Audit 9933

FY End
2023-06-30
Total Expended
$42.69M
Findings
4
Programs
22
Year: 2023 Accepted: 2024-01-05
Auditor: Kpmg LLP

Organization Exclusion Status:

Checking exclusion status...

Findings

ID Ref Severity Repeat Requirement
7581 2023-001 Material Weakness - B
7582 2023-002 Material Weakness - L
584023 2023-001 Material Weakness - B
584024 2023-002 Material Weakness - L

Contacts

Name Title Type
TXKHAN6KC279 Michael Gleason Auditee
2255267493 Susan Warren Auditor
No contacts on file

Notes to SEFA

Title: Basis of Presentation Accounting Policies: For purposes of the Schedule, expenditures of federal award programs are recognized 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 as to reimbursement. De Minimis Rate Used: N Rate Explanation: The System has elected not to use the 10-percent de minimis indirect cost rate as allowed under the Uniform Guidance. The accompanying schedule of expenditures of federal awards (the Schedule) includes the federal grant activity of Franciscan Missionaries of Our Lady Health System, Inc. and affiliated organizations (the System) under programs of the federal government for the year ended June 30, 2023. The System’s consolidated financial statements include the operations of Villa St. Francis, Inc., Assisi Village, Inc., Calais House, Inc., and Chateau Louise, Inc. from July 1, 2022 to April 17, 2023, which collectively expended $9,377,722 in federal awards, which is not included in the Schedule, because those U.S. Housing and Urban Development (HUD) Projects listed above arranged to have separate audits performed in accordance with the Uniform Guidance. On April 18, 2023, the System and Villa St. Francis, Inc., Assisi Village, Inc., Calais House, Inc., and Chateau Louise, Inc. sold the property assets of Villa St. Francis, Inc., Assisi Village, Inc., Calais House, Inc., and Chateau Louise, Inc. to a third party. The amounts reported as federal expenditures were obtained from the System’s general ledger. Because the Schedule presents only a selected portion of the operations of the System, it is not intended to and does not present the financial position, results of operations, changes in net assets, and cash flows of the System. For purposes of the Schedule, federal expenditures include all grants, contracts, and similar agreements entered into directly between the System, the agencies and departments of the federal government, and all subawards to the System by nonfederal organizations pursuant to federal grants, contracts, and similar agreements. The information in the Schedule is presented in accordance with the audit requirements of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance).
Title: Provider Relief Funds (ALN 93.498) Accounting Policies: For purposes of the Schedule, expenditures of federal award programs are recognized 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 as to reimbursement. De Minimis Rate Used: N Rate Explanation: The System has elected not to use the 10-percent de minimis indirect cost rate as allowed under the Uniform Guidance. As required by the granting agency, the Provider Relief Fund (PRF) amounts presented in the Schedule represent lost revenues and expenses as reported to the U.S. Department of Health and Human Services for the PRF Portal Reporting time periods of January 1, 2023 to March 31, 2023 and July 1, 2023 to September 30, 2023.
Title: Federal Direct Student Loans (ALN 84.268) Accounting Policies: For purposes of the Schedule, expenditures of federal award programs are recognized 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 as to reimbursement. De Minimis Rate Used: N Rate Explanation: The System has elected not to use the 10-percent de minimis indirect cost rate as allowed under the Uniform Guidance. The System’s Federal Direct Student Loans (Direct Loans) included in the Schedule represent loans received by students during fiscal year 2023, which were not made by the System. The System is responsible only for the performance of certain administrative duties with respect to its Direct Loans Program, and accordingly, these loans are not included in its consolidated financial statements. The System is not required to maintain the balance of the loans outstanding to students and former students of the System under these programs. Such balances are maintained and administered by the lenders and guarantors of these loans.During the year ended June 30, 2023, the System advanced the following amounts of new loans under the Direct Loan Program: See the notes to the SEFA for the chart/table
Title: Relationship to Consolidated Financial Statements Accounting Policies: For purposes of the Schedule, expenditures of federal award programs are recognized 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 as to reimbursement. De Minimis Rate Used: N Rate Explanation: The System has elected not to use the 10-percent de minimis indirect cost rate as allowed under the Uniform Guidance. Federal expenditures are reported in the System’s 2023 consolidated financial statements as follows: See the notes to the SEFA for the chart/table
Title: Expenditures of Federal Awards to Subrecipients Accounting Policies: For purposes of the Schedule, expenditures of federal award programs are recognized 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 as to reimbursement. De Minimis Rate Used: N Rate Explanation: The System has elected not to use the 10-percent de minimis indirect cost rate as allowed under the Uniform Guidance. The System did not pass through any expenditures of federal awards to subrecipients during 2023.

