Audit 8165

Section III – Federal Award Findings and Questioned Costs Finding Reference: 2021-001 Federal Program Information Federal Agency: U.S. Department of Health and Human Services (HHS), Health Resources and Services Administration (HRSA) Award: Assistance Listing Number 93.461 COVID-19 - HRSA COVID-19 Claims Reimbursement for the Uninsured Program and the COVID-19 Coverage Assistance Fund Award Period: February 4, 2020 – April 5, 2022 Description: Internal control deficiency over review of claims prior to submission Type of Finding: Material Weakness in Internal Control Over Compliance Criteria or specific requirement (including statutory, regulatory or other citation) In accordance with Title 2 U.S. Code of Federal Regulations, Part 200.303, Internal controls, “Establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award.” 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). A. Activities Allowed or Unallowed – Activities allowed include required primary health services as described in the terms and conditions of the award for uninsured individuals, including reimbursement of payments for COVID-19 testing and testing-related items for individuals who do not have coverage through an individual or employer-sponsored plan, a federal healthcare program, or the Federal Employees Health Benefits Program at the time the services were rendered. E. Eligibility – Services must be for individuals who at the time the services were provided were uninsured as described in the terms and conditions of the award. Condition The System did not retain audit evidence of its internal controls over its review and approval of claims ensuring the patients were eligible and the services are allowable under the program’s terms and conditions prior to submission on the HRSA portal for reimbursement. Cause Management designed a process to verify that claims were in full compliance with the program’s terms and conditions, noting patients were eligible and services were allowable, prior to submission to HRSA; however, they did not retain supporting documentation to evidence that the internal review controls were appropriately designed and functioning throughout the process. Effect or potential effect The patient could have had insurance coverage at the time the service was performed or the amount submitted for reimbursement could have been partially or wholly unallowable under the program’s terms and conditions, resulting in receiving funds from the HRSA COVID-19 Uninsured Program inappropriately or not providing refunds to HRSA on a timely basis. Questioned costs None Identification of a repeat finding This is a repeat finding. Context Management did not retain evidence supporting their internal control over the process to seek reimbursement for claims submitted to the HRSA portal. Recommendation We recommend that management develop appropriate documentation to support the internal controls that would ensure claims are reviewed and complied with the program’s terms and conditions prior to submission on the HRSA portal to ensure appropriate reimbursement or that amounts required to be refunded to HRSA are analyzed on a timely basis. View of responsible officials There is no disagreement with the audit finding.

Finding Reference: 2021-002 Federal Program Information Federal Agency: U.S. Department of Health and Human Services (HHS), Health Resources and Services Administration (HRSA) Award: Assistance Listing Number 93.461 COVID-19 - HRSA COVID-19 Claims Reimbursement for the Uninsured Program and the COVID-19 Coverage Assistance Fund Award Period: February 4, 2020 – April 5, 2022 Description: Timely Preparation of Schedule of Expenditures of Federal Awards Type of Finding: Material Weakness in Internal Control Over Compliance Criteria or specific requirement (including statutory, regulatory or other citation) In accordance with Title 2 U.S. Code of Federal Regulations, Part 200.303, Internal controls, “Establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award.” 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 The System had not developed a formal process to prepare and review its Schedule of Expenditures of Federal Awards and was not able to complete the Schedule for the year ended June 30, 2021 in a timely manner. Cause During the year ended June 30, 2021, the System was required to prepare the Schedule for the second time since its expenditures exceeded $750,000. This was primarily due to a new grant that arose suddenly in response to treating Covid-19 patients. Consequently, the System had not identified individuals with the appropriate knowledge and training to prepare the Schedule for this fiscal period. This also occurred as a result of Covid-19 which impacted the availability of resources due to the challenges presented to the System which were unexpected and strained existing resources and the ability to hire new resources on a timely basis. Effect or potential effect The reporting and verification of the completeness and accuracy of the expenditures required more time than expected since this was the initial preparation of the Schedule and the unique requirements of the Covid-19 funds. Questioned costs None Identification of a repeat finding This is a repeat finding. Context The audit was not completed and the reporting submitted within the earlier of 30 calendar days after receipt of the auditor’s report(s), or nine months after the end of the audit period as required by the Uniform Guidance. Recommendation The System’s should develop a formal process to prepare and review the Schedule and identify resources with appropriate knowledge to be involved in this process. View of responsible officials There is no disagreement with the audit finding

