Finding 391172 (2023-003)

Material Weakness
Requirement
ABN
Questioned Costs
$1
Year
2023
Accepted
2024-04-01
Audit: 301777
Organization: Mercy Health (MO)

AI Summary

  • Core Issue: Inadequate documentation for costs charged to FEMA programs, including average unit costs for PPE and approval records for non-FAM expenditures.
  • Impacted Requirements: Non-compliance with 2 CFR Sections 200.303 and 200.403 regarding internal controls and cost allowability.
  • Recommended Follow-Up: Implement stronger internal controls for cost review and approval processes to ensure compliance with federal requirements.

Finding Text

Finding 2023-003 Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Special Tests and Provisions Identification of the federal program: Federal Grantor: United States Department of Homeland Security Pass-Through Grantors: State of Missouri, State Emergency Management Agency Arkansas Division of Emergency Management Assistance Listing No.: 97.036, COVID-19 Disaster Grants – Public Assistance (Presidentially Declared Disasters) (FEMA) Pass-Through Award Numbers and Award Periods: Project# 185883 P/W# 529 01/20/2020–09/14/2020 Project# 699963 P/W# 624 01/01/2022–07/01/2022 Project# 699667 P/W# 233 01/01/2022–07/01/2022 Project# 699670 P/W# 211 01/01/2022–07/01/2022 Criteria or Specific Requirement (Including Statutory, Regulatory, or Other Citation): 2 CFR Section 200.303 of the Uniform Guidance states the following regarding internal control: “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 or the “Internal Control Integrated Framework,” issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” As described in Title 2 Code of Federal Regulations (C.F.R.) § 200.333, financial records, supporting documents, statistical records and all other non-Federal entity records pertinent to a Federal award must be retained for a period of three (3) years from the date of submission of the final expenditure report or, for Federal awards that are renewed quarterly or annually, from the date of the submission of the quarterly or annual financial report, respectively, as reported to the Federal awarding agency or pass-through entity in the case of a subrecipient. In addition, 2 CFR Section 200.403 of the Uniform Guidance states the following regarding the factors affecting the allowability of costs: “Except where otherwise authorized by statue, costs must meet the following general criteria in order to be allowable under Federal awards: (g) Be adequately documented.” Condition: Adequate documentation was not retained to support the average unit cost applied to COVID-19 personal protective equipment (PPE) inventory usage charged to the FEMA program as Force Account Material (FAM) costs. In addition, for 12 of 40 non-FAM costs (including purchased equipment, purchased supplies, and rental equipment) charged to the program, we noted adequate documentation was not retained to evidence review and approval of the expenditure for allowability. Cause: Management did not have sufficiently designed internal controls in place over the review and approval of average unit costs applied to FAM usage charged to the FEMA program. In addition, for 11 non-FAM (purchased equipment) transactions from fiscal year 2020 charged to the FEMA program, expenditure approvals were maintained in a legacy general ledger system and upon migration to the current general ledger system, the approval trail was not retained. For one other non-FAM (purchased equipment) transaction from fiscal year 2022 charged to the FEMA program, the required level of approvals of the purchase-card transaction was not retained. Effect or potential effect: For FAM costs, Mercy Health is not in compliance with the general criteria of maintaining adequate documentation that supports the average unit costs used in the calculation and determination of the costs charged to the federal program. For non-FAM costs, Mercy Health may not be compliant with the allowability of costs requirements of the FEMA program. Questioned costs: $45 – Assistance Listing No. 97.036 (COVID-19). Context: We sampled 40 FAM costs (totaling $2,826 in federal expenditures) and agreed the PPE inventory item’s usage to supporting requisition documentation. In addition, we obtained the external vendor invoice for the purchase of the PPE inventory item immediately prior to the usage of the PPE inventory item. However, for all 40 sampled FAM costs, we could not verify the average unit cost that is used in determining the amount charged to the FEMA program. The net overstatement of the costs based on the average unit cost for these 40 sampled FAM costs in comparison to the external vendor invoices was $45. In addition, we sampled 40 non-FAM costs (totaling $218,110 in federal expenditures) and noted that 12 purchased equipment transactions (totaling $182,048 in federal expenditures) did not have support retained to evidence review and approval of the expenditure for allowability. FAM costs and non-FAM costs represent 71% and 29%, respectively, of total federal expenditures for the FEMA program of $3,383,897 for the year ended June 30, 2023. Identification as a repeat finding, if applicable: The finding is not a repeat finding from the prior year. Recommendation: Management should design and implement effective internal controls over the review and approval of all costs charged to the FEMA program. Views of Responsible Officials: Mercy Health has a system to calculate average cost of inventory items. We rely on this system, but it was not tested as part of compliance. In addition, Mercy Health has a robust capital approval process (for all equipment) and financial approval thresholds. All COVID purchases were logged in the capital system (VFA) and approvals were documented. During this time, we changed approval systems from VFA to Strata. We will ensure all capital is reviewed and approved in Strata going forward.

