
93.884 Primary Care Training and Enhancement $283,356 - 0
14.267 Continuum of Care Program $274,160 Yes 1
93.604 Assistance for Torture Victims $271,742 - 0
14.241 Housing Opportunities for Persons with Aids $260,876 - 0
93.898 Cancer Prevention and Control Programs for State, Territorial and Tribal Organizations $220,114 - 0
93.788 Opioid Str $199,564 - 0
14.231 Emergency Solutions Grant Program $197,365 - 0
93.914 Hiv Emergency Relief Project Grants $192,205 - 0
16.575 Crime Victim Assistance $189,908 Yes 0
93.912 Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement $188,428 - 0
93.994 Maternal and Child Health Services Block Grant to the States $181,360 - 0
93.426 The National Cardiovascular Health Program $175,000 - 0
97.008 Non-Profit Security Program $144,560 - 0
93.276 Drug-Free Communities Support Program Grants $144,081 - 0
93.575 Child Care and Development Block Grant $133,332 - 0
93.243 Substance Abuse and Mental Health Services Projects of Regional and National Significance $124,172 - 0
10.561 State Administrative Matching Grants for the Supplemental Nutrition Assistance Program $118,725 - 0
93.566 Refugee and Entrant Assistance State/replacement Designee Administered Programs $101,268 - 0
84.007 Federal Supplemental Educational Opportunity Grants $92,938 - 0
10.557 Wic Special Supplemental Nutrition Program for Women, Infants, and Children $86,152 - 0
93.391 Activities to Support State, Tribal, Local and Territorial (stlt) Health Department Response to Public Health Or Healthcare Crises $67,029 - 0
93.940 Hiv Prevention Activities Health Department Based $61,271 - 0
84.425 Education Stabilization Fund $58,439 - 0
93.497 Family Violence Prevention and Services/ Sexual Assault/rape Crisis Services and Supports $50,250 - 0
93.011 National Organizations for State and Local Officials $49,303 - 0
93.958 Block Grants for Community Mental Health Services $48,365 - 0
14.218 Community Development Block Grants/entitlement Grants $46,328 - 0
93.889 National Bioterrorism Hospital Preparedness Program $43,000 - 0
93.959 Block Grants for Prevention and Treatment of Substance Abuse $41,427 Yes 0
84.126 Rehabilitation Services Vocational Rehabilitation Grants to States $35,855 - 0
16.838 Comprehensive Opioid, Stimulant, and Other Substances Use Program $33,866 - 0
16.588 Violence Against Women Formula Grants $30,856 - 0
93.310 Trans-Nih Research Support $29,499 - 0
93.747 Elder Abuse Prevention Interventions Program $27,403 - 0
93.778 Medical Assistance Program $26,242 - 0
93.866 Aging Research $24,901 - 0
10.558 Child and Adult Care Food Program $21,715 - 0
93.268 Immunization Cooperative Agreements $21,500 - 0
93.839 Blood Diseases and Resources Research $17,430 - 0
93.241 State Rural Hospital Flexibility Program $15,750 - 0
93.301 Small Rural Hospital Improvement Grant Program $10,800 - 0
16.529 Education, Training, and Enhanced Services to End Violence Against and Abuse of Women with Disabilities $8,404 - 0
20.600 State and Community Highway Safety $8,015 - 0
16.017 Sexual Assault Services Formula Program $7,938 - 0
84.033 Federal Work-Study Program $6,658 - 0
10.551 Supplemental Nutrition Assistance Program $6,059 - 0
93.323 Epidemiology and Laboratory Capacity for Infectious Diseases (elc) $5,662 - 0
93.247 Advanced Nursing Education Workforce Grant Program $5,107 - 0
93.436 Well-Integrated Screening and Evaluation for Women Across the Nation (wisewoman) $4,986 - 0
93.226 Research on Healthcare Costs, Quality and Outcomes $3,500 - 0
20.616 National Priority Safety Programs $3,457 - 0
97.067 Homeland Security Grant Program $2,906 - 0
93.283 Centers for Disease Control and Prevention Investigations and Technical Assistance $2,250 - 0
93.395 Cancer Treatment Research $2,229 - 0
93.837 Cardiovascular Diseases Research $1,500 - 0
93.853 Extramural Research Programs in the Neurosciences and Neurological Disorders $1,438 - 0
93.879 Medical Library Assistance $1,200 - 0
45.025 Promotion of the Arts Partnership Agreements $1,100 - 0
93.847 Diabetes, Digestive, and Kidney Diseases Extramural Research $157 - 0

Contacts

Name Title Type
KCBGNFJGK478 Laura Barron Auditee
2482456287 Melissa Jagst Auditor
No contacts on file

Notes to SEFA

