Audit 37993

FY End
2022-12-31
Total Expended
$310.05M
Findings
12
Programs
151
Organization: Atrium Health, Inc. (NC)
Year: 2022 Accepted: 2023-09-29
Auditor: Kpmg LLP

Organization Exclusion Status:

Checking exclusion status...

Findings

ID Ref Severity Repeat Requirement
35896 2022-004 Significant Deficiency - B
35897 2022-003 Significant Deficiency - B
35898 2022-003 Significant Deficiency - B
35899 2022-003 Significant Deficiency - B
35900 2022-001 Significant Deficiency Yes B
35901 2022-002 Significant Deficiency - BL
612338 2022-004 Significant Deficiency - B
612339 2022-003 Significant Deficiency - B
612340 2022-003 Significant Deficiency - B
612341 2022-003 Significant Deficiency - B
612342 2022-001 Significant Deficiency Yes B
612343 2022-002 Significant Deficiency - BL

Programs

ALN Program Spent Major Findings
93.498 Covid-19 Provider Relief Fund $44.16M Yes 1
21.027 Coronavirus State and Local Fiscal Recovery Fund $2.25M - 0
84.268 Federal Direct Student Loans $1.57M - 0
93.361 Nursing Research $1.07M Yes 2
93.889 Hospital Preparedness Program Cooperative Agreement $951,564 - 0
93.253 Poison Center Support and Enhancement Grants $848,474 - 0
93.889 Metrolina Healthcare Preparedness Region 21-22 $759,157 - 0
93.121 Orarad Renewal $749,942 Yes 0
93.958 Implementing A Coordinated Specialty Care (csc) Model Program in Mecklenburg County Block Grants for Community Mental Health Services $734,903 - 0
93.461 Covid-19 Claims Reimbursement to Health Care Providers and Facilities for Testing, Treatment, and Vaccine Administration for the Uninsured $651,210 Yes 0
93.840 Primary Care Implementation and Evaluation of Coach McLungs An Asthma Shared Decision-Making Intervention, Across A Large Healthcare System $439,180 Yes 0
84.GSA_MIGRATION Covid-19 Heerf Education Emergency Relief Fund (heerf) Student Aid Portion $420,200 - 0
93.391 Community Health Workers Model 2021-2023 $374,068 - 0
93.121 Oral Diseases and Disorders Research $348,327 Yes 0
93.323 Birth Defects and Developmental Disabilities Prevention and Surveillance $314,352 Yes 0
12.420 Evaluation of A New Strategy for Protocolized Antibiotic Care for Severe Open Fractures $312,509 Yes 0
84.063 Federal Pell Grant Program $284,444 - 0
16.320 Services for Trafficking Victims $271,355 - 0
93.889 Metrolina Healthcare Preparedness Region 22-23 $256,923 - 0
12.U00 The Mobility Toolkit: Electronically Augmented Assessment of Functional Recovery Following Lower-Extremity Trauma $221,776 Yes 0
93.994 Prenatal Region III Locate 2021-2022 $217,639 - 0
93.137 Minority Systemic Lupus $215,324 - 0
93.273 Alcohol Research Programs $214,458 Yes 0
93.136 Injury Prevention and Control Research and State and Community Based Programs $211,173 Yes 0
12.420 Injury Risk in Special Forces Operations $209,565 Yes 0
93.669 Atrium Health Cabarrus Jeff Gordan Childrens Advocacy Centers of North Carolina Department of Health and Human Services Supplemental Funds $197,625 - 0
93.365 Sickle Cell Treatment Demonstration Program $196,018 Yes 0
93.395 Dual Pi3k/brd4 Inhibitory Chemotype for Maximum Inhibition of Myc and Cancer $186,732 Yes 1
93.226 Personalized Clinical Decision Support to Improve Participation in Hospital at Home $169,407 Yes 0
93.394 Cancer Detection and Diagnosis Research $166,657 Yes 0
93.686 Recast Training $155,273 - 0
93.396 Role of Pten and Pi-3 Kinase in Medulloblastomagenesis $152,609 Yes 1
93.137 Speech Profiles and Cue Responsiveness After Left Hemisphere Stroke $152,272 Yes 0
16.575 Cabarrus Jeff Gordon Childrens Advocacy Center 2020-2022 $136,186 - 0
16.575 Stanly Butterfly House 2020-2022 $131,523 - 0
12.420 Prophylactic Nail $129,543 Yes 0
93.994 Perinatal/neonatal Program Region III $122,523 - 0
93.853 Preclinic Dose and Delivery Regime Optimization and Long-Term Efficacy Evaluation of Ribitol Treatment for Fkrp Related Dystroglycanopathy $119,157 Yes 0
93.855 Covid-19 Prevention Network (covpn) Site Preparedness Funding $112,459 Yes 0
93.069 Nc Public Health Preparedness 2021-2022 $102,000 - 0
93.107 Model State Supported Area Health Education Center Program (hrsa) $96,359 Yes 0
93.865 Natpro - Rct of Natural Vs Programmed Cycles for Frozen Embryo Transfer $88,913 Yes 0
93.069 Public Health Epidemiologist $79,282 Yes 0
93.879 Medical Library Assistance $79,048 Yes 0
93.323 Public Health Epidemiologist 2022-2023 $78,273 - 0
93.866 Pragmatic Evaluation of Events and Benefits of Lipid-Lowering in Older Adults (preventable) $74,140 Yes 0
10.310 A Nutrimetabolomics Approach to Identify the Biomarkers of Whole Grain Intake $61,828 Yes 0
93.145 Hiv Linkage $61,024 - 0
93.838 The Capture Study: Validating A Unique Copd Screening Tool in Primary Care $59,396 Yes 0
93.853 Statins Use in Intracerebral Hemorrhage Patients $55,830 Yes 0
