MEDINA COUNTY COMBINED GENERAL HEALTH DISTRICT

Finding Number: 2024-003 AL Number and Title: Federal Transit Cluster Federal Award Identification Number / Year: OH-2020-048-00, OH-2021-014-00, OH-2021-033-00, OH-2022-021-00, OH-2023-034-00, OH-2022-003-00, OH-2022-021-00 Federal Agency: U.S. Department of Transportation Compliance Requirement: Procurement, Suspension, and Debarment Pass-Through Entity: N/A Repeat Finding from Prior Audit? No Material Weakness and Noncompliance 2 CFR § 1200.10 states, in part, this part adopts the Office of Management and Budget (OMB) guidance in subparts A through I of 2 CFR part 180, as supplemented by this part, as the Department of Transportation policies and procedures for nonprocurement suspension and debarment. It thereby gives regulatory effect for the Department of Transportation to the OMB guidance as supplemented by this part. In addition, 2 CFR § 1201.1 indicates except as otherwise provided in this part, the Department of Transportation adopts the Office of Management and Budget Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (2 CFR part 200). This part supersedes and repeals the requirements of the Department of Transportation Common Rules (49 CFR part 18 and part 19). 2 CFR § 180.305 states that Non-Federal entities are prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred or whose principals are suspended or debarred, unless the Federal agency responsible for the transaction grants an exception under 2 CFR § 180.135. 2 CFR § 180.200 identifies “covered transactions” as nonprocurement or procurement transactions at the primary tier, between a Federal agency and a person; or at the lower tier, between a participant in a covered transaction and another person. Procurement contracts for goods and services awarded under a nonprocurement transaction (e.g., grant or cooperative agreement) are covered transactions if the contracts are expected to equal or exceed $25,000 or meet certain other specified criteria outlined in 2 CFR § 180.220 and 2 CFR § 1200.220. All nonprocurement transactions as defined in 2 CFR § 180.970 (i.e., subawards to subrecipients), irrespective of award amount, are considered covered transactions, unless exempt by 2 CFR § 180.215. When a non-Federal entity enters into a covered transaction with an entity at a lower tier, the non-Federal entity must verify that the entity is not suspended or debarred or otherwise excluded. This verification may be accomplished by checking SAM exclusions (https://sam.gov/content/home); collecting a certification from the entity, or adding a clause or condition to the covered transactions with that entity. In addition, the Medina County Transit Purchasing Policies and Procedures Manual III-5 Responsible Bidder section requires documentation of an excluded parties list search for contractors and subcontractors whose contract exceeds $25,000. 2 CFR § 200.318 requires the non-Federal entity to maintain records sufficient to detail the history of procurement. These records will include, but are not necessarily limited to, the following: Rationale for the method of procurement, selection of contract type, contractor selection or rejection, and the basis for the contract price. In addition, the Medina County Transit Purchasing Policies and Procedures Manual I-14 Source Selection requires the Transit Director to maintain records detailing the listing of procurement, including the selection of type of contract type, reasons for selection, basis for contract price, and rationale for method of procurement. The County did not have proper internal controls in place to verify that all entities, with whom the County had entered covered transactions, had not been suspended or debarred. There were three instances in which the Federal Transit Cluster grant made total payments to vendors of more than $25,000 and there was no evidence the County checked the SAM exclusions, collected a certification from the entity, or added a clause or condition to the covered transactions with the vendors. In addition, for 24 of 27 procurement transactions, the County did not maintain adequate documentation to detail the full history of procurement. Failure to have appropriate controls in place may result in vendors receiving federal funds that are suspended or debarred, and noncompliance with federal procurement requirements. The County should verify vendors are not suspended or debarred by checking the SAM exclusions, collecting a certification from the vendor, or adding a clause or condition to the covered transaction with the vendor prior to contracting with vendors that will be paid with federal funds. In addition, the County should maintain documentation of the history of procurements.