Title: BASIS OF ACCOUNTING Accounting Policies: The accompanying Consolidated Supplemental Schedule of Expenditures of Federal Awards (the “Schedule” or “SEFA”) includes the federal grant activity of Trinity Health under programs of the federal government for the year ended June 30, 2024. The information in the Schedule is presented in accordance with the Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (“Uniform Guidance”). The Schedule is presented using the accrual basis of accounting. Under this method, certain revenues are recognized when earned rather than when received and certain obligations are recognized when incurred rather than when they are paid. The accompanying SEFA includes the transactions of all federal awards of Trinity Health, except as described in Note 2. Federal awards received directly from federal agencies, as well as federal awards passed through other agencies, are included in the Schedule. Indirect Costs – The Corporation does not elect to use the de minimis indirect cost rate allowed under the Uniform Guidance. All rates used by the Corporation were approved by the awarding grant agencies. De Minimis Rate Used: N Rate Explanation: The auditee did not use the de minimis cost rate. The accompanying Consolidated Supplemental Schedule of Expenditures of Federal Awards (the “Schedule” or “SEFA”) includes the federal grant activity of Trinity Health under programs of the federal government for the year ended June 30, 2024. The information in the Schedule is presented in accordance with the Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (“Uniform Guidance”). The Schedule is presented using the accrual basis of accounting. Under this method, certain revenues are recognized when earned rather than when received and certain obligations are recognized when incurred rather than when they are paid. The accompanying SEFA includes the transactions of all federal awards of Trinity Health, except as described in Note 2. Federal awards received directly from federal agencies, as well as federal awards passed through other agencies, are included in the Schedule. Indirect Costs – The Corporation does not elect to use the de minimis indirect cost rate allowed under the Uniform Guidance. All rates used by the Corporation were approved by the awarding grant agencies.
Title: EXPENDITURES AND OTHER REPORTING Accounting Policies: The accompanying Consolidated Supplemental Schedule of Expenditures of Federal Awards (the “Schedule” or “SEFA”) includes the federal grant activity of Trinity Health under programs of the federal government for the year ended June 30, 2024. The information in the Schedule is presented in accordance with the Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (“Uniform Guidance”). The Schedule is presented using the accrual basis of accounting. Under this method, certain revenues are recognized when earned rather than when received and certain obligations are recognized when incurred rather than when they are paid. The accompanying SEFA includes the transactions of all federal awards of Trinity Health, except as described in Note 2. Federal awards received directly from federal agencies, as well as federal awards passed through other agencies, are included in the Schedule. Indirect Costs – The Corporation does not elect to use the de minimis indirect cost rate allowed under the Uniform Guidance. All rates used by the Corporation were approved by the awarding grant agencies. De Minimis Rate Used: N Rate Explanation: The auditee did not use the de minimis cost rate. The Corporation’s consolidated financial statements include, for the year ended June 30, 2024, the operations of Saint Joseph’s Tower, Inc. (“Tower”), a subsidiary of Trinity Continuing Care Services. Tower reported total expenditures of federal awards of $3,347,587 for the year ended June 30, 2024. Included in these total expenditures is $2,680,737, which represents the outstanding mortgage balances insured under the Federal Housing Administration’s (“FHA”) Section 202 Supportive Housing for the Elderly. In addition, Tower earned $666,850 of its revenue in the year ended June 30, 2024, from the U.S. Department of Housing and Urban Development under the terms of the Housing Assistance Payment contracts. The accompanying consolidated SEFA does not include the federal awards activity of Tower because the federal expenditures were included in a separate audit report in accordance with the Uniform Guidance. The Corporation’s consolidated financial statements include the operations of Saint Joseph’s Mercy Care Services, Inc. (“SJMCS”) for the year ended June 30, 2024. SJMCS reported total expenditures of federal awards of $9,744,349 for the year ended June 30, 2024. The accompanying SEFA does not include the federal award activity of SJMCS because the federal expenditures were included in a separate audit report in accordance with the Uniform Guidance. The Corporation’s consolidated financial statements include the operations of Trinity Health Of New England, Inc. (“THOfNE”) for the year ended June 30, 2024. THOfNE recorded total expenditures of federal awards of $2,762,359 for the year ended June 30, 2024. Included in these total expenditures is $768,435, which represents expenditures of Mercy Hospital, Inc. & Subsidiaries. THOfNE’s fiscal year end is September 30 and THOfNE’s consolidated financial statements and schedule of Federal Expenditures will be audited separately for the year ended September 30, 2024. Accordingly, the federal expenditures will be included in a separate audit report in accordance with the Uniform Guidance.