93.360 A Double-Blind, Randomized, Placebo-Controlled Study to Evaluate the Efficacy and Safety of Intravenous Ganaxolone in Status Epilepticus $53,880 Yes 0
20.600 T- Sbirt - Traffic Counseling Toward Impaired Drivers and Seatbelt Use in A Trauma Center $52,968 - 0
93.865 Using Interactive Virtual Presence to Remotely Assist Parents with Child Restraint $52,551 Yes 0
93.395 Repurposing Leflunomide to Delay Progression of Smoldering Multiple Myeloma in African Americans $42,888 Yes 0
93.865 A Randomized Controlled Trial of Frozen Embryo Transfers Performed in Modified Natural Versus Programmed Cycles (natpro) $41,400 Yes 0
93.884 Training Primary Care Champions $39,318 - 0
16.575 Cabarrus Jeff Gordon Childrens Advocacy Center 2022-2024 $38,086 - 0
93.847 Aldh1l1 Polymorphisms in Regulation of Glycine Metabolism $35,929 Yes 0
93.884 Primary Care Training and Enhancement: Training Primary Care Champions $35,277 - 0
93.558 2021-2022 Cacnc Butterfly House $33,858 - 0
93.855 Modeling and Simulation Tools for Optimizing Design of Network-Informed Clinical Trials of Combination Hiv Prevention Interventions $32,164 Yes 0
16.575 Stanly Butterfly House 2022-2024 $31,908 - 0
93.360 Biomedical Advanced Research and Development Authority (barda), Biodefense Medical Countermeasure Development $31,126 Yes 0
93.116 Tb Consults 2022 $30,180 - 0
93.398 Workload Intensity Nih National Clinical Trial Network (ntn) Grant Successor to Nih Cog Chair Grant $29,500 Yes 0
93.433 Traumatic Brain Injury Model Systems National Data and Statistical Center $27,550 Yes 0
93.137 Covid-19 Resources with Ahec $27,160 - 0
93.914 Ryan White Minority Aids Initiative (mai) $25,632 - 0
93.839 Blood and Marrow Transplant Clinical Trials Network $25,321 Yes 0
93.310 Trials and Research Network for Even More (transform-2) $25,179 Yes 0
93.433 Characterization and Treatment of Chronic Pain After Severe Traumatic Brain Injury $24,050 Yes 0
93.226 Screening and Management of Unhealthy Alcohol Use in Primary Care: Dissemination and Implementation of Pcor Evidence $23,549 - 0
93.837 Heartshare $22,345 Yes 0
12.420 The Major Extremity Trauma and Rehabilitation Research Consortium $22,261 Yes 0
93.U00 A Phase Ii, Single-Stage, Single Arm Investigation of Oral Valganciclovir Therapy in Infants with Asymptomatic Congenital Cytomegalovirus Infection $22,000 Yes 0
93.837 Metabolic Pathways to Cardiovascular Disease $21,913 Yes 0
93.395 A Randomized Phase Ii/iii Trial of De-Intensified Radiation Therapy for Patients with Early-Stage, P16-Positive, Non-Smoking Associated Oropharyngeal $21,775 Yes 0
93.558 2022-2023 Cacnc Butterfly House Dhhs $21,759 - 0
84.007 Federal Supplemental Education Opportunity Grant Program $21,681 - 0
20.614 Crash Injury Research and Engineering Network (ciren) Motor Vehicle Occupant Enrollment - National Highway Traffic Safety Administration Discretionary $21,482 - 0
93.958 Project Seed Expansion $21,107 - 0
93.073 Birth Defects and Developmental Disabilities Prevention and Surveillance $20,000 Yes 0
93.914 Covid-19 Hiv Emergency Relief Project Grants $19,780 - 0
93.395 Randomized Trial of Standard Chemotherapy Alone Or Combined with Atezolizumab As Adjuvant Therapy for Patients with Stage III Colon Cancer and Deficient Dna Mismatch Repair $19,662 Yes 0
93.855 Congenital and Perinatal Infections Rare Diseases $18,000 Yes 0
93.395 A Randomized Phase Ii/iii Open-Label Study of Ipilimumab and Nivolumab Versus Temozolomide in Patients with Newly Diagnosed Mgmt Glioblastoma (tumor O-6-Methylguanine Dna Methyltransferase) Unmethylated $17,800 Yes 0
93.080 Public Health Surveillance for the Prevention of Complications of Bleeding Disorders $17,628 Yes 0
93.395 A Randomized Phase III Study of Paclitaxel and Carboplatin with Or Without Pembrolizumab (mk-3475) for Measurable Stage III Or Iva, Stage Ivb Or Recurrent Endometrial Cancer $16,650 Yes 0
93.839 Sickle Cell Disease and Cardiovascular Risk Red Cell Exchange Trial (scd-Carre) $16,165 Yes 0
93.395 A Phase Iii, Randomized Study of Nivolumab (opdivo) Or Brentuximab Vedotin (adcetris) Plus Avd in Patients (age >/= 12 Years) with Newly Diagnosed Advanced Stage Classical Hodgkin Lympho $14,850 Yes 0
93.395 Childrens Oncology Group $13,750 Yes 0
93.914 Ryan White Part A $12,749 - 0
93.395 A Randomized Phase Ii/iii Trial of Prophylactic Cranial Irradiation with Or Without Hippocampal Avoidance for Small Cell Lung Cancer $12,200 Yes 0
93.839 A Comparison of Individualized Vs. Weight Based Protocols to Treat Vaso-Occlusive Episodes in Sickle Cell Disease (compare-Voe) $11,240 Yes 0
93.853 Extramural Research Programs in the Neurosciences and Neurological Disorders $10,740 Yes 0
93.395 A Phase 3 Randomized Trial for Patients with De Novo Aml Comparing Standard Therapy Including Gemtuzumab Ozogamicin (go) to Cpx-351 with Go, with Flt3 Mutations and the Addition of the Flt3 Inhibitor Gilteritinib for Patients $10,200 Yes 0
