Audit 45744

FY End
2022-06-30
Total Expended
$6.19M
Findings
4
Programs
1
Year: 2022 Accepted: 2023-01-03

Organization Exclusion Status:

Checking exclusion status...

Findings

ID Ref Severity Repeat Requirement
48129 2022-001 Material Weakness Yes A
48130 2022-002 Material Weakness Yes L
624571 2022-001 Material Weakness Yes A
624572 2022-002 Material Weakness Yes L

Programs

ALN Program Spent Major Findings
93.498 Provider Relief Fund $6.19M Yes 2

Contacts

Name Title Type
ZS3YMNTMXVE3 Dessy Chi Auditee
9512950326 Debbie Kohnle Auditor
No contacts on file

Notes to SEFA

Title: Provider Relief Fund and American Rescue Plan (ARP) Rural Distributions Accounting Policies: The accompanying schedule of expenditures of federal awards (the Schedule) includes the federal grant activity of Faculty Physicians and Surgeons of LLUSM (FP&S) under the programs of the federal government for the year ended June 30, 2022. The information in this Schedule is presented in accordance with the requirements of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles and Audit Requirement for Federal Awards (uniform Guidance). Because the Schedule presents only a selected portion of the operations of FP&S, it is not intended to and does not present the financial position, statement of activities or cash flows of FP&S. Expenditures reported on the Schedule are reported on the accrual basis of accounting. Such expenditures are recognized following the cost principles contained in the Uniform Guidance wherein certain types of expenditures are not allowable or are limited to reimbursement. De Minimis Rate Used: N Rate Explanation: The auditee did not use the de minimis cost rate. The amount presented on the SEFA for Assistance Listing Number 93.498, Provider Relief Fund (PRF) and American Rescue Plan (ARP) Rural Distribution, is for the year ended June 30, 2022. The amount presented reconciles to the information reported to the Health Resources and Services Administration (HRSA) as follows: (SEE TABLE IN SEFA FOOTNOTES) Health and Human Services (HHS) has indicated the PRF on the SEFA be reported corresponding to reporting requirements of the HRSA PRF Reporting 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. FP&S reports into the HRSA PRF Reporting Portal after each Periods deadline to use the funds (i.e., after the end of the Period of Availability).The SEFA includes $6,189,783 of PRF received on October 19, 2020. In accordance with guidance from HHS, these amounts are presented as Period 2. Such amounts were recognized as other revenue in Faculty Physicians and Surgeons of LLUSM financial statements in the year ended June 30, 2021.

