Finding 1168160 (2025-002)

Finding 2025-002 – Eligibility Identification of the federal program: Health Resources and Services Administration HIV Emergency Relief Project Grants Assistance Listing No. 93.914 Pass Through Number Pass Through Entity Grant Period 11987 PREV King County Public Health 3/1/2024–2/28/2025 13548 PREV King County Public Health 3/1/2025–2/28/2026 Location: Virginia Mason Medical Center, Bailey-Boushay House (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, document, and maintain effective internal control over the Federal award that provides reasonable assurance that the recipient or subrecipient is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should align with the guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States or the “Internal Control Integrated Framework” issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” Condition: Bailey-Boushay House has processes in place to verify whether participants are eligible; however, documentation to evidence the execution of the controls was not retained. Cause: Bailey-Boushay House management did not retain evidence of the execution of controls due to lack of understanding of the need to retain the documentation. Effect or potential effect: Ineligible individuals may be provided services. Questioned costs: None. Context: We issued a material weakness for Bailey-Boushay House related to internal controls in the prior year. Based upon the implementation date of February 2025 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. Total expenditures for Bailey-Boushay House were approximately $1.1 million and represent 29.8% of the total HIV program expenditures of approximately $3.8 million. However, expenditures are not based upon serving eligible patients. Identification of a repeat finding: This is a repeat finding – Finding 2024-004. Recommendation: We recommend management maintain evidence of the execution of internal controls related to documentation that individuals served are eligible to participate in the program. Views of responsible officials: Management agrees with the finding and implemented corrective action in February 2025.