93.395 Phase III Study of Daratumumab/rhuph20 + Lenalidomide Or Lenalidomide As Post-Autologous Stem Cell Transplant $9,384 Yes 0
93.856 Multimodal Treatment for Hemiplegic Shoulder Pain $8,775 Yes 0
93.U00 A Randomized Phase III Trial of Consolidation with Autologous Hematopoietic Cell Transplantation Followed by Maintenance $8,550 Yes 0
93.395 Nrg-Lu005: Limited Stage Small Cell Lung Cancer (ls-Sclc): A Phase Ii/iii Randomized Study of Chemoradiation Versus Chemoradiation Plus Atezolizumab $8,350 Yes 0
93.262 A Randomized, Double-Blind, Phase III Trial of Paclitaxel/trastuzumab/pertuzumab with Atezolizumab Or Placebo in First-Line Her2-Positive Metastatic Breast Cancer $7,895 Yes 0
93.116 Tb Consults 2021 $7,545 Yes 0
93.395 National Surgical Adjuvant Breast and Bowel Project (nsabp)/radiation Therapy Oncology Group (rtog)/gynecologic Oncology Group (gog) $7,000 Yes 0
93.395 Randomized Phase Ii/iii Trial of Adjuvant Radiation Therapy with Cisplatin, Docetaxel-Cetuximab, Or Cisplatin-Atezolizumab in Pathologic High-Risk Squamous Cell Cancer of the Head and Neck $6,550 Yes 0
93.433 The Traumatic Brain Injury Model Systems National Data and Statistical Center 2021-2022 $6,048 - 0
93.395 Nrg-Gu009: Parallel Phase III Randomized Trials for High-Risk Prostate Cancer Evaluating De-Intensification for Lower Genomic Risk and Intensification of Concurrent Therapy for Higher Genomic Risk with Radiation (predict-Rt) $6,000 Yes 0
93.853 Statins Use in Intracerebral Hemorrhage Patients (saturn) Study $5,566 Yes 0
12.420 Novel Topical Antibiotic Therapy to Reduce Infection After Operative Treatment of Fracturesat High Risk of Infection: Tobra -A Multicenter Randomized, Controlled Trial $5,350 Yes 0
93.399 National Surgical Adjuvant Breast and Bowel Project $5,225 Yes 0
93.395 A Phase 3 Randomized Trial of Inotuzumab Ozogamicin for Newly Diagnosed High-Risk B-All; Risk-Adapted Post-Induction Therapy for High-Risk B-All, Mixed Phenotype Acute Leukemia, and Disseminated B-Lly $5,000 Yes 0
93.669 Geriatrics Workforce Enhancement Program $5,000 - 0
93.360 A Randomized, Double-Blind, Multi-Center Study to Establish the Efficacy and Safety of Ceftobiprole Medocaril Compared to Daptomycin $4,950 Yes 0
93.394 A Phase III Clinical Trial Evaluating De-Escalation of Breast Radiation for Conservative Treatment of Stage I, Hormone Sensitive, Her2-Negative, Oncotype Recurrence Score $4,800 Yes 0
93.669 Butterfly House Childrens Advocacy Centers of North Carolina Department of Health and Human Services Supplemental Funds $4,705 - 0
93.395 Phase II Randomized Study of Maintenance Atezolizumab Versus Atezolizumab in Combination with Talazoparib in Patients with Slfn11 Positive Extensive Stage Small Cell Lung Cancer (es-Sclc) $4,250 Yes 0
21.019 Covid-19 Coronavirus Relief Fund $3,737 - 0
93.395 A Phase 3 Trial Investigating Blinatumomab in Combination with Chemotherapy in Patients with Newly Diagnosed $3,600 Yes 0
93.395 A Phase 3 Randomized Non-Inferiority Study of Carboplatin and Vincristine Versus Selumetinib (nsc# 748727) in Newly Diagnosed Or Previously Untreated Low-Grade Glioma (lgg) Not Associated with Brafv600e Mutations Or Systemic Neurofibromatosis Type 1 (nf1) $3,600 Yes 0
93.U00 Alliance for Clinical Trials in Oncology $3,500 Yes 0
93.110 Hemophilia Treatment Centers (sprans) $3,102 Yes 0
93.080 2021-2022 Nc Sickle Cell Data Collection Program $2,762 - 0
93.395 A Phase 2 Trial of Chemotherapy Followed by Response-Based Whole Ventricular & Spinal Canal Irradiation (wvsci) for Patients with Localized Non-Germinomatous Central Nervous System Germ Cell Tumor $2,700 Yes 0
93.395 Risk-Stratified Therapy for Am $2,700 Yes 0
93.395 A Randomized Phase Iii, Two-Arm Trial of Paclitaxel/carboplatin/maintenance Letrozole Versus Letrozole Monotherapy in Patients with Stage II-Iv, Primary Low-Grade Serous Carcinoma of the Ovary Or Peritoneum $2,700 Yes 0
93.399 International Phase 3 Trial in Philadelphia Chromosome-Positive Acute Lymphoblastic Leukemia (ph+ All) Testing Imatinib in Combination with Two Different Cytotoxic Chemotherapy Backbones $2,700 Yes 0
12.420 Randomized Trial of Early Hemodynamic Management of Patients Following Acute Spinal Cord Injury Temple $2,700 Yes 0
93.853 Sleep Smart $2,658 Yes 0
93.839 Clinical Transplant-Related Long-Term Outcomes of Alternative Donor Allogeneic Transplantation (ctrl-Alt-D) Bmt $2,512 Yes 0
93.110 Hemophilia Treatment Centers (sprans Yr5-10) $2,354 - 0
93.116 Project Grants and Cooperative Agreements for Tuberculosis Control Programs $1,953 Yes 0
93.226 Short-Term Clinical Deterioration After Acute Pulmonary Embolism $1,710 Yes 0
