FAC Explorer

Finding 1098728 (2024-001)

Material Weakness Repeat Finding
Requirement
B
Questioned Costs
$1
Year
2024
Accepted
2025-02-06
Audit: 341568
Organization: Commonspirit Health (IL)
Auditor: Ernst & Young LLP

AI Summary

  • Core Issue: St. Mary Medical Center and Bailey-Boushay House lack effective internal controls for managing federal grant expenditures, leading to unallowable payroll charges.
  • Impacted Requirements: Non-compliance with 2 CFR 200.303(a) and 2 CFR 200.430 regarding internal controls and documentation of personnel expenses.
  • Recommended Follow-Up: Management should ensure proper approval processes for timecards and strengthen internal controls to prevent future discrepancies in grant expenditures.

Finding Text

Finding 2024-001 – Allowable Costs/Cost Principles Identification of the federal program: Health Resources and Services Administration HIV Emergency Relief Project Grants Assistance Listing No. 93.914 Pass Through Numbers Pass Through Entity Grant Period PH-002898 County of Los Angeles 01/11/2011–02/28/2025 PH-002375 County of Los Angeles 12/01/2012–06/30/2025 PH-003746 County of Los Angeles 12/01/2012–06/30/2025 PH-003802 County of Los Angeles 01/01/2013–06/30/2025 H-208518 County of Los Angeles 04/01/2006–07/31/2025 PH-004205 County of Los Angeles 06/01/2020–02/28/2025 10126 PREV King County Public Health 03/01/2023–02/29/2024 11987 PREV King County Public Health 03/01/2024–02/28/2025 St. Mary Medical Center – Long Beach Bailey-Boushay House Criteria or specific requirement (including statutory, regulatory, or other citation): 2 CFR 200.303(a) requires that a 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 and the “Internal Control Integrated Framework”, issued by the Bailey-Boushay House Committee of Sponsoring Organizations of the Treadway Commission (COSO).” 2 CFR 200.430 (i) states “Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflected the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federal assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity’s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.” Only expenditures incurred related to the federal program should be requested for reimbursement. Condition: St. Mary Medical Center – Long Beach and Bailey-Boushay House did not have effective internal controls addressing the requirements of 2 CFR 200.303(a) and 2 CFR 200.430, including consistent approval of employees’ timecards. At Bailey-Boushay House, one employee’s salary that was charged to the grant was not supported by the underlying timesheet for the respective pay period and the related expenditures should not have been charged to the grant and requested for reimbursement. Cause: St. Mary Medical Center – Long Beach and Bailey-Boushay House management have been developing and implementing internal controls in response to the prior year finding; however, controls were not implemented during the entire period under audit. For one employee at Bailey-Boushay House, the timecard reflected zero hours for grant award 10126-PREV. There was a clerical error whereby the hours transferred from the timecard were reported to the wrong grant, resulting in an overcharge to the federal grant. Effect or potential effect: Unallowable and/or inaccurate payroll expenditures could be charged to the federal program. Questioned costs: $504, calculated as the amount charged to the grant that was not supported by the underlying time sheet for one employee. Context: We issued a material weakness for St. Mary Medical Center – Long Beach and Bailey-Boushay House related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding. For one employee, the clerical error resulted in an overcharge to the grant. Total payroll expenditures for St. Mary Medical Center – Long Beach were approximately $1.1 million and represent 24% of the total HIV Emergency Relief Project Grants expenditures of approximately $4.6 million. Total payroll expenditures, including fringe benefits, for Bailey-Boushay House were approximately $1.4 million and represent 30% of the total HIV Emergency Relief Project Grants expenditures of approximately $4.6 million. We selected a sample of 43 payroll expenditures totaling $52,706 to perform compliance testing. Of the 43 samples, 18 samples totaling $18,451 and 25 samples totaling $34,255 were obtained from Bailey-Boushay House and St. Mary Medical Center – Long Beach, respectively. For 1 of the 18 samples selected from Bailey-Boushay House, comprising $403 in salary and $101 in related fringe benefit expense, for a total of $504, the expenditures were not supported by the related employee timesheet. Identification of a repeat finding: This is a repeat finding for St. Mary Medical Center – Long Beach – Finding 2023-003. For internal controls, this is a repeat finding for Bailey-Boushay House – Findings 2023-003, 2022-007, and 2021-008, but this current year finding is the first time noncompliance has been noted in our testing. Recommendation: We recommend management at St. Mary Medical Center – Long Beach and Bailey-Boushay House execute its processes to properly approve all time charged to federal grants in accordance with 2 CFR 200.430. Additionally, we recommend management execute and retain evidence of its internal controls over the allowability of payroll expenditures. At Bailey-Boushay House, we recommend that only expenses supported by an underlying timesheet be charged to the grant. Views of responsible officials: Management agrees with the finding. Corrective action over timecard approval was implemented in April 2024. For the noncompliance noted at Bailey-Boushay House, Bailey-Boushay House will return the funds to the grantor for amounts that were not supported by an underlying timesheet.