Finding Reference: 2021-003 Federal Program Information Federal Agency: U.S. Department of Health and Human Services (HHS), Health Resources and Services Administration (HRSA) Award: Assistance Listing Number 93.498 COVID-19 - Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Award Period: January 1, 2020 – June 30, 2021 Description: Internal control deficiency over review of report submission Type of Finding: Material Weakness in Internal Control Over Compliance Criteria or specific requirement (including statutory, regulatory or other citation) In accordance with Title 2 U.S. Code of Federal Regulations, Part 200.303, Internal controls, “Establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award.” 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). A. Activities Allowed or Unallowed L. Reporting The terms and conditions of the award require the recipient to submit reports to the secretary of HHS for each reporting period to ensure compliance with conditions that are imposed on the payment, and such report shall be in such form, with such content, as specified by the secretary of HHS in program instructions directed to all recipients. Condition The System did not retain audit evidence of its internal controls over its review and approval of the supporting documentation underlying the data submitted in the HHS portal for the Provider Relief Fund (PRF). Cause Management designed a process to verify that the information submitted in the reports were in compliance with the program’s terms and conditions, prior to submission to HRSA; however, they did not retain supporting documentation to evidence that the internal review controls were appropriately designed and functioning throughout the process. Effect or potential effect A deficiency in internal control over the review of the data submitted in the HHS portal could result in a misstatement of the amounts reported in the HHS portal. Questioned costs None Identification of a repeat finding This is not a repeat finding. Context Management did not retain evidence supporting their internal control over their review and approval process of the information in their report prior to submission to the HRSA portal. Recommendation We recommend that management develop appropriate documentation to support the internal controls that would ensure the data was reviewed and complied with the program’s terms and conditions prior to submission on the HRSA portal to ensure appropriate reimbursement. View of responsible officials There is no disagreement with the audit finding

Section III – Federal Award Findings and Questioned Costs Finding Reference: 2021-001 Federal Program Information Federal Agency: U.S. Department of Health and Human Services (HHS), Health Resources and Services Administration (HRSA) Award: Assistance Listing Number 93.461 COVID-19 - HRSA COVID-19 Claims Reimbursement for the Uninsured Program and the COVID-19 Coverage Assistance Fund Award Period: February 4, 2020 – April 5, 2022 Description: Internal control deficiency over review of claims prior to submission Type of Finding: Material Weakness in Internal Control Over Compliance Criteria or specific requirement (including statutory, regulatory or other citation) In accordance with Title 2 U.S. Code of Federal Regulations, Part 200.303, Internal controls, “Establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award.” 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). A. Activities Allowed or Unallowed – Activities allowed include required primary health services as described in the terms and conditions of the award for uninsured individuals, including reimbursement of payments for COVID-19 testing and testing-related items for individuals who do not have coverage through an individual or employer-sponsored plan, a federal healthcare program, or the Federal Employees Health Benefits Program at the time the services were rendered. E. Eligibility – Services must be for individuals who at the time the services were provided were uninsured as described in the terms and conditions of the award. Condition The System did not retain audit evidence of its internal controls over its review and approval of claims ensuring the patients were eligible and the services are allowable under the program’s terms and conditions prior to submission on the HRSA portal for reimbursement. Cause Management designed a process to verify that claims were in full compliance with the program’s terms and conditions, noting patients were eligible and services were allowable, prior to submission to HRSA; however, they did not retain supporting documentation to evidence that the internal review controls were appropriately designed and functioning throughout the process. Effect or potential effect The patient could have had insurance coverage at the time the service was performed or the amount submitted for reimbursement could have been partially or wholly unallowable under the program’s terms and conditions, resulting in receiving funds from the HRSA COVID-19 Uninsured Program inappropriately or not providing refunds to HRSA on a timely basis. Questioned costs None Identification of a repeat finding This is a repeat finding. Context Management did not retain evidence supporting their internal control over the process to seek reimbursement for claims submitted to the HRSA portal. Recommendation We recommend that management develop appropriate documentation to support the internal controls that would ensure claims are reviewed and complied with the program’s terms and conditions prior to submission on the HRSA portal to ensure appropriate reimbursement or that amounts required to be refunded to HRSA are analyzed on a timely basis. View of responsible officials There is no disagreement with the audit finding.

