FAC Explorer

Finding 1123842 (2024-001)

Significant Deficiency
Requirement
N
Questioned Costs
$1
Year
2024
Accepted
2025-03-31
Audit: 351637
Organization: Trinity Health (MI)
Auditor: Deloitte & Touche LLP

AI Summary

  • Core Issue: SPHP failed to provide documentation for rent reasonableness reviews and improperly reimbursed for damage payments exceeding one month's rent.
  • Impacted Requirements: Lack of documentation prevents verification of compliance with federal regulations (24 CFR 578.51(g)) regarding rent charges and damage payments.
  • Recommended Follow-Up: SPHP should establish procedures for maintaining documentation and implement controls to ensure damage reimbursements comply with regulations.

Finding Text

Condition – St. Peter's Health Partners ("SPHP") was unable to provide supporting documentation to evidence the occurrence of the rent reasonableness review was completed for three rental charges. SPHP received reimbursement for two damage payments that exceed the related tenants' one month's rent. Further, SPHP was reimbursed for three invoices related to repairs that were made during the normal course of the rental versus being identified during the exit process. Cause – SPHP does not have appropriate procedures in place to ensure sufficient documentation is retained. Additionally, SPHP did not design and implement controls to ensure damage payments made were in compliance with federal regulations. Effect – With the absence of underlying records, we were unable to verify compliance with the special test requirements for the three rent charges in pursuant to 24 CFR 578.51(g). Failure to establish effective internal controls (including review of documentation) over damage payments could potentially result in undetected noncompliance, exposing SPHP to consequences from regulatory agencies. Questioned Costs - $7,635 Context - Although there was no material noncompliance identified, 4 out of 5 damage payments (total population) were not in compliance as an adequate review was not performed. Repeat Finding – No. Recommendation – We recommend SPHP implement procedures to ensure documentation is appropriately maintained and available. We also recommend SPHP design and implement controls to ensure invoices related to damages that are submitted for reimbursement relate only to damages identified during the participant’s exit of the housing unit and do not exceed one month’s rent.

Categories

Questioned Costs Cash Management Internal Control / Segregation of Duties

Other Findings in this Audit

  • 547400 2024-001
    Significant Deficiency
  • 547401 2024-002
    Significant Deficiency
  • 547402 2024-002
    Significant Deficiency
  • 547403 2024-002
    Significant Deficiency
  • 547404 2024-002
    Significant Deficiency
  • 547405 2024-002
    Significant Deficiency
  • 1123843 2024-002
    Significant Deficiency
  • 1123844 2024-002
    Significant Deficiency
  • 1123845 2024-002
    Significant Deficiency
  • 1123846 2024-002
    Significant Deficiency
  • 1123847 2024-002
    Significant Deficiency

Programs in Audit

ALN Program Name Expenditures
93.399 Cancer Control $3.10M
84.268 Federal Direct Student Loans $1.75M
93.988 Cooperative Agreements for Diabetes Control Programs $1.57M
93.696 Certified Community Behavioral Health Clinic Expansion Grants $1.32M
21.027 Coronavirus State and Local Fiscal Recovery Funds $786,031
93.074 Hospital Preparedness Program (hpp) and Public Health Emergency Preparedness (phep) Aligned Cooperative Agreements $501,297
93.917 Hiv Care Formula Grants $474,311
84.063 Federal Pell Grant Program $470,293
93.918 Grants to Provide Outpatient Early Intervention Services with Respect to Hiv Disease $465,179
93.150 Projects for Assistance in Transition From Homelessness (path) $391,256
97.036 Disaster Grants - Public Assistance (presidentially Declared Disasters) $346,044
93.969 Pphf Geriatric Education Centers $319,685
93.261 Scaling the National Diabetes Prevention Program to Priority Populations $291,421
93.884 Primary Care Training and Enhancement $283,356
14.267 Continuum of Care Program $274,160
93.604 Assistance for Torture Victims $271,742
14.241 Housing Opportunities for Persons with Aids $260,876
93.898 Cancer Prevention and Control Programs for State, Territorial and Tribal Organizations $220,114
93.788 Opioid Str $199,564
14.231 Emergency Solutions Grant Program $197,365
93.914 Hiv Emergency Relief Project Grants $192,205
16.575 Crime Victim Assistance $189,908
93.912 Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement $188,428
93.994 Maternal and Child Health Services Block Grant to the States $181,360
93.426 The National Cardiovascular Health Program $175,000
97.008 Non-Profit Security Program $144,560
93.276 Drug-Free Communities Support Program Grants $144,081
93.575 Child Care and Development Block Grant $133,332
93.243 Substance Abuse and Mental Health Services Projects of Regional and National Significance $124,172
10.561 State Administrative Matching Grants for the Supplemental Nutrition Assistance Program $118,725
93.566 Refugee and Entrant Assistance State/replacement Designee Administered Programs $101,268
84.007 Federal Supplemental Educational Opportunity Grants $92,938
10.557 Wic Special Supplemental Nutrition Program for Women, Infants, and Children $86,152
93.391 Activities to Support State, Tribal, Local and Territorial (stlt) Health Department Response to Public Health Or Healthcare Crises $67,029
93.940 Hiv Prevention Activities Health Department Based $61,271
84.425 Education Stabilization Fund $58,439
93.497 Family Violence Prevention and Services/ Sexual Assault/rape Crisis Services and Supports $50,250
93.011 National Organizations for State and Local Officials $49,303
93.958 Block Grants for Community Mental Health Services $48,365
14.218 Community Development Block Grants/entitlement Grants $46,328
93.889 National Bioterrorism Hospital Preparedness Program $43,000
93.959 Block Grants for Prevention and Treatment of Substance Abuse $41,427
84.126 Rehabilitation Services Vocational Rehabilitation Grants to States $35,855
16.838 Comprehensive Opioid, Stimulant, and Other Substances Use Program $33,866
16.588 Violence Against Women Formula Grants $30,856
93.310 Trans-Nih Research Support $29,499
93.747 Elder Abuse Prevention Interventions Program $27,403
93.778 Medical Assistance Program $26,242
93.866 Aging Research $24,901
10.558 Child and Adult Care Food Program $21,715
93.268 Immunization Cooperative Agreements $21,500
93.839 Blood Diseases and Resources Research $17,430
93.241 State Rural Hospital Flexibility Program $15,750
93.301 Small Rural Hospital Improvement Grant Program $10,800
16.529 Education, Training, and Enhanced Services to End Violence Against and Abuse of Women with Disabilities $8,404
20.600 State and Community Highway Safety $8,015
16.017 Sexual Assault Services Formula Program $7,938
84.033 Federal Work-Study Program $6,658
10.551 Supplemental Nutrition Assistance Program $6,059
93.323 Epidemiology and Laboratory Capacity for Infectious Diseases (elc) $5,662
93.247 Advanced Nursing Education Workforce Grant Program $5,107
93.436 Well-Integrated Screening and Evaluation for Women Across the Nation (wisewoman) $4,986
93.226 Research on Healthcare Costs, Quality and Outcomes $3,500
20.616 National Priority Safety Programs $3,457
97.067 Homeland Security Grant Program $2,906
93.283 Centers for Disease Control and Prevention Investigations and Technical Assistance $2,250
93.395 Cancer Treatment Research $2,229
93.837 Cardiovascular Diseases Research $1,500
93.853 Extramural Research Programs in the Neurosciences and Neurological Disorders $1,438
93.879 Medical Library Assistance $1,200
45.025 Promotion of the Arts Partnership Agreements $1,100
93.847 Diabetes, Digestive, and Kidney Diseases Extramural Research $157