Categories

Questioned Costs Allowable Costs / Cost Principles

Other Findings in this Audit

  • 522285 2024-001
    Material Weakness Repeat
  • 522286 2024-001
    Material Weakness Repeat
  • 522287 2024-001
    Material Weakness Repeat
  • 522288 2024-001
    Material Weakness Repeat
  • 522289 2024-001
    Material Weakness Repeat
  • 522290 2024-001
    Material Weakness Repeat
  • 522291 2024-001
    Material Weakness Repeat
  • 522292 2024-002
    Significant Deficiency
  • 522293 2024-003
    Significant Deficiency Repeat
  • 522294 2024-004
    Material Weakness
  • 522295 2024-005
    Significant Deficiency Repeat
  • 522296 2024-005
    Significant Deficiency Repeat
  • 522297 2024-006
    Significant Deficiency
  • 1098727 2024-001
    Material Weakness Repeat
  • 1098729 2024-001
    Material Weakness Repeat
  • 1098730 2024-001
    Material Weakness Repeat
  • 1098731 2024-001
    Material Weakness Repeat
  • 1098732 2024-001
    Material Weakness Repeat
  • 1098733 2024-001
    Material Weakness Repeat
  • 1098734 2024-002
    Significant Deficiency
  • 1098735 2024-003
    Significant Deficiency Repeat
  • 1098736 2024-004
    Material Weakness
  • 1098737 2024-005
    Significant Deficiency Repeat
  • 1098738 2024-005
    Significant Deficiency Repeat
  • 1098739 2024-006
    Significant Deficiency