93.395 A Randomized, Phase III Trial to Evaluate the Efficacy and Safety of Mk-3475 (pembrolizumab) As Adjuvant Therapy for Triple Receptor-Negative Breast Cancer with >/=1 Cm Residual Invasive Cancer Or Positive Lymph Nodes (ypn+) After Neoadjuvant Chemotherapy $1,705 Yes 0
12.420 Rehabilitation Enhanced by Partial Arterial Inflow Restriction $1,542 Yes 0
93.395 Phase III Randomized Trial of Standard Systemic Therapy (sst) Versus Standard Systemic Therapy Plus Definitive Treatment (surgery Or Radiation) of the Primary Tumor in Metastatic Prostate Cancer $1,200 Yes 0
93.421 Pediatric Public Health Partnership on Fetal Alcohol Spectrum Disorders $1,148 Yes 0
93.847 Developing A Biomarker Panel to Assess Choline Nutritional Status $1,097 Yes 0
93.399 Pediatric Match (molecular Analysis for Therapy Choice) $763 Yes 0
93.847 Apol1 Long-Term Kidney Transplantation Outcomes Network $700 Yes 0
93.395 A Phase 2 Study of Reduced Therapy for Newly Diagnosed Average-Risk Wnt-Driven Medulloblastoma Patients $600 Yes 0
93.U00 A Phase 3 Study of Active Surveillance for Low Risk and A Randomized Trial of Carboplatin Vs. Cisplatin for Standard Risk Pediatric $500 Yes 0
12.420 Effect of Early Weight Bearing $388 Yes 0
93.669 2021-2022 Cacnc Butterfly House $385 - 0
93.839 Composite Health Assessment Model for Older Adults: Applying Pre-Transplant Comorbidity, Geriatric Assessment, and Biomarkers to Predict Non-Relapse Mortality After Allogeneic Transplantation (charm) $305 Yes 0
93.669 2022-2023 Cacnc Butterfly House Dhhs $250 - 0
93.395 Phase Ii/iii Study of Circulating Tumor Dna As A Predictive Biomarker in Adjuvant Chemotherapy in Patients with Stage Iia Colon Cancer (cobra) $150 Yes 0
93.283 Virtual Network to Investigate the Trajectory of Covid-19-Related Severe Outcomes $67 Yes 0
93.395 Treatment of Newly Diagnosed Diffuse Anaplastic Wilms Tumors (dawt) and Relapsed Favorable Histology Wilms Tumors (fhwt) $-806 Yes 0
93.855 A Phase 2b, Multicenter, Randomized, Open-Label, Assessor-Blinded Superiority Study to Compare the Efficacy and Safety of Dalbavancin to Standard of Care Antibiotic Therapy for the Completion of Treatment of Patients with Complicated S. Aureus Bacteremia $-2,875 Yes 0
93.395 Southwest Oncology Group Network Group Operations Center of the Nctn $-16,000 Yes 0
20.U00 Crash Risk Associated with Drug and Alcohol Use by Drivers in Fatal and Serious Injury Crashes $-56,663 - 0
93.994 Perinatal/neonatal Outreach Coordinator Program Region III - Maternal and Child Health Services Block Grant to States $-66,621 - 0

Contacts

Name Title Type
LCSFK2KRP5A4 David Thomas Auditee
7043553210 Jennifer Hall Auditor
No contacts on file

Notes to SEFA

Accounting Policies: The expenditures on the Schedules are reported on the accrual basis of accounting when Atrium Health Enterprise has met the qualifications for the incurred expenses according to the grant requirements. Atrium Health Enterprise has elected not to use the 10-percent de minimis indirect cost rate as allowed under the Uniform Guidance. De Minimis Rate Used: N Rate Explanation: The auditee did not use the de minimis cost rate.

Finding Details

Finding No. 2022-004: Allowability of Costs Federal Program: Research and Development Cluster, ALN 93.361, Award Number R01NR018434 Federal Agency: U.S. Department of Health and Human Services Pass through entity: N/A Federal Award year: July 23, 2019 through July 31, 2023 Criteria or Requirement: Per 2 CFR 200.303, the nonfederal entity must establish and maintain effective internal control over the award that provides reasonable assurance that the nonfederal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. Condition Found, Including Perspective: During our testwork over payroll costs charged to the cluster, we identified one individual in a sample of 40 with certified effort less than the amount charged to the grant. While the individual and management agree that the amount charged was appropriate based on the actual effort performed, the records included a difference which had not been reconciled or explained. Cause and Possible Effect: While there is an effort certification process and review control in place to ensure all effort charged to federal grants is accurate and allowable, the control did not operate effectively to identify the difference reported on the effort certification. Questioned Costs: None. Statistical Validity: The sample was not intended to be, and was not, a statistically valid sample. Repeat Finding in the Prior Year: No Recommendation: We recommend that management reinforce the policies related to the effort certification process and the related reviews through training. Views of Responsible Officials: Atrium Health management agrees with the finding. To address the current year finding, Office of Sponsored Programs will review Huron Employee Compensation Compliance (ECC) system and enhance controls over changing effort percentages.