Finding Reference: 2021-002 Federal Program Information Federal Agency: U.S. Department of Health and Human Services (HHS), Health Resources and Services Administration (HRSA) Award: Assistance Listing Number 93.461 COVID-19 - HRSA COVID-19 Claims Reimbursement for the Uninsured Program and the COVID-19 Coverage Assistance Fund Award Period: February 4, 2020 – April 5, 2022 Description: Timely Preparation of Schedule of Expenditures of Federal Awards Type of Finding: Material Weakness in Internal Control Over Compliance Criteria or specific requirement (including statutory, regulatory or other citation) In accordance with Title 2 U.S. Code of Federal Regulations, Part 200.303, Internal controls, “Establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award.” 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 The System had not developed a formal process to prepare and review its Schedule of Expenditures of Federal Awards and was not able to complete the Schedule for the year ended June 30, 2021 in a timely manner. Cause During the year ended June 30, 2021, the System was required to prepare the Schedule for the second time since its expenditures exceeded $750,000. This was primarily due to a new grant that arose suddenly in response to treating Covid-19 patients. Consequently, the System had not identified individuals with the appropriate knowledge and training to prepare the Schedule for this fiscal period. This also occurred as a result of Covid-19 which impacted the availability of resources due to the challenges presented to the System which were unexpected and strained existing resources and the ability to hire new resources on a timely basis. Effect or potential effect The reporting and verification of the completeness and accuracy of the expenditures required more time than expected since this was the initial preparation of the Schedule and the unique requirements of the Covid-19 funds. Questioned costs None Identification of a repeat finding This is a repeat finding. Context The audit was not completed and the reporting submitted within the earlier of 30 calendar days after receipt of the auditor’s report(s), or nine months after the end of the audit period as required by the Uniform Guidance. Recommendation The System’s should develop a formal process to prepare and review the Schedule and identify resources with appropriate knowledge to be involved in this process. View of responsible officials There is no disagreement with the audit finding

Finding Reference: 2021-003 Federal Program Information Federal Agency: U.S. Department of Health and Human Services (HHS), Health Resources and Services Administration (HRSA) Award: Assistance Listing Number 93.498 COVID-19 - Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Award Period: January 1, 2020 – June 30, 2021 Description: Internal control deficiency over review of report submission Type of Finding: Material Weakness in Internal Control Over Compliance Criteria or specific requirement (including statutory, regulatory or other citation) In accordance with Title 2 U.S. Code of Federal Regulations, Part 200.303, Internal controls, “Establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award.” 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). A. Activities Allowed or Unallowed L. Reporting The terms and conditions of the award require the recipient to submit reports to the secretary of HHS for each reporting period to ensure compliance with conditions that are imposed on the payment, and such report shall be in such form, with such content, as specified by the secretary of HHS in program instructions directed to all recipients. Condition The System did not retain audit evidence of its internal controls over its review and approval of the supporting documentation underlying the data submitted in the HHS portal for the Provider Relief Fund (PRF). Cause Management designed a process to verify that the information submitted in the reports were in compliance with the program’s terms and conditions, prior to submission to HRSA; however, they did not retain supporting documentation to evidence that the internal review controls were appropriately designed and functioning throughout the process. Effect or potential effect A deficiency in internal control over the review of the data submitted in the HHS portal could result in a misstatement of the amounts reported in the HHS portal. Questioned costs None Identification of a repeat finding This is not a repeat finding. Context Management did not retain evidence supporting their internal control over their review and approval process of the information in their report prior to submission to the HRSA portal. Recommendation We recommend that management develop appropriate documentation to support the internal controls that would ensure the data was reviewed and complied with the program’s terms and conditions prior to submission on the HRSA portal to ensure appropriate reimbursement. View of responsible officials There is no disagreement with the audit finding