Finding 46184 (2022-001)

Material Weakness
Requirement
ABL
Questioned Costs
-
Year
2022
Accepted
2023-03-21
Audit: 41344
Organization: Caromont Health, Inc. (NC)
Auditor: Forvis LLP

AI Summary

  • Core Issue: The System overstated lost revenues in PRF submissions by including amounts from both parent and subsidiary levels.
  • Impacted Requirements: Compliance with PRF and ARP terms, specifically regarding allowable expenses and accurate reporting of lost revenues.
  • Recommended Follow-Up: Implement stronger controls and oversight to ensure accurate reporting and compliance with funding criteria.

Finding Text

Finding 2022-001 Allowable Costs, Activities Allowed and Reporting 93.498 Provider Relief Fund (PRF) and American Rescue Plan (ARP) Rural Distributions Material Weakness and Material Noncompliance Criteria: The Department of Health and Human Services provided terms and conditions associated with the Provider Relief Fund (PRF) and American Rescue Plan (ARP) Rural Distributions. Those terms and conditions outlined the usages of the PRF distributions received, specifically related to expenses, and lost revenues. PRF distributions should only be used for expenses to prevent, prepare for and respond to the coronavirus that have not been reimbursed by other sources or that other sources are not obligated to reimburse and calculate lost revenues as outlined in the terms and conditions. Management should have effectively designed controls in place to prevent or detect and correct noncompliance. Condition: The System submitted lost revenues through the Department of Health and Human Services PRF portal for the second period of availability in which the lost revenue calculations were overstating the lost revenues between two separate portal submissions. Lost revenues were reported on a consolidated basis for the parent portal submission and included subsidiary lost revenues that were also included on a separate subsidiary portal submission, therefore overstating lost revenues on the parent portal submission. Context: During testing of period 2 reporting, we noted lost revenues were included both at the parent level and subsidiary level resulting in an overstatement of lost revenues. Questioned Costs: N/A Effect: Management failed to prevent, or detect and correct, noncompliance such that the System overstated lost revenues under the terms and conditions of the program. Cause: Lack of effectively designed and implemented controls, including oversight and detail review of the portal submission through the Department of Health and Human Services PRF portal for the second period of availability. Identification as a repeat finding: N/A Auditors? Recommendation: Effective controls over compliance and financial reporting should be implemented to ensure lost revenues submitted through the Department of Health and Human Services PRF portal meet the criteria established in the terms and conditions and there is not a reasonable possibility that the schedule could be materially misstated. Management Response: See corrective action plan.

Corrective Action Plan

Finding 2022-001 Contact Person: Shari Reese Completion Date: March 13, 2023 Managements Response: Reporting Period 1: During Reporting Period 1, several subsidiaries of CaroMont Health, Inc. (?Parent?) received general distributions from the CARES Act Provider Relief Fund (?PRF?). Management reported all the general distributions received by the subsidiaries under the Parent entity in the portal, including the general distributions received by CaroMont Regional Medical Center (?Hospital?). Management listed the TINS of the subsidiaries, including the Hospital, in the Subsidiary Data section in the Parent?s portal. Management reported lost revenues utilizing option i, 2019 Actual Revenues, for the subsidiaries in the Parent?s portal. Reporting Period 2: During Reporting Period 2, the Hospital received both general and a targeted distributions (High Impact Area) from the CARES Act PRF. Management was unsure how to report so it contacted the HRSA Provider Support Line. HRSA opened case #00025470 and on January 18, 2022, Management had a phone conference with a representative of HRSA to discuss Period 2 reporting. HRSA advised management to report as follows: ? Hospital ? report the targeted distribution. Only report revenue, expenses, and data for the Hospital. ? Parent ? report general distributions. Don?t change any numbers from Period 1. Report revenue, expenses, and data for all subsidiary TINS listed in the portal. Management specifically remembers explaining to the HRSA representative that this approach would result in double counting of Total Unused Lost Revenues because Hospital revenues would be reported in both portals. The HRSA representative said that would be okay because Management answered YES to ?Is the parent entity reporting on your General Distribution payments?? in the Hospital portal, because the Hospital?s TIN is listed in the Subsidiary Information section in the Parent?s portal, and because the Parent?s TIN is listed in the Subsidiary Questionnaire section in the Hospital?s portal. Management documented these instructions in their notes made during the call. Management also specifically remembers asking the HRSA representative if the Hospital revenue should be removed from the prior quarters in the Parent portal when reporting Period 2 to which the representative replied, ?don?t change any numbers?. Management documented these instructions in their notes made during the call. Management filed the Period 2 reports for the Parent and the Hospital in accordance with HRSA?s instructions received during this phone conference. Management reported lost revenues under option i, 2019 Actual Revenues, for the listed subsidiaries in the Parent portal and for the Hospital in the Hospital portal. However, since Management was concerned this approach would result in double counting of unused lost revenues, they created a reconciliation spreadsheet on February 1, 2022. This spreadsheet documented unused lost revenues from the PRF Financial Reporting Summary Reporting pages in the Parent and Hospital portals for Period 1 and Period 2 and calculated the correct total unused lost revenues when the reports were combined and the double counting was eliminated. Management?s intent was to update this reconciliation during Period 4 reporting to ensure the remaining unused lost revenues in both the Parent and Hospital portals exceeded the combined reconciled lost revenue ? thereby ensuring there would be no double counting of lost revenues after all PRF reporting was completed. Reporting Period 4: During Report Period 4, several subsidiaries of the Parent received general distributions from the CARES Act PRF and targeted distributions from the American Rescue Plan (?ARP?). By the time the Portal Reporting opened for Period 4, CaroMont?s auditors were conducting the Single Audit for the year ended June 30, 2022, and reached out to Management to discuss their concerns about potential double counting of lost revenues in the Period 2 portal reporting. Management explained their process for reporting Period 2 and shared with the auditors their reconciliation spreadsheet that was created on February 1, 2022. The auditors had also performed a reconciliation that resulted in the same outcome. The auditors and management subsequently had several discussions on the different alternatives available to correct the Period 2 overstatement. Management evaluated the alternatives and ultimately decided to change its calculation of Lost Revenues in the Parent portal for Period 4 from option i, 2019 Actual Revenue, to option iii, Alternative Method of Calculating Lost Revenues Attributable to COVID-19. However, management continued to report lost revenues in the Hospital portal for Period 4 utilizing option i, 2019 Actual Revenue, as it had in Period 2. Management created another reconciliation spreadsheet on February 23, 2023 that demonstrated the Hospital revenue was excluded from the Parent?s lost revenue calculations in Period 4. This spreadsheet was uploaded as supporting documentation for option iii in the Parent?s portal. By changing from option i to option iii for lost revenues in the Parent portal for Period 4, management corrected the overstatement of lost revenues identified in the Audit of Federal Awards Performed in Accordance with U.S. Office of Management and Budget Uniform Guidance for the year ended June 30, 2022.

Categories

Allowable Costs / Cost Principles Material Weakness Reporting Internal Control / Segregation of Duties

Other Findings in this Audit

  • 622626 2022-001
    Material Weakness

Programs in Audit

ALN Program Name Expenditures
93.498 Provider Relief Fund $9.96M
93.461 Covid-19 Testing for the Uninsured $1.20M
32.006 Covid-19 Telehealth Program $130,083