Finding 1162411 (2024-001)

Material Weakness Repeat Finding
Requirement
CJL
Questioned Costs
$1
Year
2024
Accepted
2025-11-15
Audit: 372193
Organization: Inova Health System (VA)

AI Summary

  • Core Issue: IJP failed to apply program income before requesting cash reimbursements, leading to questioned costs totaling $153,967.
  • Impacted Requirements: Non-compliance with federal regulations requiring timely application of program income as per HRSA guidelines.
  • Recommended Follow-Up: IJP should continue to evaluate and enhance internal controls to ensure program income is applied before cash requests, as agreed upon by management.

Finding Text

Federal Program Information Federal Agencies: Department of Health and Human Services (“HHS”) Pass-Through Entity: Virginia Department of Health; Not Applicable Pass-Through Entity Number: INORWB611-GY23; INORWB611-GY24; Not Applicable Awards: Assistance Listing 93.917 – HIV Emergency Relief Project Grants; Assistance Listing 93.918 – Grants to Provide Outpatient Early Intervention Services with Respect to HIV Disease Award Periods: April 1, 2023 to March 31, 2024; April 1, 2024 to March 31, 2025; May 1, 2023 to April 30, 2024; May 1, 2024 to April 30, 2025 Description: Timely Application of Program Income Prior to Requesting Additional Cash Payments Criteria 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.” Per the terms and conditions of the notice of award (Assistance Listing 93.918) and the pass-through entity agreement between the Virginia Department of Health (the Department) (Assistance Listing 93.917) and the Inova Juniper Program (IJP), IJP is required to follow Health Resources and Services Administration (HRSA) guidelines related to the program. HRSA develops multiple policies to help grant recipients and subrecipients understand and carry out legislation applicable to Ryan White programs. Per the Policy Clarification Notice included on the official HRSA website for Ryan White, “Under the uniform administrative requirements, to the extent available, recipients and subrecipients must disburse funds available from program income, rebates, refunds, contract settlements, audit recoveries and interest earned on such funds before requesting additional cash payments.” As such, program income must be used for the purpose and subject to the conditions of the Federal award. The requirements within the pass-through entity agreement with the Virginia Department of Health are consistent with those required by the original Federal awarding agency, the Department of Health and Human Services (HHS), HRSA as included in the notice of award. Per the frequently asked questions (FAQs) presented by HRSA’s HIV/AIDS Bureau (HAB) for Policy Clarification Notice (PCN) 15-03, Clarification Regarding the Ryan White HIV/AIDS Program and Program Income, released on March 21, 2016, program income is gross income earned by the non-Federal entity that is directly generated by a supported activity or earned as a result of the Federal award during the period of performance (or grant period). Program Income includes the core medical and support services that HRSA considers allowable uses of Ryan White grant funds and the individuals eligible to receive those services. Condition IHS did not have appropriately designed internal controls in place to ensure that program income was applied to offset expenditures prior to requesting additional cash reimbursements each month during the grant period. Cause IJP has policies and procedures in place to ensure program income was applied to offset expenditures in its entirety prior to the end of the calendar and grant period. However, during the grant period, program income was not timely applied prior to cash reimbursement requests. Effect or potential effect Cash payments were being requested and reimbursed prior to application of program income. Questioned costs $109,290 of known questioned costs for Assistance Listing 93.917 $44,677 of known questioned costs for Assistance Listing 93.918 The costs questioned represent the amount of program income that should have been applied prior to requesting cash reimbursement. Identification of a repeat finding This is a repeat finding and relates to prior year finding 2023-002. Context Cash reimbursement requests under Assistance Listing 93.917 are submitted monthly. During our audit for Assistance Listing 93.917, we selected a sample of 4 months for testing and identified exceptions within 2 months where program income was not being applied timely to the cash reimbursement requests. The total amount of program income that should have been applied prior to requesting cash reimbursement was $32,843 for the 2 months selected. As a result, we obtained management’s summary of program income for the fiscal year and identified that a total of 7 months or a total of $109,290 did not apply program income prior to requesting cash reimbursements. Cash reimbursement requests under Assistance Listing 93.918 are submitted quarterly. During our audit for Assistance Listing 93.918, we selected a sample of 2 quarters for testing and identified that program income was not being applied timely to the first quarter cash reimbursement request. The cumulative program income not applied prior to the cash reimbursement for the first quarter was $44,677. As a result, we obtained management’s summary of program income for the fiscal year and identified that there were no other quarters impacted. Recommendation During the latter part of the fiscal year and as a result of prior year audit findings, IJP implemented various checkpoints in their processes to ensure that program income was applied prior to requesting cash reimbursements. IJP should continue to assess existing policies and procedures to ensure the program income balance is applied timely. HRSA recommends that recipients and subrecipients strive to proactively secure and estimate the extent to which program income will be accrued. View of responsible officials Management concurs with the finding and has implemented procedures to ensure the appropriate and timely application of program income.