Finding No. 2022-003: Allowability of Costs Federal Program: Research and Development Cluster, ALN 93.396, 93.361, 93.395, Award Numbers R01CA172513, R01NR018434, R01CA215651 Federal Agency: U.S. Department of Health and Human Services Pass through entity: N/A Federal Award year: August 6, 2020 through February 28, 2023, July 23, 2019 through July 31, 2023, August 28, 2020 through July 31, 2023 Criteria or Requirement: Per 2 CFR 200.303, the nonfederal entity must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the nonfederal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. Uniform Guidance Part ?200.300(b), statutory and national policy requirements, establishes that the non Federal entity is responsible for complying with all requirements of the Federal award. Federal awards under the Consolidated Appropriations Act 2016 (H.R. 2029) granted by HHS National Institute of Health (NIH), have restrictions on the amount of direct salary charged to the awards limited to the Executive Level II of the Federal Executive pay scale (salary cap). Uniform Guidance Part ?200.408, limitation on allowance of costs, states that the Federal award may be subject to statutory requirements that limit the allowability of costs. When the maximum allowable under a limitation is less than the total amount of the award, the amount not recoverable under the Federal award may not be charged to the Federal award. Condition Found, Including Perspective: During our testwork over the NIH salary cap, we identified three individuals in a sample of 10 with a salary charged to an award in excess of the salary cap by $3,206. The sampled salary for NIH salary cap population was a charge to the grant of $187,586. Total salary charged to NIH was $2,128,430. Cause and Possible Effect: While there is a control in place to review all effort charged to NIH grants to ensure that charges, including any relevant cost transfers, do not exceed the defined salary cap, the control was not operating effectively in order to identify the overages. Questioned Costs: $3,206 Statistical Validity: The sample was not intended to be, and was not, a statistically valid sample. Repeat Finding in the Prior Year: No Recommendation: We recommend that management review its current policies and reinforce through training the elements necessary to fully comply with its policies and all requirements governing salary cap allowability. Views of Responsible Officials: Atrium Health management agrees with the finding. To address the current year finding, Office of Sponsored Programs has implemented internal control improvements to ensure all requirements that limit the salary cap allowability of costs are completed and documented appropriately.
Finding No. 2022-003: Allowability of Costs Federal Program: Research and Development Cluster, ALN 93.396, 93.361, 93.395, Award Numbers R01CA172513, R01NR018434, R01CA215651 Federal Agency: U.S. Department of Health and Human Services Pass through entity: N/A Federal Award year: August 6, 2020 through February 28, 2023, July 23, 2019 through July 31, 2023, August 28, 2020 through July 31, 2023 Criteria or Requirement: Per 2 CFR 200.303, the nonfederal entity must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the nonfederal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. Uniform Guidance Part ?200.300(b), statutory and national policy requirements, establishes that the non Federal entity is responsible for complying with all requirements of the Federal award. Federal awards under the Consolidated Appropriations Act 2016 (H.R. 2029) granted by HHS National Institute of Health (NIH), have restrictions on the amount of direct salary charged to the awards limited to the Executive Level II of the Federal Executive pay scale (salary cap). Uniform Guidance Part ?200.408, limitation on allowance of costs, states that the Federal award may be subject to statutory requirements that limit the allowability of costs. When the maximum allowable under a limitation is less than the total amount of the award, the amount not recoverable under the Federal award may not be charged to the Federal award. Condition Found, Including Perspective: During our testwork over the NIH salary cap, we identified three individuals in a sample of 10 with a salary charged to an award in excess of the salary cap by $3,206. The sampled salary for NIH salary cap population was a charge to the grant of $187,586. Total salary charged to NIH was $2,128,430. Cause and Possible Effect: While there is a control in place to review all effort charged to NIH grants to ensure that charges, including any relevant cost transfers, do not exceed the defined salary cap, the control was not operating effectively in order to identify the overages. Questioned Costs: $3,206 Statistical Validity: The sample was not intended to be, and was not, a statistically valid sample. Repeat Finding in the Prior Year: No Recommendation: We recommend that management review its current policies and reinforce through training the elements necessary to fully comply with its policies and all requirements governing salary cap allowability. Views of Responsible Officials: Atrium Health management agrees with the finding. To address the current year finding, Office of Sponsored Programs has implemented internal control improvements to ensure all requirements that limit the salary cap allowability of costs are completed and documented appropriately.
Finding No. 2022-003: Allowability of Costs Federal Program: Research and Development Cluster, ALN 93.396, 93.361, 93.395, Award Numbers R01CA172513, R01NR018434, R01CA215651 Federal Agency: U.S. Department of Health and Human Services Pass through entity: N/A Federal Award year: August 6, 2020 through February 28, 2023, July 23, 2019 through July 31, 2023, August 28, 2020 through July 31, 2023 Criteria or Requirement: Per 2 CFR 200.303, the nonfederal entity must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the nonfederal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. Uniform Guidance Part ?200.300(b), statutory and national policy requirements, establishes that the non Federal entity is responsible for complying with all requirements of the Federal award. Federal awards under the Consolidated Appropriations Act 2016 (H.R. 2029) granted by HHS National Institute of Health (NIH), have restrictions on the amount of direct salary charged to the awards limited to the Executive Level II of the Federal Executive pay scale (salary cap). Uniform Guidance Part ?200.408, limitation on allowance of costs, states that the Federal award may be subject to statutory requirements that limit the allowability of costs. When the maximum allowable under a limitation is less than the total amount of the award, the amount not recoverable under the Federal award may not be charged to the Federal award. Condition Found, Including Perspective: During our testwork over the NIH salary cap, we identified three individuals in a sample of 10 with a salary charged to an award in excess of the salary cap by $3,206. The sampled salary for NIH salary cap population was a charge to the grant of $187,586. Total salary charged to NIH was $2,128,430. Cause and Possible Effect: While there is a control in place to review all effort charged to NIH grants to ensure that charges, including any relevant cost transfers, do not exceed the defined salary cap, the control was not operating effectively in order to identify the overages. Questioned Costs: $3,206 Statistical Validity: The sample was not intended to be, and was not, a statistically valid sample. Repeat Finding in the Prior Year: No Recommendation: We recommend that management review its current policies and reinforce through training the elements necessary to fully comply with its policies and all requirements governing salary cap allowability. Views of Responsible Officials: Atrium Health management agrees with the finding. To address the current year finding, Office of Sponsored Programs has implemented internal control improvements to ensure all requirements that limit the salary cap allowability of costs are completed and documented appropriately.