Finding Number: 2023-001 AL Number and Title: Health Center Program Cluster Federal Award Identification Number / Year: 2023 Federal Agency: U.S. Department of Health and Human Services Compliance Requirement: Special Tests and Provisions – Sliding Fee Discounts Pass-Through Entity: Not Applicable Repeat Finding from Prior Audit? Yes Prior Audit Finding Number: 2022-001 Noncompliance and Significant Deficiency – Sliding Fee Discounts 42 CFR § 51c.303(f) requires a community health center to prepare a schedule of fees or payments for the provision of its services designed to cover its reasonable costs of operation and a corresponding schedule of discounts adjusted on the basis of the patient's ability to pay. Provided, That such schedule of discounts shall provide for a full discount to individuals and families with annual incomes at or below those set forth in the poverty guidelines updated periodically in the Federal Register by the U.S. Department of Health and Human Services under the authority of 42 U.S.C. 9902(2); and for no discount to individuals and families with annual incomes greater than twice those set forth in such Guidelines, except that nominal fees for services may be collected from individuals with annual incomes at or below such levels where imposition of such fees is consistent with project goals. The Medina County Health Department Sliding Fee Discount Program Policy indicates the Medina County Health Center will provide services to all patients regardless of their ability to pay. A sliding fee scale for patients with income at or below 200% of the federal poverty level will provide discounts based solely upon family size and income Lack of proper internal controls over Federal Grants management led to 1 of 25 Health Center patients not receiving the proper discount based on annual income. Failure to correctly calculate and apply sliding fee discounts for eligible patients could result in patients paying more for services than required and possible misuse of federal funds. The District should implement policies and procedures to ensure accurate calculation and application of sliding fee discounts.

42 CFR ? 51c.303(f) requires a community health center to prepare a schedule of fees or payments for the provision of its services designed to cover its reasonable costs of operation and a corresponding schedule of discounts adjusted on the basis of the patient's ability to pay. Provided, That such schedule of discounts shall provide for a full discount to individuals and families with annual incomes at or below those set forth in the poverty guidelines updated periodically in the Federal Register by the U.S. Department of Health and Human Services under the authority of 42 U.S.C. 9902(2); and for no discount to individuals and families with annual incomes greater than twice those set forth in such Guidelines, except that nominal fees for services may be collected from individuals with annual incomes at or below such levels where imposition of such fees is consistent with project goals. The Medina County Health Department Sliding Fee Discount Program Policy indicates the Medina County Health Center will provide services to all patients regardless of their ability to pay. A sliding fee scale for patients with income at or below 200% of the federal poverty level will provide discounts based solely upon family size and income Lack of proper internal controls over Federal Grants management led to 3 of 25 Health Center patients not receiving the proper discount based on annual income. Failure to correctly calculate and apply sliding fee discounts for eligible patients could result in misuse of federal funds.Failure to correctly calculate and apply sliding fee discounts for eligible patients could result in misuse of federal funds. The District should implement policies and procedures to ensure accurate calculation and application of sliding fee discounts.

45 CFR 75.405(a) indicates a cost is allocable to a particular Federal award or other cost objective if the goods or services involved are chargeable or assignable to that Federal award or cost objective in accordance with relative benefits received. This standard is met if the cost: (1) Is incurred specifically for the Federal award; (2) Benefits both the Federal award and other work of the non-Federal entity and can be distributed in proportions that may be approximated using reasonable methods; and (3) Is necessary to the overall operation of the non-Federal entity and is assignable in part to the Federal award in accordance with the principles in this subpart. Due to an oversight in the invoice review process, the County was invoiced twice for Family Peer Support fees for the month of September 2021 and both invoices were subsequently approved and paid. In accordance with the above facts, and pursuant to Ohio Rev. Code ? 117.28, a Finding for Recovery for public money illegally expended is hereby issued against the vendor in the amount of $1,541 and in favor of Medina County's ADAMH Board - Federal Programs Fund. The County was reimbursed $1,541 on August 23, 2022 by the vendor. The County should implement procedures to ensure vendors are paid in accordance with the grant requirements and approved allocations.

2 CFR ? 200.416 requires a process whereby central service costs can be identified and assigned to benefitted activities on a reasonable and consistent basis. Additionally, 2 CFR ? 200.430 indicates random moment sampling (RMS) may be used to allocate salaries and wages to a Federal award. The Ohio Department of Job and Family Services has implemented a cost allocation plan approved by the U.S. Department of Health and Human Services, and has communicated time sampling requirements to county agencies. Ohio Admin. Code ? 5101:9-7-20(E)(2)(b) and Ohio Admin. Code ? 5101:9-7-23(E)(2)(b) requires the employee completing the RMS observation moment to complete the comment section. Comments shall demonstrate that the selected program and activity codes support the work being performed by the assigned position at the time of the observation. i. An employee working on a case shall include a case number or other unique identifier establishing case/client identity. ii. An employee not working on a case enters comments. The employee shall ensure that adequate backup documentation is available to verify the activity being performed. iii. An employee attending a meeting or training at the time of the observation moment shall enter the title/subject, location, and facilitator. iv. An employee on break, at lunch, on leave or on personal business at the time of the observation shall indicate the position was idle. Backup documentation for two of twenty-five RMS observations tested, one in the child support cost pool and one in the social services cost pool, did not support the activity reported for the time of the sampled moment. Both RMS observations should have been reported as unfunded codes. Failure to properly code RMS activity could result in improper allocation of costs to Federal funding.

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