Finding Details

Finding 2022-001 ? Internal Control Deficiency over A. Activities Allowed or Unallowed Identification of the federal program: Federal Grantor: United States Department of Health and Human Services Assistance Listing No.: 93.498 Provider Relief Funds Award Period of Performance: Period 1 ? July 1, 2021 to June 30, 2022 Criteria or Specific Requirement (including statutory, regulatory or other citation): Title 2, Subtitle A Chapter II Part 200 Subpart D 200.303 Internal controls. The non-Federal entity must: (a) Establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). The terms and conditions of the award requires the following: ? The recipient certified that the payment will only be used to prevent, prepare for, and respond to coronavirus, and that the payment shall reimburse the recipient only for health care related expenses or lost revenues that are attributable to coronavirus. ? The recipient certifies that it will not use the payment to reimburse expenses or losses that have been reimbursed from other sources or that other sources are obligated to reimburse. ? The recipient shall submit reports as the secretary of Health and Human Services (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: Per discussion with management, the Company has processes and internal controls over the terms and conditions of the award and transactional level internal controls in place to ensure Coronavirus related expenses reported to HHS through their reporting portal (the Portal). However, management did not retain documentation evidencing the performance of these controls. Effect or potential effect: There is no documentation to support the performance of internal controls for the term and conditions of the award and the expenses attributable to Coronavirus calculation. Questioned Costs: None Context: During our testing over the PRF program, we observed that management did not retain evidence of controls surrounding the terms and condition of the award and the calculation of expenses attributable to Coronavirus reported during July 1, 2021 to June 30, 2022. Identification as a repeat finding, if applicable: The finding is a repeat finding. Recommendation: Management should refine its process and retain documentation evidencing that management adheres to the terms and conditions of the award and retain documentation evidencing that management reviewed the completeness and accuracy of expenses attributable to Coronavirus calculation. View of Responsible Officials: Management agrees with the finding. Management will develop internal controls to review and approve supporting documentation and calculations of the Provider Relief Fund federal expenditures and terms and conditions.
Finding 2022-002 ? Internal Control Deficiency over L. Reporting Identification of the federal program: Federal Grantor: United States Department of Health and Human Services, Health Resources and Services Administration (HRSA) Assistance Listing No.: 93.498 Provider Relief Funds Award Period of Performance: July 1, 2021 ? June 30, 2022 Criteria or Specific Requirement (including statutory, regulatory or other citation): Section 200.303 of the Uniform Guidance states the following regarding internal control: ?The non-Federal entity must: (a) Establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). Condition: Per discussion with management, the Company has processes and internal controls in place to ensure the lost revenue calculation submitted for PRF was complete and accurate and complied with the terms and conditions as reported in the HRSA Portal filings. However, management did not retain documentation evidencing the performance of these controls. Effect or potential effect: There is no documentation to support the performance of internal controls for the lost revenue calculation. Questioned Costs: None Context: Total PRF lost revenues were $26,172,865. Management selected budget versus actual to calculate lost revenues. The amounts reported agreed to the budget and actual revenues as reported in the portal. Identification as a repeat finding, if applicable: The finding is a repeat finding. Recommendation: Management should refine its process and retain documentation evidencing that management reviewed the completeness and accuracy of the lost revenue calculation. View of Responsible Officials: Management agrees with the finding. Management will develop internal controls to review and approve supporting documentation and calculations of the Provider Relief Fund federal lost revenues.
Finding 2022-001 ? Internal Control Deficiency over A. Activities Allowed or Unallowed Identification of the federal program: Federal Grantor: United States Department of Health and Human Services Assistance Listing No.: 93.498 Provider Relief Funds Award Period of Performance: Period 1 ? July 1, 2021 to June 30, 2022 Criteria or Specific Requirement (including statutory, regulatory or other citation): Title 2, Subtitle A Chapter II Part 200 Subpart D 200.303 Internal controls. The non-Federal entity must: (a) Establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). The terms and conditions of the award requires the following: ? The recipient certified that the payment will only be used to prevent, prepare for, and respond to coronavirus, and that the payment shall reimburse the recipient only for health care related expenses or lost revenues that are attributable to coronavirus. ? The recipient certifies that it will not use the payment to reimburse expenses or losses that have been reimbursed from other sources or that other sources are obligated to reimburse. ? The recipient shall submit reports as the secretary of Health and Human Services (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: Per discussion with management, the Company has processes and internal controls over the terms and conditions of the award and transactional level internal controls in place to ensure Coronavirus related expenses reported to HHS through their reporting portal (the Portal). However, management did not retain documentation evidencing the performance of these controls. Effect or potential effect: There is no documentation to support the performance of internal controls for the term and conditions of the award and the expenses attributable to Coronavirus calculation. Questioned Costs: None Context: During our testing over the PRF program, we observed that management did not retain evidence of controls surrounding the terms and condition of the award and the calculation of expenses attributable to Coronavirus reported during July 1, 2021 to June 30, 2022. Identification as a repeat finding, if applicable: The finding is a repeat finding. Recommendation: Management should refine its process and retain documentation evidencing that management adheres to the terms and conditions of the award and retain documentation evidencing that management reviewed the completeness and accuracy of expenses attributable to Coronavirus calculation. View of Responsible Officials: Management agrees with the finding. Management will develop internal controls to review and approve supporting documentation and calculations of the Provider Relief Fund federal expenditures and terms and conditions.
Finding 2022-002 ? Internal Control Deficiency over L. Reporting Identification of the federal program: Federal Grantor: United States Department of Health and Human Services, Health Resources and Services Administration (HRSA) Assistance Listing No.: 93.498 Provider Relief Funds Award Period of Performance: July 1, 2021 ? June 30, 2022 Criteria or Specific Requirement (including statutory, regulatory or other citation): Section 200.303 of the Uniform Guidance states the following regarding internal control: ?The non-Federal entity must: (a) Establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). Condition: Per discussion with management, the Company has processes and internal controls in place to ensure the lost revenue calculation submitted for PRF was complete and accurate and complied with the terms and conditions as reported in the HRSA Portal filings. However, management did not retain documentation evidencing the performance of these controls. Effect or potential effect: There is no documentation to support the performance of internal controls for the lost revenue calculation. Questioned Costs: None Context: Total PRF lost revenues were $26,172,865. Management selected budget versus actual to calculate lost revenues. The amounts reported agreed to the budget and actual revenues as reported in the portal. Identification as a repeat finding, if applicable: The finding is a repeat finding. Recommendation: Management should refine its process and retain documentation evidencing that management reviewed the completeness and accuracy of the lost revenue calculation. View of Responsible Officials: Management agrees with the finding. Management will develop internal controls to review and approve supporting documentation and calculations of the Provider Relief Fund federal lost revenues.