Title: LOAN PROGRAMS Accounting Policies: The accompanying Consolidated Supplemental Schedule of Expenditures of Federal Awards (the “Schedule” or “SEFA”) includes the federal grant activity of Trinity Health under programs of the federal government for the year ended June 30, 2024. The information in the Schedule is presented in accordance with the Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (“Uniform Guidance”). The Schedule is presented using the accrual basis of accounting. Under this method, certain revenues are recognized when earned rather than when received and certain obligations are recognized when incurred rather than when they are paid. The accompanying SEFA includes the transactions of all federal awards of Trinity Health, except as described in Note 2. Federal awards received directly from federal agencies, as well as federal awards passed through other agencies, are included in the Schedule. Indirect Costs – The Corporation does not elect to use the de minimis indirect cost rate allowed under the Uniform Guidance. All rates used by the Corporation were approved by the awarding grant agencies. De Minimis Rate Used: N Rate Explanation: The auditee did not use the de minimis cost rate. The loan program listed below is administered directly by the Corporation. The balance relating to this program is included in the Corporation’s consolidated financial statements.
Title: COMMITMENTS AND CONTINGENCIES Accounting Policies: The accompanying Consolidated Supplemental Schedule of Expenditures of Federal Awards (the “Schedule” or “SEFA”) includes the federal grant activity of Trinity Health under programs of the federal government for the year ended June 30, 2024. The information in the Schedule is presented in accordance with the Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (“Uniform Guidance”). The Schedule is presented using the accrual basis of accounting. Under this method, certain revenues are recognized when earned rather than when received and certain obligations are recognized when incurred rather than when they are paid. The accompanying SEFA includes the transactions of all federal awards of Trinity Health, except as described in Note 2. Federal awards received directly from federal agencies, as well as federal awards passed through other agencies, are included in the Schedule. Indirect Costs – The Corporation does not elect to use the de minimis indirect cost rate allowed under the Uniform Guidance. All rates used by the Corporation were approved by the awarding grant agencies. De Minimis Rate Used: N Rate Explanation: The auditee did not use the de minimis cost rate. The Corporation participates in numerous state and federal grant programs, which are governed by various rules and regulations of the grantor agencies. Costs charged to the respective grant programs are subject to audit and adjustments by the grantor agencies. While the Corporation believes it has complied with all of the rules and regulations, to the extent that the Corporation has not complied with rules and regulations governing the grants, refund of any money received may be required and the collectability of any related receivable at June 30, 2024, may be impaired.

Finding Details

Finding 2024-001
Condition – St. Peter's Health Partners ("SPHP") was unable to provide supporting documentation to evidence the occurrence of the rent reasonableness review was completed for three rental charges. SPHP received reimbursement for two damage payments that exceed the related tenants' one month's rent. Further, SPHP was reimbursed for three invoices related to repairs that were made during the normal course of the rental versus being identified during the exit process. Cause – SPHP does not have appropriate procedures in place to ensure sufficient documentation is retained. Additionally, SPHP did not design and implement controls to ensure damage payments made were in compliance with federal regulations. Effect – With the absence of underlying records, we were unable to verify compliance with the special test requirements for the three rent charges in pursuant to 24 CFR 578.51(g). Failure to establish effective internal controls (including review of documentation) over damage payments could potentially result in undetected noncompliance, exposing SPHP to consequences from regulatory agencies. Questioned Costs - $7,635 Context - Although there was no material noncompliance identified, 4 out of 5 damage payments (total population) were not in compliance as an adequate review was not performed. Repeat Finding – No. Recommendation – We recommend SPHP implement procedures to ensure documentation is appropriately maintained and available. We also recommend SPHP design and implement controls to ensure invoices related to damages that are submitted for reimbursement relate only to damages identified during the participant’s exit of the housing unit and do not exceed one month’s rent.