Finding No. 2022-001: Allowability Federal Program: COVID-19 ? HRSA COVID-19 Claims Reimbursement for the Uninsured Program and the COVID-19 Coverage Assistance Fund (ALN 93.461) Federal Award Year: January 1, 2022 through December 31, 2022 Federal Award Agency: U.S. Department of Health and Human Services Criteria or Requirement: Per 2 CFR 200.303, the nonfederal entity must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the nonfederal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. Condition Found, Including Perspective: While no insurance was identified for any of the patients sampled, for 4 out of 40 patients sampled, there was no documentation available to demonstrate that an insurance check was performed prior to Health Resources and Services Administration (HRSA) claim submission. Possible Cause and Asserted Effect: The control to ensure appropriate documentation supporting the performance of the insurance check for each patient prior to the claim submission was not operating effectively. Questioned Costs: None. Statistical Validity: The sample was not intended to be, and was not, a statistically valid sample. Repeat Finding in the Prior Year: Yes, Finding 2021-001 Recommendation: We recommend Atrium Health Enterprise improve its existing insurance verification process to ensure documentation evidencing that all patients identified on the claim form were uninsured individuals at the time the services were provided is retained. Views of Responsible Officials: Atrium Health CMHA currently has an insurance verification process for potentially uninsured patients meeting the criteria prescribed by HRSA whereby identified accounts are sent nightly to Experian, a multinational consumer credit reporting company, who searches for insurance coverage. Negative confirmation documentation is inserted into the patient record. Management is aware of the importance of this process and has continued education efforts with applicable teammates to ensure this process is followed and documented with each patient. Additionally, the HRSA COVID-19 Uninsured Program ended in April of 2022.
Finding No. 2022-002: Reporting and Allowable Costs Federal Program: COVID-19 ? Provider Relief Fund and American Rescue Plan Rural Distribution (ALN 93.498) Federal Award Year: January 1, 2022 through December 31, 2022 Federal Award Agency: U.S. Department of Health and Human Services Criteria or Requirement: Per 2 CFR 200.303, the nonfederal entity must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the nonfederal 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 award, recipients are required to submit a report in the Provider Relief Fund reporting portal for reach reporting period. Condition Found, Including Perspective: Certain costs reported for Wilkes Regional Medical Center totaling $2,063,873 were reported in Period 4 as Other Healthcare Expenses while the expenses to support the draw should have been allocated to the Personnel, Fringe Benefits, Equipment, and Supplies sections of the report. Further, for certain costs of Wilkes Regional Medical Center totaling $29,454 the materials were not received and should not have been charged. Possible Cause and Asserted Effect: The control to ensure that all costs claimed were allowable per the grant and reported appropriately was not operating effectively to ensure that the appropriate costs categories were claimed for Wilkes Regional Medical Center. Questioned Costs: $29,454 Statistical Validity: The sample was not intended to be, and was not, a statistically valid sample Repeat Finding in the Prior Year: No Recommendation: We recommend Wilkes Regional Medical Center enhance its controls over review of expenditures claimed to ensure that the appropriate costs are claimed within the appropriate categories for the Provider Relief Fund reporting. Views of Responsible Officials: Atrium Health management believes that, while the Provider Relief Funds reporting was completed on a periodic basis throughout the pandemic, the intent from HRSA was to document the use of those funds for COVID-19 expenses and for lost revenues over the course of the entire pandemic. Because the PRF portal did not allow for previous periods to be restated in response to new information or corrections identified from previous reported periods, the only recourse available for health systems to restate COVID-19 expenses or lost revenues is through future PRF reporting or through the HRSA audit process. Management agrees that the control process in place during the initial reporting process for Wilkes Regional Medical Center did not yield the ultimate cost categorization that was corrected in the PRF reporting noted above; however, management?s interaction with HRSA throughout 2022 and the resulting clarification of COVID-19 expenses, is now incorporated into the overall PRF reporting control process. With respect to the identified questioned costs, management agrees that these costs should not have been included as COVID-19 related expenses for that period. However, management also recognizes that Wilkes Regional Medical Center has unused lost revenues more than this amount and as such, the questioned costs would not be subject to a return of the PRF proceeds. This position is supported by a similar finding in the 2021 Atrium Health Enterprise audit that was resolved with this conclusion and is documented in the Management Decision Letter issued by HRSA dated June 26, 2023
Finding No. 2022-004: Allowability of Costs Federal Program: Research and Development Cluster, ALN 93.361, Award Number R01NR018434 Federal Agency: U.S. Department of Health and Human Services Pass through entity: N/A Federal Award year: July 23, 2019 through July 31, 2023 Criteria or Requirement: Per 2 CFR 200.303, the nonfederal entity must establish and maintain effective internal control over the award that provides reasonable assurance that the nonfederal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. Condition Found, Including Perspective: During our testwork over payroll costs charged to the cluster, we identified one individual in a sample of 40 with certified effort less than the amount charged to the grant. While the individual and management agree that the amount charged was appropriate based on the actual effort performed, the records included a difference which had not been reconciled or explained. Cause and Possible Effect: While there is an effort certification process and review control in place to ensure all effort charged to federal grants is accurate and allowable, the control did not operate effectively to identify the difference reported on the effort certification. Questioned Costs: None. Statistical Validity: The sample was not intended to be, and was not, a statistically valid sample. Repeat Finding in the Prior Year: No Recommendation: We recommend that management reinforce the policies related to the effort certification process and the related reviews through training. Views of Responsible Officials: Atrium Health management agrees with the finding. To address the current year finding, Office of Sponsored Programs will review Huron Employee Compensation Compliance (ECC) system and enhance controls over changing effort percentages.