Programs in Audit

ALN Program Name Expenditures
93.498 Provider Relief Fund and American Rescue Plan (arp) Rural Distribution $259.08M
93.600 Head Start $6.23M
84.268 Federal Direct Student Loans $4.18M
97.036 Disaster Grants - Public Assistance (presidentially Declared Disasters) $3.67M
21.027 Coronavirus State and Local Fiscal Recovery Funds $2.74M
84.063 Federal Pell Grant Program $1.76M
10.557 Wic Special Supplemental Nutrition Program for Women, Infants, and Children $1.74M
93.912 Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement $1.26M
14.241 Housing Opportunities for Persons with Aids $1.26M
93.556 Marylee Allen Promoting Safe and Stable Families Program $1.15M
93.846 Arthritis, Musculoskeletal and Skin Diseases Research $1.13M
93.RD Federal Contract – Unmodified and Post Translationally Modified Cd4+ $1.09M
93.596 Child Care Mandatory and Matching Funds of the Child Care and Development Fund $894,897
93.U01 Aids Medical Waiver $872,171
93.918 Grants to Provide Outpatient Early Intervention Services with Respect to Hiv Disease $830,790
93.914 Hiv Emergency Relief Project Grants $731,388
17.277 Wioa National Dislocated Worker Grants / Wia National Emergency Grants $657,662
12.420 Military Medical Research and Development $649,658
16.320 Services for Trafficking Victims $622,471
93.493 Congressional Directives $590,000
93.778 Medical Assistance Program $476,394
10.568 Emergency Food Assistance Program (administrative Costs) $377,912
93.959 Block Grants for Prevention and Treatment of Substance Abuse $374,710
94.011 Americorps Seniors Foster Grandparent Program (fgp) 94.011 $348,354
93.211 Telehealth Programs $327,982
93.940 Hiv Prevention Activities Health Department Based $314,610
16.839 Stop School Violence $312,157
93.884 Primary Care Training and Enhancement $285,100
93.268 Immunization Cooperative Agreements $269,982
10.558 Child and Adult Care Food Program $253,574
93.276 Drug-Free Communities Support Program Grants $243,780
93.155 Rural Health Research Centers $213,209
93.310 Trans-Nih Research Support $202,906
10.855 Distance Learning and Telemedicine Loans and Grants $198,301
93.327 Demonstration Grants for Domestic Victims of Human Trafficking $196,733
93.324 State Health Insurance Assistance Program $180,022
93.045 Special Programs for the Aging, Title Iii, Part C, Nutrition Services $169,295
93.597 Grants to States for Access and Visitation Programs $167,500
16.589 Rural Domestic Violence, Dating Violence, Sexual Assault, and Stalking Assistance Program $151,055
93.043 Special Programs for the Aging, Title Iii, Part D, Disease Prevention and Health Promotion Services $150,750
10.331 Gus Schumacher Nutrition Incentive Program $136,341
93.048 Special Programs for the Aging, Title Iv, and Title Ii, Discretionary Projects $135,016
93.788 Opioid Str $126,344
84.425F Education Stabilization Fund $124,820
94.002 Americorps Seniors Retired and Senior Volunteer Program (rsvp) 94.002 $123,059
10.572 Wic Farmers' Market Nutrition Program (fmnp) $115,116
93.837 Cardiovascular Diseases Research $112,151
16.575 Crime Victim Assistance $111,095
93.575 Child Care and Development Block Grant $109,925
93.394 Cancer Detection and Diagnosis Research $108,154
16.842 Opioid Affected Youth Initiative $103,735
16.582 Crime Victim Assistance/discretionary Grants $98,900
93.988 Cooperative Agreements for Diabetes Control Programs $97,291
93.426 The National Cardiovascular Health Program $93,019
20.513 Enhanced Mobility of Seniors and Individuals with Disabilities $90,615
93.301 Small Rural Hospital Improvement Grant Program $87,888
93.053 Nutrition Services Incentive Program $87,695
93.241 State Rural Health Flexibility Program $81,790
93.350 National Center for Advancing Translational Sciences $78,508
93.838 Lung Diseases Research $78,388
94.016 Americorps Seniors Senior Companion Program (scp) 94.016 $72,269
93.686 Ending the Hiv Epidemic: A Plan for America � Ryan White Hiv/aids Program Parts A and B $63,100
93.044 Special Programs for the Aging, Title Iii, Part B, Grants for Supportive Services and Senior Centers $60,007
93.052 National Family Caregiver Support, Title Iii, Part E $43,655
20.616 National Priority Safety Programs $40,596
93.262 Occupational Safety and Health Program $39,626
84.007 Federal Supplemental Educational Opportunity Grants $39,157
93.558 Temporary Assistance for Needy Families $36,892
93.RD Federal Contract - Tn-25: Rituximab Followed by Abatacept for Prevention Or Reversal of Type 1 Diabetes (t1d) $33,563
93.395 Cancer Treatment Research $33,347
93.435 The Innovative Cardiovascular Health Program $33,334
93.855 Allergy and Infectious Diseases Research $29,754
93.994 Maternal and Child Health Services Block Grant to the States $26,611
93.840 Translation and Implementation Science Research for Heart, Lung, Blood Diseases, and Sleep Disorders $25,368
93.RD Federal Contract - Tn-28: Low Dose Atg in Prevention $23,818
93.069 Public Health Emergency Preparedness $23,199
93.870 Maternal, Infant and Early Childhood Homevisiting Grant Program $22,996
32.006 Covid-19 Telehealth Program $19,163
93.839 Blood Diseases and Resources Research $19,040
93.235 Title V State Sexual Risk Avoidance Education (title V State Srae) Program $16,686
93.889 National Bioterrorism Hospital Preparedness Program $16,620
93.898 Cancer Prevention and Control Programs for State, Territorial and Tribal Organizations $16,503
93.667 Social Services Block Grant $16,279
93.RD Federal Contract – Tn01 - Pathway to Prevention $15,485
93.658 Foster Care Title IV-E $14,991
93.226 Research on Healthcare Costs, Quality and Outcomes $14,813
93.734 Empowering Older Adults and Adults with Disabilities Through Chronic Disease Self-Management Education Programs � Financed by Prevention and Public Health Funds (pphf) $14,442
93.866 Aging Research $13,513
93.121 Oral Diseases and Disorders Research $9,809
93.847 Diabetes, Digestive, and Kidney Diseases Extramural Research $9,692
93.243 Substance Abuse and Mental Health Services Projects of Regional and National Significance $9,105
93.865 Child Health and Human Development Extramural Research $8,931
93.958 Block Grants for Community Mental Health Services $8,704
93.991 Preventive Health and Health Services Block Grant $8,021
94.021 Americorps Volunteer Generation Fund 94.021 $7,683
93.RD Federal Contract – Intergovernmental Personnel $6,477
93.967 Centers for Disease Control and Prevention Collaboration with Academia to Strengthen Public Health $5,842
93.RD Federal Contract - Tn-31: Trialnet Jakpot Study $4,594
93.113 Environmental Health $4,246
84.181 Special Education-Grants for Infants and Families $4,200
10.561 State Administrative Matching Grants for the Supplemental Nutrition Assistance Program $3,635
93.568 Low-Income Home Energy Assistance $2,493
93.RD Federal Contract - Tn-16: Long Term Investigative Follow-Up in Trialnet $1,779
93.354 Public Health Emergency Response: Cooperative Agreement for Emergency Response: Public Health Crisis Response $1,507
97.067 Homeland Security Grant Program $702
10.766 Community Facilities Loans and Grants $598
93.393 Cancer Cause and Prevention Research $273
93.433 Acl National Institute on Disability, Independent Living, and Rehabilitation Research $162
93.RD Federal Contract - Tn-35: Qualitative Research on Participant Engagement with Trialnet Studies $35
93.RD Federal Contract – Tn-18: Prevention of Abnormal Glucose Tolerance and Diabetes in Relatives At-Risk for T1d Mellitus $28
93.853 Extramural Research Programs in the Neurosciences and Neurological Disorders $1