Federal Program Information:
Federal Agency: U.S. Department of Health and Human Services
Awards: Assistance Listing Number 93.498 COVID-19 – Provider Relief
Fund and American Rescue Plan (ARP) Rural Distribution
Award Periods: Period 3 – January 1, 2021 to June 30, 2022
Period 4 – June 30, 2021 to ...
Federal Program Information:
Federal Agency: U.S. Department of Health and Human Services
Awards: Assistance Listing Number 93.498 COVID-19 – Provider Relief
Fund and American Rescue Plan (ARP) Rural Distribution
Award Periods: Period 3 – January 1, 2021 to June 30, 2022
Period 4 – June 30, 2021 to December 31, 2022
Description: Review and Approval of the expenditures included in the HRSA
portal submission
Type of Finding: Significant Deficiency in Internal Control Over Compliance
Recommendation: Management should design internal controls related to the documentation of the review of the expenditures for the HRSA portal submission to ensure that the reported amounts are
accurate.
View of Responsible Officials: Management concurs with the finding and will implement procedures to ensure that HRSA reporting reports are prepared by individuals with HRSA reporting experience and reviewed by management prior to submission.
Name(s) of the Contact Person(s) Responsible for Corrective Action:
Christopher T. Smith, Vice President of Finance and Corporate Controller, 571-472-8122.
Christopher Trump, Senior Director of Financial Reporting, 571-373-2868.
Michael H. Lowen, Director, Grant Accounting, 571-472-8108.
Corrective Action Planned:
Activities Allowed or Unallowed, Allowable Costs/Cost Principles - Inova has an established process
that identifies actions needed to carry out specific responses to identified internal control risks related to
the review of the expenditures for the HRSA portal submissions, specifically that the reported amounts
are accurate. Part of that process is to review the HRSA portal submissions for specific allowable
activities requirements, and those activities/costs that require pre-approval by the awarding agency.
Additionally, monthly, the Director of Grants Accounting reviews the budget versus actual reports
investigating unusual or unexpected variances and documents results of follow-up work performed. In
order to improve both of these processes and ensure more accurate reviews, Inova’s Director of Grants
Accounting will develop a training program that ensures a timely cadence, of no less than bi-annually,
whereby all applicable personnel obtain current knowledge of allowable activities and associated costs
to be submitted to HRSA and other governing agencies as deemed appropriate. The program will
include self-guided training in addition to enlisting industry experts to instruct on relevant updates.
External trainings will be documented either electronically, if so allowed, or through properly recorded
minutes.
Reporting - Management will identify, and put into effect, actions needed to carry out specific responses
to identified risks related to reporting. Such actions will include enhancing current knowledge of
reporting requirements through a training program as discussed above, develop and document all controls
over reporting that were leveraged to create and review manually prepared spreadsheets and reports.
Prior to the HRSA portal submissions, our review process, as identified above, will be formally
documented and evidenced by proper signoffs. Further, we will also address segregation of duties
concerns that will alleviate risk of fraud and develop and appropriately document bridge between source
data and final reports for any reconciling items and lack of or inappropriate source data or analysis used
as the basis of reporting. Inova management will review, and periodically update applicable award
agreements or contracts for specific reporting requirements and establish a reporting calendar for review
and approval. The calendar will be periodically reviewed with the Grants Management Office (“GMO”)
for the completeness and accuracy of and adherence to the reporting calendar.
Written policies and procedures will be created outlining processes and control activities for ensuring
reporting to federal awarding agencies and pass-through entities are complete and accurate.
Planned Completion Date for Corrective Action Planned:
Ongoing with a completion date of December 31, 2023.