Finding No. 2022-003: Allowability of Costs Federal Program: Research and Development Cluster, ALN 93.396, 93.361, 93.395, Award Numbers R01CA172513, R01NR018434, R01CA215651 Federal Agency: U.S. Department of Health and Human Services Pass through entity: N/A Federal Award year: August 6, 2020 through February 28, 2023, July 23, 2019 through July 31, 2023, August 28, 2020 through July 31, 2023 Criteria or Requirement: Per 2 CFR 200.303, the nonfederal entity must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the nonfederal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. Uniform Guidance Part ?200.300(b), statutory and national policy requirements, establishes that the non Federal entity is responsible for complying with all requirements of the Federal award. Federal awards under the Consolidated Appropriations Act 2016 (H.R. 2029) granted by HHS National Institute of Health (NIH), have restrictions on the amount of direct salary charged to the awards limited to the Executive Level II of the Federal Executive pay scale (salary cap). Uniform Guidance Part ?200.408, limitation on allowance of costs, states that the Federal award may be subject to statutory requirements that limit the allowability of costs. When the maximum allowable under a limitation is less than the total amount of the award, the amount not recoverable under the Federal award may not be charged to the Federal award. Condition Found, Including Perspective: During our testwork over the NIH salary cap, we identified three individuals in a sample of 10 with a salary charged to an award in excess of the salary cap by $3,206. The sampled salary for NIH salary cap population was a charge to the grant of $187,586. Total salary charged to NIH was $2,128,430. Cause and Possible Effect: While there is a control in place to review all effort charged to NIH grants to ensure that charges, including any relevant cost transfers, do not exceed the defined salary cap, the control was not operating effectively in order to identify the overages. Questioned Costs: $3,206 Statistical Validity: The sample was not intended to be, and was not, a statistically valid sample. Repeat Finding in the Prior Year: No Recommendation: We recommend that management review its current policies and reinforce through training the elements necessary to fully comply with its policies and all requirements governing salary cap allowability. Views of Responsible Officials: Atrium Health management agrees with the finding. To address the current year finding, Office of Sponsored Programs has implemented internal control improvements to ensure all requirements that limit the salary cap allowability of costs are completed and documented appropriately.
Finding No. 2022-003: Allowability of Costs Federal Program: Research and Development Cluster, ALN 93.396, 93.361, 93.395, Award Numbers R01CA172513, R01NR018434, R01CA215651 Federal Agency: U.S. Department of Health and Human Services Pass through entity: N/A Federal Award year: August 6, 2020 through February 28, 2023, July 23, 2019 through July 31, 2023, August 28, 2020 through July 31, 2023 Criteria or Requirement: Per 2 CFR 200.303, the nonfederal entity must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the nonfederal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. Uniform Guidance Part ?200.300(b), statutory and national policy requirements, establishes that the non Federal entity is responsible for complying with all requirements of the Federal award. Federal awards under the Consolidated Appropriations Act 2016 (H.R. 2029) granted by HHS National Institute of Health (NIH), have restrictions on the amount of direct salary charged to the awards limited to the Executive Level II of the Federal Executive pay scale (salary cap). Uniform Guidance Part ?200.408, limitation on allowance of costs, states that the Federal award may be subject to statutory requirements that limit the allowability of costs. When the maximum allowable under a limitation is less than the total amount of the award, the amount not recoverable under the Federal award may not be charged to the Federal award. Condition Found, Including Perspective: During our testwork over the NIH salary cap, we identified three individuals in a sample of 10 with a salary charged to an award in excess of the salary cap by $3,206. The sampled salary for NIH salary cap population was a charge to the grant of $187,586. Total salary charged to NIH was $2,128,430. Cause and Possible Effect: While there is a control in place to review all effort charged to NIH grants to ensure that charges, including any relevant cost transfers, do not exceed the defined salary cap, the control was not operating effectively in order to identify the overages. Questioned Costs: $3,206 Statistical Validity: The sample was not intended to be, and was not, a statistically valid sample. Repeat Finding in the Prior Year: No Recommendation: We recommend that management review its current policies and reinforce through training the elements necessary to fully comply with its policies and all requirements governing salary cap allowability. Views of Responsible Officials: Atrium Health management agrees with the finding. To address the current year finding, Office of Sponsored Programs has implemented internal control improvements to ensure all requirements that limit the salary cap allowability of costs are completed and documented appropriately.