Finding 2024-002
Condition – Pittsburgh Mercy Health System did not track or review individual matching expenditures to ensure that the sources were allowable. Additionally, there was a lack of documentation and a review of such documentation substantiating that the total dollar threshold for matching was satisfied. However, total matching expenditures for the program were subsequently analyzed and Pittsburgh Mercy Health System did expend sufficient allowable expenditures ($481,325) to fulfill the matching requirement. Cause – Pittsburgh Mercy Health System did not design and implement controls to ensure that there were sufficient expenditures to meet the matching requirement, and that such expenditures were allowable under the Continuum of Care Program. Effect –The lack of review and documentation of matching expenditures could have resulted in a breach of contractual obligations for the matching requirement. Questioned Costs – None. Context - Pittsburgh Mercy Health System failed to establish a system to regularly monitor matching activities and review the status of federal matching to ensure compliance. Lack of tracking and reviewing of matching requirements would potentially result in insufficient and inadequate match, and repayment of funds. Repeat Finding – No. Recommendation – We recommend Pittsburgh Mercy Health System establish internal control policies and procedures to ensure reviews are performed and documented for all expenditures related to the matching requirement.
Finding 2024-002
Condition – Pittsburgh Mercy Health System did not track or review individual matching expenditures to ensure that the sources were allowable. Additionally, there was a lack of documentation and a review of such documentation substantiating that the total dollar threshold for matching was satisfied. However, total matching expenditures for the program were subsequently analyzed and Pittsburgh Mercy Health System did expend sufficient allowable expenditures ($481,325) to fulfill the matching requirement. Cause – Pittsburgh Mercy Health System did not design and implement controls to ensure that there were sufficient expenditures to meet the matching requirement, and that such expenditures were allowable under the Continuum of Care Program. Effect –The lack of review and documentation of matching expenditures could have resulted in a breach of contractual obligations for the matching requirement. Questioned Costs – None. Context - Pittsburgh Mercy Health System failed to establish a system to regularly monitor matching activities and review the status of federal matching to ensure compliance. Lack of tracking and reviewing of matching requirements would potentially result in insufficient and inadequate match, and repayment of funds. Repeat Finding – No. Recommendation – We recommend Pittsburgh Mercy Health System establish internal control policies and procedures to ensure reviews are performed and documented for all expenditures related to the matching requirement.
Finding 2024-002
Condition – Pittsburgh Mercy Health System did not track or review individual matching expenditures to ensure that the sources were allowable. Additionally, there was a lack of documentation and a review of such documentation substantiating that the total dollar threshold for matching was satisfied. However, total matching expenditures for the program were subsequently analyzed and Pittsburgh Mercy Health System did expend sufficient allowable expenditures ($481,325) to fulfill the matching requirement. Cause – Pittsburgh Mercy Health System did not design and implement controls to ensure that there were sufficient expenditures to meet the matching requirement, and that such expenditures were allowable under the Continuum of Care Program. Effect –The lack of review and documentation of matching expenditures could have resulted in a breach of contractual obligations for the matching requirement. Questioned Costs – None. Context - Pittsburgh Mercy Health System failed to establish a system to regularly monitor matching activities and review the status of federal matching to ensure compliance. Lack of tracking and reviewing of matching requirements would potentially result in insufficient and inadequate match, and repayment of funds. Repeat Finding – No. Recommendation – We recommend Pittsburgh Mercy Health System establish internal control policies and procedures to ensure reviews are performed and documented for all expenditures related to the matching requirement.
Finding 2024-002
Condition – Pittsburgh Mercy Health System did not track or review individual matching expenditures to ensure that the sources were allowable. Additionally, there was a lack of documentation and a review of such documentation substantiating that the total dollar threshold for matching was satisfied. However, total matching expenditures for the program were subsequently analyzed and Pittsburgh Mercy Health System did expend sufficient allowable expenditures ($481,325) to fulfill the matching requirement. Cause – Pittsburgh Mercy Health System did not design and implement controls to ensure that there were sufficient expenditures to meet the matching requirement, and that such expenditures were allowable under the Continuum of Care Program. Effect –The lack of review and documentation of matching expenditures could have resulted in a breach of contractual obligations for the matching requirement. Questioned Costs – None. Context - Pittsburgh Mercy Health System failed to establish a system to regularly monitor matching activities and review the status of federal matching to ensure compliance. Lack of tracking and reviewing of matching requirements would potentially result in insufficient and inadequate match, and repayment of funds. Repeat Finding – No. Recommendation – We recommend Pittsburgh Mercy Health System establish internal control policies and procedures to ensure reviews are performed and documented for all expenditures related to the matching requirement.