Categories

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles Equipment & Real Property Management Special Tests & Provisions Procurement, Suspension & Debarment Matching / Level of Effort / Earmarking

Other Findings in this Audit

  • 391168 2023-001
    Material Weakness
  • 391169 2023-002
    Significant Deficiency
  • 391170 2023-003
    Material Weakness
  • 391171 2023-004
    Significant Deficiency
  • 391173 2023-004
    Significant Deficiency
  • 391174 2023-003
    Material Weakness
  • 391175 2023-004
    Significant Deficiency
  • 391176 2023-003
    Material Weakness
  • 391177 2023-004
    Significant Deficiency
  • 967610 2023-001
    Material Weakness
  • 967611 2023-002
    Significant Deficiency
  • 967612 2023-003
    Material Weakness
  • 967613 2023-004
    Significant Deficiency
  • 967614 2023-003
    Material Weakness
  • 967615 2023-004
    Significant Deficiency
  • 967616 2023-003
    Material Weakness
  • 967617 2023-004
    Significant Deficiency
  • 967618 2023-003
    Material Weakness
  • 967619 2023-004
    Significant Deficiency

Programs in Audit

ALN Program Name Expenditures
93.498 Covid-19: Provider Relief Fund and American Rescue Plan (arp) Rural Distribution $104.54M
93.493 Congressional Directives $1.00M
97.036 Covid-19: Disaster Grants - Public Assistance (presidentially Declared Disasters) $689,052
32.006 Covid-19: Covid-19 Telehealth Program $497,692
93.155 Covid-19: Rural Health Research Centers $473,291
16.575 Crime Victim Assistance $337,103
10.855 Distance Learning and Telemedicine Loans and Grants $336,510
93.243 Substance Abuse and Mental Health Services_projects of Regional and National Significance $290,537
93.889 National Bioterrorism Hospital Preparedness Program $168,145
93.575 Covid-19: Child Care and Development Block Grant $131,950
16.588 Violence Against Women Formula Grants $127,186
21.027 Covid-19: Coronavirus State and Local Fiscal Recovery Funds $103,031
93.103 Food and Drug Administration_research $86,990
93.671 Covid-19: Family Violence Prevention and Services/domestic Violence Shelter and Supportive Services $71,096
93.558 Temporary Assistance for Needy Families $65,493
93.671 Family Violence Prevention and Services/domestic Violence Shelter and Supportive Services $57,013
93.301 Small Rural Hospital Improvement Grant Program $56,983
14.231 Emergency Solutions Grant Program $34,891
93.898 Cancer Prevention and Control Programs for State, Territorial and Tribal Organizations $32,123
20.600 State and Community Highway Safety $30,958
93.945 Assistance Programs for Chronic Disease Prevention and Control $29,666
10.558 Child and Adult Care Food Program $18,826
93.667 Social Services Block Grant $16,150
93.994 Maternal and Child Health Services Block Grant to the States $13,411
93.310 Trans-Nih Research Support $6,518
93.497 Family Violence Prevention and Services/ Sexual Assault/rape Crisis Services and Support $4,621
16.590 Grants to Encourage Arrest Policies and Enforcement of Protection Orders Program $1,916
93.242 Mental Health Research Grants $1,000
93.853 Extramural Research Programs in the Neurosciences and Neurological Disorders $1,000
14.231 Covid-19: Emergency Solutions Grant Program $936