Finding No. 2022-003: Allowability of Costs Federal Program: Research and Development Cluster, ALN 93.396, 93.361, 93.395, Award Numbers R01CA172513, R01NR018434, R01CA215651 Federal Agency: U.S. Department of Health and Human Services Pass through entity: N/A Federal Award year: August 6, 2020 through February 28, 2023, July 23, 2019 through July 31, 2023, August 28, 2020 through July 31, 2023 Criteria or Requirement: Per 2 CFR 200.303, the nonfederal entity must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the nonfederal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. Uniform Guidance Part ?200.300(b), statutory and national policy requirements, establishes that the non Federal entity is responsible for complying with all requirements of the Federal award. Federal awards under the Consolidated Appropriations Act 2016 (H.R. 2029) granted by HHS National Institute of Health (NIH), have restrictions on the amount of direct salary charged to the awards limited to the Executive Level II of the Federal Executive pay scale (salary cap). Uniform Guidance Part ?200.408, limitation on allowance of costs, states that the Federal award may be subject to statutory requirements that limit the allowability of costs. When the maximum allowable under a limitation is less than the total amount of the award, the amount not recoverable under the Federal award may not be charged to the Federal award. Condition Found, Including Perspective: During our testwork over the NIH salary cap, we identified three individuals in a sample of 10 with a salary charged to an award in excess of the salary cap by $3,206. The sampled salary for NIH salary cap population was a charge to the grant of $187,586. Total salary charged to NIH was $2,128,430. Cause and Possible Effect: While there is a control in place to review all effort charged to NIH grants to ensure that charges, including any relevant cost transfers, do not exceed the defined salary cap, the control was not operating effectively in order to identify the overages. Questioned Costs: $3,206 Statistical Validity: The sample was not intended to be, and was not, a statistically valid sample. Repeat Finding in the Prior Year: No Recommendation: We recommend that management review its current policies and reinforce through training the elements necessary to fully comply with its policies and all requirements governing salary cap allowability. Views of Responsible Officials: Atrium Health management agrees with the finding. To address the current year finding, Office of Sponsored Programs has implemented internal control improvements to ensure all requirements that limit the salary cap allowability of costs are completed and documented appropriately.
Finding No. 2022-001: Allowability Federal Program: COVID-19 ? HRSA COVID-19 Claims Reimbursement for the Uninsured Program and the COVID-19 Coverage Assistance Fund (ALN 93.461) Federal Award Year: January 1, 2022 through December 31, 2022 Federal Award Agency: U.S. Department of Health and Human Services Criteria or Requirement: Per 2 CFR 200.303, the nonfederal entity must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the nonfederal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. Condition Found, Including Perspective: While no insurance was identified for any of the patients sampled, for 4 out of 40 patients sampled, there was no documentation available to demonstrate that an insurance check was performed prior to Health Resources and Services Administration (HRSA) claim submission. Possible Cause and Asserted Effect: The control to ensure appropriate documentation supporting the performance of the insurance check for each patient prior to the claim submission was not operating effectively. Questioned Costs: None. Statistical Validity: The sample was not intended to be, and was not, a statistically valid sample. Repeat Finding in the Prior Year: Yes, Finding 2021-001 Recommendation: We recommend Atrium Health Enterprise improve its existing insurance verification process to ensure documentation evidencing that all patients identified on the claim form were uninsured individuals at the time the services were provided is retained. Views of Responsible Officials: Atrium Health CMHA currently has an insurance verification process for potentially uninsured patients meeting the criteria prescribed by HRSA whereby identified accounts are sent nightly to Experian, a multinational consumer credit reporting company, who searches for insurance coverage. Negative confirmation documentation is inserted into the patient record. Management is aware of the importance of this process and has continued education efforts with applicable teammates to ensure this process is followed and documented with each patient. Additionally, the HRSA COVID-19 Uninsured Program ended in April of 2022.
Finding No. 2022-002: Reporting and Allowable Costs Federal Program: COVID-19 ? Provider Relief Fund and American Rescue Plan Rural Distribution (ALN 93.498) Federal Award Year: January 1, 2022 through December 31, 2022 Federal Award Agency: U.S. Department of Health and Human Services Criteria or Requirement: Per 2 CFR 200.303, the nonfederal entity must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the nonfederal 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 award, recipients are required to submit a report in the Provider Relief Fund reporting portal for reach reporting period. Condition Found, Including Perspective: Certain costs reported for Wilkes Regional Medical Center totaling $2,063,873 were reported in Period 4 as Other Healthcare Expenses while the expenses to support the draw should have been allocated to the Personnel, Fringe Benefits, Equipment, and Supplies sections of the report. Further, for certain costs of Wilkes Regional Medical Center totaling $29,454 the materials were not received and should not have been charged. Possible Cause and Asserted Effect: The control to ensure that all costs claimed were allowable per the grant and reported appropriately was not operating effectively to ensure that the appropriate costs categories were claimed for Wilkes Regional Medical Center. Questioned Costs: $29,454 Statistical Validity: The sample was not intended to be, and was not, a statistically valid sample Repeat Finding in the Prior Year: No Recommendation: We recommend Wilkes Regional Medical Center enhance its controls over review of expenditures claimed to ensure that the appropriate costs are claimed within the appropriate categories for the Provider Relief Fund reporting. Views of Responsible Officials: Atrium Health management believes that, while the Provider Relief Funds reporting was completed on a periodic basis throughout the pandemic, the intent from HRSA was to document the use of those funds for COVID-19 expenses and for lost revenues over the course of the entire pandemic. Because the PRF portal did not allow for previous periods to be restated in response to new information or corrections identified from previous reported periods, the only recourse available for health systems to restate COVID-19 expenses or lost revenues is through future PRF reporting or through the HRSA audit process. Management agrees that the control process in place during the initial reporting process for Wilkes Regional Medical Center did not yield the ultimate cost categorization that was corrected in the PRF reporting noted above; however, management?s interaction with HRSA throughout 2022 and the resulting clarification of COVID-19 expenses, is now incorporated into the overall PRF reporting control process. With respect to the identified questioned costs, management agrees that these costs should not have been included as COVID-19 related expenses for that period. However, management also recognizes that Wilkes Regional Medical Center has unused lost revenues more than this amount and as such, the questioned costs would not be subject to a return of the PRF proceeds. This position is supported by a similar finding in the 2021 Atrium Health Enterprise audit that was resolved with this conclusion and is documented in the Management Decision Letter issued by HRSA dated June 26, 2023