Corrective Action Plan

Federal Program Information Federal Agencies: Department of Health and Human Services (“HHS”) Pass-Through Entity: Virginia Department of Health; Not Applicable Pass-Through Entity Number: INORWB611-GY23; INORWB611-GY24; Not Applicable Awards: Assistance Listing 93.917 – HIV Emergency Relief Project Grants; Assistance Listing 93.918 – Grants to Provide Outpatient Early Intervention Services with Respect to HIV Disease Award Periods: April 1, 2023 to March 31, 2024; April 1, 2024 to March 31, 2025; May 1, 2023 to April 30, 2024; May 1, 2024 to April 30, 2025 Type of Finding: Significant Deficiency in Internal Control Over Compliance Description: Timely Application of Program Income Prior to Requesting Additional Cash Payments Recommendation: During the latter part of the fiscal year and as a result of prior year audit findings, IJP implemented various checkpoints in their monthly processes to ensure that program income was disbursed prior to requesting cash reimbursements. IJP should continue to assess existing policies and procedures to ensure the program income balance is spent timely. HRSA recommends that recipients and subrecipients strive to proactively secure and estimate the extent to which program income will be accrued. View of responsible officials: Management concurs with the finding and has implemented procedures to ensure appropriate and timely application of program income. Corrective Action Planned: Inova Grants Accounting and Inova Juniper Program (IJP) directors will work collaboratively to disburse funds available from program income prior to requesting additional cash payments from RWHAP funds. Inova implemented a Program Income from Sponsored Programs policy in February 2025. Inova will assess this written procedure and revise as necessary to ensure that program income is applied before requesting federal reimbursement. Inova will review federal grant requirements related to program income and identify sources of program income during kickoff meetings for new awards. Mandatory training will be conducted for program and finance staff responsible for the administration of these awards. (2 CFR 200.307 and 200.305) Inova will require a monthly reconciliation of program income earned and expenditures by grant. Program income tracking will also be included in monthly grant variance reports. Planned Completion Date for Corrective Action Planned: Ongoing with completion date of December 31, 2025.

Categories

Questioned Costs Subrecipient Monitoring Cash Management Period of Performance Reporting

Other Findings in this Audit

  • 1162409 2024-001
    Material Weakness Repeat
  • 1162410 2024-002
    Material Weakness Repeat

Programs in Audit

ALN Program Name Expenditures
97.036 COVID-19 - DISASTER GRANTS - PUBLIC ASSISTANCE (PRESIDENTIALLY DECLARED DISASTERS) $25.10M
12.750 UNIFORMED SERVICES UNIVERSITY MEDICAL RESEARCH PROJECTS $3.72M
93.917 HIV CARE FORMULA GRANTS $3.64M
93.918 GRANTS TO PROVIDE OUTPATIENT EARLY INTERVENTION SERVICES WITH RESPECT TO HIV DISEASE $3.46M
93.939 HIV PREVENTION ACTIVITIES NON-GOVERNMENTAL ORGANIZATION BASED $848,323
93.153 COORDINATED SERVICES AND ACCESS TO RESEARCH FOR WOMEN, INFANTS, CHILDREN, AND YOUTH $771,133
20.614 NATIONAL HIGHWAY TRAFFIC SAFETY ADMINISTRATION (NHTSA) DISCRETIONARY SAFETY GRANTS AND COOPERATIVE AGREEMENTS $440,840
93.145 HIV-RELATED TRAINING AND TECHNICAL ASSISTANCE $256,098
93.914 HIV EMERGENCY RELIEF PROJECT GRANTS $241,844
93.399 CANCER CONTROL $239,674
93.767 CHILDREN'S HEALTH INSURANCE PROGRAM $224,095
16.753 CONGRESSIONALLY RECOMMENDED AWARDS $149,052
93.103 FOOD AND DRUG ADMINISTRATION RESEARCH $104,814
93.865 CHILD HEALTH AND HUMAN DEVELOPMENT EXTRAMURAL RESEARCH $68,472
93.397 CANCER CENTERS SUPPORT GRANTS $61,982
16.575 CRIME VICTIM ASSISTANCE $56,183
93.RD NHLBI Graft Sample and Data Collection Project $52,800
93.RD Population Health Research Support $49,458
93.RD NHLBI/Inova Pulmonary Vascular Program $47,301
93.121 ORAL DISEASES AND DISORDERS RESEARCH $31,659
93.RD Observational Prospective Study-The Diversification of the Pregnant Vaginal Microbiome $20,000
12.420 MILITARY MEDICAL RESEARCH AND DEVELOPMENT $19,150
93.837 CARDIOVASCULAR DISEASES RESEARCH $16,624
93.RD Tactile and Ultrasound Imaging Fusion for Functional Assessment of the Female Pelvic Floor $11,124
93.088 ADVANCING SYSTEM IMPROVEMENTS FOR KEY ISSUES IN WOMEN'S HEALTH $10,539
93.838 LUNG DISEASES RESEARCH $7,050
93.866 AGING RESEARCH $2,250
93.853 EXTRAMURAL RESEARCH PROGRAMS IN THE NEUROSCIENCES AND NEUROLOGICAL DISORDERS $1,594
21.027 COVID-19 - CORONAVIRUS STATE AND LOCAL FISCAL RECOVERY FUNDS $1,291