Finding 1218352 (2025-001)

Material Weakness Repeat Finding
Requirement
AB
Questioned Costs
-
Year
2025
Accepted
2026-06-24
Audit: 404614
Organization: Fairview Health Services (MN)

AI Summary

  • Core Issue: Internal controls over payroll for the federal grant were inadequate, leading to incorrect pay rates being applied.
  • Impacted Requirements: Compliance with 2 CFR 200.303, which mandates effective internal controls for managing federal awards.
  • Recommended Follow-Up: Improve payroll review processes to ensure charges are based on authorized rates and errors are corrected before submission.

Finding Text

Finding 2025-001 – Activities Allowed or Unallowed, Allowable Costs/Cost Principles Identification of the federal program: Federal Grantor: United States Department of Health and Human Services Assistance Listing No.: 93.817 Hospital Preparedness Program (HPP) Ebola Preparedness and Response Activities Criteria or specific requirement (including statutory, regulatory, or other citation): 2 CFR 200.303 requires that the 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 Committee of Sponsoring Organizations of the Treadway Commission (COSO).” Condition: Internal controls over payroll charged to the federal program were not sufficiently precise to ensure that payroll expenses were recorded using the correct authorized pay rates. Cause: Fairview did not have controls operating effectively, to review payroll calculations at a level of precision sufficient to detect discrepancies between applied pay rates and authorized rates prior to charging costs to the federal award. Effect or potential effect: Expenses may be charged to the federal award that are not in compliance with the federal grant agreements. Questioned costs: None. Context: Of the 23 payroll transactions sampled (totaling $67,035), two payroll transactions (totaling $404) were calculated using incorrect pay rates, resulting in inaccurate payroll charges to the federal program. For Assistance Listing No. 93.817, total payroll costs for Fairview were $537,540, representing 25.4% of total federal expenditures of $2,115,184 for the year ended December 31, 2025. Identification as a repeat finding, if applicable: The finding is not a repeat finding from the prior year. Recommendation: Management should enhance controls over payroll review processes to ensure payroll charges to federal programs are based on authorized pay rates and are reviewed at a sufficient level of precision to identify and correct errors prior to being charged to the award. Views of responsible officials: Management agrees with the finding and has developed a plan to correct the finding. To prevent recurrence, Fairview will enhance controls over payroll review processes to ensure accuracy prior to submission. These enhancements include reinforcing review expectations with project directors and including detailed review procedures for validating pay rate and wage calculations prior to reimbursement submissions.

Corrective Action Plan

Finding 2025-001 Federal Grantor: United States Department of Health and Human Services Planned Corrective Actions: Responsible Official – Dawn Ksepka, VP of Finance and System Controller Anticipated completion date – June 30, 2026 Management agrees with the finding. Remediation: Fairview has corrected the payroll reimbursement request for the inaccurate payroll charges identified in the finding. To prevent recurrence, Fairview will enhance controls over payroll review processes to ensure accuracy prior to submission. These enhancements include reinforcing review expectations with project directors and including detailed review procedures for validating pay rate and wage calculations prior to reimbursement submissions. Management believes these actions will improve the accuracy of payroll charges and ensure compliance with federal program requirements.

Categories

Allowable Costs / Cost Principles Cash Management Matching / Level of Effort / Earmarking

Programs in Audit

ALN Program Name Expenditures
93.817 HOSPITAL PREPAREDNESS PROGRAM (HPP) EBOLA PREPAREDNESS AND RESPONSE ACTIVITIES $2.12M
93.912 RURAL HEALTHCARE SERVICES PROGRAMS $666,359
93.268 IMMUNIZATION COOPERATIVE AGREEMENTS $465,836
93.155 RURAL HEALTH RESEARCH CENTERS $296,116
10.331 GUS SCHUMACHER NUTRITION INCENTIVE PROGRAM $218,562
93.310 TRANS-NIH RESEARCH SUPPORT $116,031
10.182 PANDEMIC RELIEF ACTIVITIES: LOCAL FOOD PURCHASE AGREEMENTS WITH STATES, TRIBES, AND LOCAL GOVERNMENTS $37,987
93.304 RACIAL AND ETHNIC APPROACHES TO COMMUNITY HEALTH $29,396
93.110 SPECIAL PROJECTS OF REGIONAL AND NATIONAL SIGNIFICANCE $25,490
93.080 BLOOD DISORDER PROGRAM: PREVENTION, SURVEILLANCE, AND RESEARCH $17,663
93.493 CONGRESSIONAL DIRECTIVES $10,100
93.354 PUBLIC HEALTH EMERGENCY RESPONSE: COOPERATIVE AGREEMENT FOR EMERGENCY RESPONSE: PUBLIC HEALTH CRISIS RESPONSE $4,352
93.173 RESEARCH RELATED TO DEAFNESS AND COMMUNICATION DISORDERS $738