Finding 754856 (2022-001)

Material Weakness Repeat Finding
Requirement
ABEN
Questioned Costs
-
Year
2022
Accepted
2023-09-10
Audit: 176613
Organization: Kettering Health Network (OH)
Auditor: Ernst and Young

AI Summary

  • Core Issue: There is a material weakness in internal controls over compliance with the HRSA COVID-19 Uninsured Program, affecting adherence to federal requirements.
  • Impacted Requirements: The lack of effective internal controls violates Section 200.303 of Title 2 U.S. Code, which mandates compliance with federal statutes and program terms.
  • Recommended Follow-Up: Implement internal controls to ensure compliance with future federal program terms and maintain documentation to support their effectiveness.

Finding Text

Finding 2022-001 ? A. Activities Allowed or Unallowed, B. Allowable Costs / Cost Principles, E. Eligibility, and N. Special Tests and Provisions ? Material Weakness in Internal Controls Over Compliance Identification of the federal program: Assistance Listing 93.461 ? COVID-19 Claims Reimbursement to Health Care Providers and Facilities for Testing, Treatment, and Vaccine Administration for the Uninsured (U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA) (HRSA COVID-19 Uninsured Program) Criteria or specific requirement (including statutory, regulatory or other citation): Section 200.303 of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance), states the following regarding internal control: ?The non-federal entity must: 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 statues, 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 (also known as the Green Book) issued by the Comptroller General of the United States or the Internal Control ? Integrated Framework (COSO Framework) issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).? Kettering Health Schedule of Findings and Questioned Costs (continued) 2307-4310198 70 Section III ? Federal Award Findings and Questioned Costs (continued) Health and Human Services (HHS) ? (HRSA issued Terms and Conditions for Participation in the HRSA COVID-19 Claims Reimbursement to Health Care Providers and Facilities for Testing, Treatment, and Vaccine Administration for the Uninsured Program (T&Cs) outlining requirements that recipients of funding from the HRSA COVID-19 Uninsured Program must comply with including the following sections: Testing Services, Treatment Services and Vaccine Administration, and General Provisions in FY2020 Consolidated Appropriations. Condition: The System did not appropriately design or implement internal controls over the HRSA COVID-19 Uninsured Program T&Cs as of and for the year ended December 31, 2022. Cause: Though there are internal controls in place with respect to the System?s revenue cycle, the System did not specifically have internal controls in place to ensure compliance with the HRSA COVID-19 Uninsured Program T&Cs. Effect or potential effect: If adequate internal controls are not designed and implemented, the System may not be in compliance with the HRSA COVID-19 Uninsured Program T&Cs, or the System may not take necessary actions required to comply with the HRSA COVID-19 Uninsured Program related to Uniform Guidance compliance requirements A. Activities Allowed or Unallowed, B. Allowable Costs/Cost Principles, E. Eligibility, and N. Special Tests and Provisions Questioned costs: None. Kettering Health Schedule of Findings and Questioned Costs (continued) 2307-4310198 71 Section III ? Federal Award Findings and Questioned Costs (continued) Context: The HRSA COVID-19 Uninsured Program had federal expenditures of $1,105,658 for the year ended December 31, 2022 and was determined to be Type A major federal program. Identification as a repeat finding, if applicable: This is a repeat finding. The prior year finding reference is Finding 2021-001. Recommendation: Due to the nature of this program and the timing of the finding identified in the prior year, the System did not have the opportunity to remediate the prior year finding. While this program likely will not exist in future periods, the System should implement internal controls to document its review and compliance with future federal program T&Cs and the Uniform Guidance and ensure appropriate documentation is retained to support the operating effectiveness of the implemented internal controls. Views of responsible officials: Management agrees with the finding and has developed a plan to address the finding and will ensure appropriate internal controls and documentation are in place for future programs.

Categories

Allowable Costs / Cost Principles Special Tests & Provisions Cash Management Eligibility Material Weakness Matching / Level of Effort / Earmarking

Other Findings in this Audit

  • 178414 2022-001
    Material Weakness Repeat
  • 178415 2022-002
    Material Weakness Repeat
  • 754857 2022-002
    Material Weakness Repeat

Programs in Audit

ALN Program Name Expenditures
93.498 Covid-19 Provider Relief Fundand American Rescue Plan (arp) Rural Distribution $27.74M
84.268 Federal Direct Student Loans $3.17M
93.461 Covid-19 Claims Reimbursement for the Uninsured Program and the Covid-19 Coverage Assistance Fund $1.11M
97.036 Covid-19 Disaster Grants - Public Assistance (presidentially Declared Disasters) $954,129
84.063 Federal Pell Grant Program $939,152
93.884 Grants for Primary Care Training and Enhancement $249,405
84.425 Covid-19 Education Stabilization Fund $194,276
93.912 Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement $121,667
84.038 Federal Perkins Loan Program $98,459
93.364 Nursing Student Loans $38,977
84.007 Federal Supplemental Educational Opportunity Grants $38,789
84.033 Federal Work-Study Program $37,563
93.516 Affordable Care Act (aca) Public Health Training Centers Program $9,146
93.043 Special Programs for the Aging_title Iii, Part D_disease Prevention and Health Promotion Services $3,623