Finding 2024-002
Condition – Pittsburgh Mercy Health System did not track or review individual matching expenditures to ensure that the sources were allowable. Additionally, there was a lack of documentation and a review of such documentation substantiating that the total dollar threshold for matching was satisfied. However, total matching expenditures for the program were subsequently analyzed and Pittsburgh Mercy Health System did expend sufficient allowable expenditures ($481,325) to fulfill the matching requirement. Cause – Pittsburgh Mercy Health System did not design and implement controls to ensure that there were sufficient expenditures to meet the matching requirement, and that such expenditures were allowable under the Continuum of Care Program. Effect –The lack of review and documentation of matching expenditures could have resulted in a breach of contractual obligations for the matching requirement. Questioned Costs – None. Context - Pittsburgh Mercy Health System failed to establish a system to regularly monitor matching activities and review the status of federal matching to ensure compliance. Lack of tracking and reviewing of matching requirements would potentially result in insufficient and inadequate match, and repayment of funds. Repeat Finding – No. Recommendation – We recommend Pittsburgh Mercy Health System establish internal control policies and procedures to ensure reviews are performed and documented for all expenditures related to the matching requirement.
Finding 2024-001
Condition – St. Peter's Health Partners ("SPHP") was unable to provide supporting documentation to evidence the occurrence of the rent reasonableness review was completed for three rental charges. SPHP received reimbursement for two damage payments that exceed the related tenants' one month's rent. Further, SPHP was reimbursed for three invoices related to repairs that were made during the normal course of the rental versus being identified during the exit process. Cause – SPHP does not have appropriate procedures in place to ensure sufficient documentation is retained. Additionally, SPHP did not design and implement controls to ensure damage payments made were in compliance with federal regulations. Effect – With the absence of underlying records, we were unable to verify compliance with the special test requirements for the three rent charges in pursuant to 24 CFR 578.51(g). Failure to establish effective internal controls (including review of documentation) over damage payments could potentially result in undetected noncompliance, exposing SPHP to consequences from regulatory agencies. Questioned Costs - $7,635 Context - Although there was no material noncompliance identified, 4 out of 5 damage payments (total population) were not in compliance as an adequate review was not performed. Repeat Finding – No. Recommendation – We recommend SPHP implement procedures to ensure documentation is appropriately maintained and available. We also recommend SPHP design and implement controls to ensure invoices related to damages that are submitted for reimbursement relate only to damages identified during the participant’s exit of the housing unit and do not exceed one month’s rent.
Finding 2024-002
Condition – Pittsburgh Mercy Health System did not track or review individual matching expenditures to ensure that the sources were allowable. Additionally, there was a lack of documentation and a review of such documentation substantiating that the total dollar threshold for matching was satisfied. However, total matching expenditures for the program were subsequently analyzed and Pittsburgh Mercy Health System did expend sufficient allowable expenditures ($481,325) to fulfill the matching requirement. Cause – Pittsburgh Mercy Health System did not design and implement controls to ensure that there were sufficient expenditures to meet the matching requirement, and that such expenditures were allowable under the Continuum of Care Program. Effect –The lack of review and documentation of matching expenditures could have resulted in a breach of contractual obligations for the matching requirement. Questioned Costs – None. Context - Pittsburgh Mercy Health System failed to establish a system to regularly monitor matching activities and review the status of federal matching to ensure compliance. Lack of tracking and reviewing of matching requirements would potentially result in insufficient and inadequate match, and repayment of funds. Repeat Finding – No. Recommendation – We recommend Pittsburgh Mercy Health System establish internal control policies and procedures to ensure reviews are performed and documented for all expenditures related to the matching requirement.
