Finding 404815 (2023-006)

Material Weakness
Requirement
ABL
Questioned Costs
-
Year
2023
Accepted
2024-07-01
Audit: 311195
Organization: Mobridge Regional Hospital (SD)
Auditor: Eide Bailly LLP

AI Summary

  • Core Issue: The Hospital lacked a proper internal control process for reviewing and approving the lost revenue calculation and special report submitted to the Department of Health and Human Services.
  • Impacted Requirements: Compliance with 2 CFR 200.303(a) regarding effective internal controls over federal awards was not met, leading to potential inaccuracies in reported lost revenue.
  • Recommended Follow-Up: Implement a control process for accurate lost revenue calculations, including a secondary review and approval before submission of reports.

Finding Text

2023-006 Department of Health and Human Services Federal Financial Assistance Listing #93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year – Period 4 TIN #460255944 Activities Allowed or Unallowed and Allowable Costs/Cost Principles Material Weakness in Internal Control over Compliance and Noncompliance Reporting Material Weakness in Internal Control over Compliance and Material Noncompliance Criteria: 2 CFR 200.303(a) establishes that the auditee must establish and maintain effective internal control over the federal award that provides assurance that the entity is managing the federal award in compliance with federal statutes, regulations, and conditions of the federal award. The Hospital selected option 1 to calculate lost revenue which consists of a comparison of 2019 actual results to 2020, 2021, and 2022 actual results by quarter. Patient care-related revenue should be reported net of adjustments for all third-party payers, charity care adjustments, bad debt, and any other discounts or adjustments, as applicable when reporting patient carerelated revenue sources. Condition: The Hospital’s lost revenue calculation was not reviewed and approved by a separate individual outside of the preparer. The Hospital’s lost revenue calculation was based upon actual revenue billed and reported within the Hospital’s electronic medical records (EMR) system which does not consider monthly or quarterly adjustments. The Hospital’s special report submitted to the Department of Health and Human Services for Period 4 TIN#460255944 was not reviewed and approved by a separate individual outside of the individual who inputted and submitted the report. Cause: The Hospital did not have an internal control process in place to ensure a secondary review and approval of the lost revenue calculation. The Hospital used the EMR system to calculate lost revenue due to the categories required to be input into the Hospital’s special report as the categories could not be identified within the general ledger system. The Hospital did not have an internal control process in place to ensure review and approval of the report submitted to the Department of Health and Human Services for Period 4 was performed and documented. Effect: The lost revenue reported within the special report submitted to the Department of Health and Human Services for Period 4 was $204,862 for 2020 and $57,757 for 2021. Had the Hospital considered monthly or quarterly adjustments in the lost revenue calculation during the period of availability, the lost revenue would have been $248,664 in 2020 and $86,392 in 2021. No lost revenue was utilized during Period 4. Questioned Costs: Lost revenue reported would increase after consideration of monthly or quarterly adjustments. As a result, there are no questioned costs for activities allowed or unallowed and allowable costs/cost principles. Context/Sampling: Key line items were tested on the Period 4 Department of Health and Human Services special report. Repeat Finding from Prior Years: No Recommendation: We recommend the Hospital implement a control process which verifies that lost revenue is calculated correctly and includes a secondary review and approval of the calculation. We recommend Hospital implement a control process to ensure the special report is reviewed and approved prior to submission. Views of Responsible Officials: Management agrees with the finding.

Corrective Action Plan

Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Federal Financial Assistance Listing #93.498 Finding Summary: The Hospital’s lost revenue calculation was not reviewed and approved by a separate individual outside of the preparer. The Hospital’s lost revenue calculation was based upon actual revenue billed and reported within the Hospital’s electronic medical records (EMR) system which does not consider monthly or quarterly adjustments. The Hospital’s special report submitted to the Department of Health and Human Services for Period 4 TIN#460255944 was not reviewed and approved by a separate individual outside of the individual who inputted and submitted the report. Responsible Individuals: Renae Karst, Chief Financial Officer Corrective Action Plan: A Grant Award Policy and Procedure Manual was established which includes, but not limited to, outlined internal controls around the review, approval, and tracking of grants/awards allowable expenses and reporting. The Hospital did not have Period 2 or Period 3 reporting requirements. The Phase 4 special report was submitted without review and approval over the report and lost revenue calculation due to limited personnel in finance. The Hospital does not have any additional special reports to complete for this federal program. Anticipated Completion Date: June 30, 2024

Categories

Allowable Costs / Cost Principles Material Weakness Reporting

Other Findings in this Audit

  • 404807 2023-003
    Material Weakness Repeat
  • 404808 2023-003
    Material Weakness Repeat
  • 404809 2023-003
    Material Weakness Repeat
  • 404810 2023-003
    Material Weakness Repeat
  • 404811 2023-004
    Material Weakness Repeat
  • 404812 2023-004
    Material Weakness Repeat
  • 404813 2023-004
    Material Weakness Repeat
  • 404814 2023-005
    Significant Deficiency
  • 404816 2023-007
    Material Weakness
  • 981249 2023-003
    Material Weakness Repeat
  • 981250 2023-003
    Material Weakness Repeat
  • 981251 2023-003
    Material Weakness Repeat
  • 981252 2023-003
    Material Weakness Repeat
  • 981253 2023-004
    Material Weakness Repeat
  • 981254 2023-004
    Material Weakness Repeat
  • 981255 2023-004
    Material Weakness Repeat
  • 981256 2023-005
    Significant Deficiency
  • 981257 2023-006
    Material Weakness
  • 981258 2023-007
    Material Weakness

Programs in Audit

ALN Program Name Expenditures
93.498 Provider Relief Fund $784,570
10.766 Community Facilities Loans and Grants $221,626
93.155 Rural Health Research Centers $59,890
10.557 Special Supplemental Nutrition Program for Women, Infants, and Children $26,617
93.301 Small Rural Hospital Improvement Grant Program $13,011