Finding Details

Finding No: 2023-001 Activities allowed/unallowed and allowable costs Federal Agency: U.S. Department of Health and Human Services Pass-Through Entities: N/A Assistance Listing Number: 93.498 Program: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Award Year: January 1 to March 31, 2023 (Period 4) and July 1 to September 30, 2023 (Period 5) Criteria or Requirement Per 2 CFR 200.303, the non-Federal entity must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. Condition Found, Including Perspective Bonuses, that were claimed to be COVID-related as reported via the PRF portal, were paid out to St. Dominic employees for which there was no supporting documentation to validate they were allowable COVID-related bonuses in accordance with the System’s policies. Possible Cause Change in control owners at St. Dominic resulting in management’s failure to retain sufficient documentation to support the bonus payments. Questioned Cost $3,000 for all St. Dominic employees Effect Federal funds were possibly expended for unallowable purposes as management could not provide documentation to support the bonuses were COVID-19 related. Statistical Validity The sample was not intended to be, and was not, a statistically valid sample. Repeat Finding in the Prior Year Not a repeat finding. Recommendation The System should strengthen controls over the retention of documentation to ensure that management can provide the necessary documentation to support grant expenditures. View of Responsible Officials Management concurs with this finding. Effective January 2022, the System has transitioned the St. Dominic payroll to be processed centrally at the System in accordance with all System’s processes and procedures.
Finding No: 2023-002 Reporting Federal Agency: U.S. Department of Health and Human Services Pass-Through Entities: N/A Assistance Listing Number: 93.498 Program: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Award Year: January 1 to March 31, 2023 (Period 4) and July 1 to September 30, 2023 (Period 5) Criteria or Requirement Per 2 CFR 200.303, the non-Federal entity must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. Condition Found, Including Perspective The review of lost revenue and related personnel expenses was not at a sufficient level of detail to demonstrate the supporting expenditures agreed to the portal reports. Although management reviewed and reconciled the expenditures to the portal reports, it was not evident how the 2022 adjustments to lost revenue made by HRSA and identified during the 2022 single audit impacted the current year portal reporting. Only a portion of the adjustments were reflected in the Period 4 and Period 5 reporting and management was not tracking which HRSA adjustments had been made, what was left to be made, and to which entities the adjustments were related to. Possible Cause Management did not have a single owner of the portal reports reconciliation process whom could identify that the HRSA adjustments were not being tracked. Questioned Cost None Effect During the audit, the System updated the reconciliation to agree to the portal reports for lost revenue amounts that had been adjusted and determined the remaining portion of the 2022 adjustments that needed to be included in Period 6 reporting. Statistical Validity The sample was not intended to be, and was not, a statistically valid sample. Repeat Finding in the Prior Year Not a repeat finding. Recommendation The System should strengthen controls over the management review process to ensure the amounts reported the HRSA portal are supported. View of Responsible Officials Management concurs with the finding. This did not result in an overstatement of qualifying expenditures and no repayment of funding was required. The reconciliation review process will be enhanced for funding that applies to multiple funding periods.
Finding No: 2023-001 Activities allowed/unallowed and allowable costs Federal Agency: U.S. Department of Health and Human Services Pass-Through Entities: N/A Assistance Listing Number: 93.498 Program: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Award Year: January 1 to March 31, 2023 (Period 4) and July 1 to September 30, 2023 (Period 5) Criteria or Requirement Per 2 CFR 200.303, the non-Federal entity must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. Condition Found, Including Perspective Bonuses, that were claimed to be COVID-related as reported via the PRF portal, were paid out to St. Dominic employees for which there was no supporting documentation to validate they were allowable COVID-related bonuses in accordance with the System’s policies. Possible Cause Change in control owners at St. Dominic resulting in management’s failure to retain sufficient documentation to support the bonus payments. Questioned Cost $3,000 for all St. Dominic employees Effect Federal funds were possibly expended for unallowable purposes as management could not provide documentation to support the bonuses were COVID-19 related. Statistical Validity The sample was not intended to be, and was not, a statistically valid sample. Repeat Finding in the Prior Year Not a repeat finding. Recommendation The System should strengthen controls over the retention of documentation to ensure that management can provide the necessary documentation to support grant expenditures. View of Responsible Officials Management concurs with this finding. Effective January 2022, the System has transitioned the St. Dominic payroll to be processed centrally at the System in accordance with all System’s processes and procedures.
Finding No: 2023-002 Reporting Federal Agency: U.S. Department of Health and Human Services Pass-Through Entities: N/A Assistance Listing Number: 93.498 Program: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Award Year: January 1 to March 31, 2023 (Period 4) and July 1 to September 30, 2023 (Period 5) Criteria or Requirement Per 2 CFR 200.303, the non-Federal entity must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. Condition Found, Including Perspective The review of lost revenue and related personnel expenses was not at a sufficient level of detail to demonstrate the supporting expenditures agreed to the portal reports. Although management reviewed and reconciled the expenditures to the portal reports, it was not evident how the 2022 adjustments to lost revenue made by HRSA and identified during the 2022 single audit impacted the current year portal reporting. Only a portion of the adjustments were reflected in the Period 4 and Period 5 reporting and management was not tracking which HRSA adjustments had been made, what was left to be made, and to which entities the adjustments were related to. Possible Cause Management did not have a single owner of the portal reports reconciliation process whom could identify that the HRSA adjustments were not being tracked. Questioned Cost None Effect During the audit, the System updated the reconciliation to agree to the portal reports for lost revenue amounts that had been adjusted and determined the remaining portion of the 2022 adjustments that needed to be included in Period 6 reporting. Statistical Validity The sample was not intended to be, and was not, a statistically valid sample. Repeat Finding in the Prior Year Not a repeat finding. Recommendation The System should strengthen controls over the management review process to ensure the amounts reported the HRSA portal are supported. View of Responsible Officials Management concurs with the finding. This did not result in an overstatement of qualifying expenditures and no repayment of funding was required. The reconciliation review process will be enhanced for funding that applies to multiple funding periods.