Finding 2024-002
Condition – Pittsburgh Mercy Health System did not track or review individual matching expenditures to ensure that the sources were allowable. Additionally, there was a lack of documentation and a review of such documentation substantiating that the total dollar threshold for matching was satisfied. However, total matching expenditures for the program were subsequently analyzed and Pittsburgh Mercy Health System did expend sufficient allowable expenditures ($481,325) to fulfill the matching requirement. Cause – Pittsburgh Mercy Health System did not design and implement controls to ensure that there were sufficient expenditures to meet the matching requirement, and that such expenditures were allowable under the Continuum of Care Program. Effect –The lack of review and documentation of matching expenditures could have resulted in a breach of contractual obligations for the matching requirement. Questioned Costs – None. Context - Pittsburgh Mercy Health System failed to establish a system to regularly monitor matching activities and review the status of federal matching to ensure compliance. Lack of tracking and reviewing of matching requirements would potentially result in insufficient and inadequate match, and repayment of funds. Repeat Finding – No. Recommendation – We recommend Pittsburgh Mercy Health System establish internal control policies and procedures to ensure reviews are performed and documented for all expenditures related to the matching requirement.
Finding 2024-002
Condition – Pittsburgh Mercy Health System did not track or review individual matching expenditures to ensure that the sources were allowable. Additionally, there was a lack of documentation and a review of such documentation substantiating that the total dollar threshold for matching was satisfied. However, total matching expenditures for the program were subsequently analyzed and Pittsburgh Mercy Health System did expend sufficient allowable expenditures ($481,325) to fulfill the matching requirement. Cause – Pittsburgh Mercy Health System did not design and implement controls to ensure that there were sufficient expenditures to meet the matching requirement, and that such expenditures were allowable under the Continuum of Care Program. Effect –The lack of review and documentation of matching expenditures could have resulted in a breach of contractual obligations for the matching requirement. Questioned Costs – None. Context - Pittsburgh Mercy Health System failed to establish a system to regularly monitor matching activities and review the status of federal matching to ensure compliance. Lack of tracking and reviewing of matching requirements would potentially result in insufficient and inadequate match, and repayment of funds. Repeat Finding – No. Recommendation – We recommend Pittsburgh Mercy Health System establish internal control policies and procedures to ensure reviews are performed and documented for all expenditures related to the matching requirement.
Finding 2024-002
Condition – Pittsburgh Mercy Health System did not track or review individual matching expenditures to ensure that the sources were allowable. Additionally, there was a lack of documentation and a review of such documentation substantiating that the total dollar threshold for matching was satisfied. However, total matching expenditures for the program were subsequently analyzed and Pittsburgh Mercy Health System did expend sufficient allowable expenditures ($481,325) to fulfill the matching requirement. Cause – Pittsburgh Mercy Health System did not design and implement controls to ensure that there were sufficient expenditures to meet the matching requirement, and that such expenditures were allowable under the Continuum of Care Program. Effect –The lack of review and documentation of matching expenditures could have resulted in a breach of contractual obligations for the matching requirement. Questioned Costs – None. Context - Pittsburgh Mercy Health System failed to establish a system to regularly monitor matching activities and review the status of federal matching to ensure compliance. Lack of tracking and reviewing of matching requirements would potentially result in insufficient and inadequate match, and repayment of funds. Repeat Finding – No. Recommendation – We recommend Pittsburgh Mercy Health System establish internal control policies and procedures to ensure reviews are performed and documented for all expenditures related to the matching requirement.
Finding 2024-002
Condition – Pittsburgh Mercy Health System did not track or review individual matching expenditures to ensure that the sources were allowable. Additionally, there was a lack of documentation and a review of such documentation substantiating that the total dollar threshold for matching was satisfied. However, total matching expenditures for the program were subsequently analyzed and Pittsburgh Mercy Health System did expend sufficient allowable expenditures ($481,325) to fulfill the matching requirement. Cause – Pittsburgh Mercy Health System did not design and implement controls to ensure that there were sufficient expenditures to meet the matching requirement, and that such expenditures were allowable under the Continuum of Care Program. Effect –The lack of review and documentation of matching expenditures could have resulted in a breach of contractual obligations for the matching requirement. Questioned Costs – None. Context - Pittsburgh Mercy Health System failed to establish a system to regularly monitor matching activities and review the status of federal matching to ensure compliance. Lack of tracking and reviewing of matching requirements would potentially result in insufficient and inadequate match, and repayment of funds. Repeat Finding – No. Recommendation – We recommend Pittsburgh Mercy Health System establish internal control policies and procedures to ensure reviews are performed and documented for all expenditures related to the matching requirement.