Medstar, Inc.

Assistance Listing Number, Federal Agency, and Program Name - 93.498, U.S. Department of Health and Human Services, COVID-19: Provider Relief Fund (PRF) and American Rescue Plan (ARP) Rural Distribution Federal Award Identification Number and Year - N/A, 2022 Pass through Entity - N/A - Direct funded Finding Type - Material weakness and material noncompliance with laws and regulations Repeat Finding - Yes, 2021-005 Criteria - Per the Provider Relief Fund distributions and American Rescue Plan (ARP) Rural Distribution Post Payment Notice of Reporting Requirements dated April 22, 2024, general distribution payments can be used on eligible expenses not reimbursed by other sources. Condition - The Organization was unable to provide supporting documentation to substantiate the allowability and accuracy of the expenses submitted in the portal. Questioned Costs - $1,252,194 If Questioned Costs are not Determinable, Description of Why Known Questioned Costs were Undetermined or Otherwise Could not be Reported - N/A Identification of How Questioned Costs Were Computed - Since the Organization could not provide supporting documentation for any of the $1,252,194 of expenses submitted, entire population is deemed questioned costs. Context - Management did not have adequate controls in place to retain supporting documentation for allowable costs under the grant. There were inadequate controls around the review of information uploaded on the granting agency's reporting portal. Management was unable to provide detail behind expense amounts submitted to the portal; therefore, a sample was unable to be selected for testing. Cause and Effect - An appropriate review of portal submission was not completed to ensure detailed supporting documentation can substantiate exact dollar amounts for allowable expenses used in the reporting portal. Due to a lack of access to documentation housed by a previously utilized vendor, the Organization could not provide sufficient detailed support for the expenses submitted in the portal. As a result, we were unable to perform adequate compliance and control testing on the federal expenditures. Recommendation - We recommend that the Organization implement controls, including levels of review, to ensure expenses and lost revenue submitted to the portal are supportable and allowable. Views of Responsible Officials and Corrective Action Plan - We recognize the challenges that arose during the audit of the $1,252,194 in COVID-19 relief funds and want to provide our views. As an ambulance provider and first responder, our commitment to the community during the pandemic never wavered. The audit period coincided with our transition to a new payroll provider, which unfortunately resulted in the loss of access to certain payroll records. This limited our ability to provide Plante & Moran, PLLC with complete documentation of specific expenses. Even so, the full scope audit reflects the extraordinary impact of the pandemic on our operations. While payroll levels remained stable because reducing staffing was not an option, our transport volume was significantly reduced. The result was a sharp loss in revenue of approximately $12 million, while personnel hours and costs remained constant or increased. These hours included extended service time nearly double the historic average time required on individual transports, extended time on scene providing treatment without transport (or revenue), staffing federal COVID hospitals, and supporting nontraditional and unfunded services requested by our public health and hospital partners. In addition, our teams were called on to transport patients to and from hospitals and, at times, to morgues, often under extremely difficult circumstances without reimbursement. We also deployed personnel to administer monoclonal antibody treatments, a vital service in the community’s fight against COVID-19. Each of these missions required us to maintain a fully staffed workforce despite a steep decline in billable transport volume. Although gaps in payroll documentation presented challenges during the audit, the evidence of our financial losses and operational commitments during the pandemic clearly demonstrates the necessity and appropriateness of the relief funds received. We remain committed to transparency, accountability, and our mission of serving the community, especially in times of crisis. The Organization changed payroll providers in June 2022, at which point we were unable to access the payroll registers by personnel name from the old provider. The Organization has full access to payroll registers through the new payroll provider.

Assistance Listing Number, Federal Agency, and Program Name - 93.498, U.S. Department of Health and Human Services, COVID 19: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution (PRF) Federal Award Identification Number and Year - N/A, 2021 Pass through Entity - N/A - Direct funded Finding Type - Material weakness and material noncompliance with laws and regulations Repeat Finding - No Criteria - Per the Provider Relief Fund distributions and American Rescue Plan (ARP) Rural Distribution Post Payment Notice of Reporting Requirements dated April 22, 2024, general distribution payments can be used on eligible expenses not reimbursed by other sources. Condition - The Organization was unable to provide supporting documentation to substantiate the allowability and accuracy of the expenses submitted in the portal. Questioned Costs - $858,046 Identification of How Questioned Costs Were Computed - Since the Organization could not provide supporting documentation for any of the $858,046 of expenses submitted, entire population is deemed questioned costs. Context - Management did not have adequate controls in place to retain supporting documentation for allowable costs under the grant. There were inadequate controls around the review of information uploaded on the granting agency's reporting portal. Management was unable to provide detail behind expense amounts submitted to the portal, therefore a sample was unable to be selected for testing. Cause and Effect - An appropriate review of portal submission was not completed to ensure detailed supporting documentation can substantiate exact dollar amounts for allowable expenses used in the reporting portal. Due to a lack of access to documentation housed by previously utilized vendor, the Organization could not provide sufficient detailed support for the expenses submitted in the portal. As a result, we were unable to perform adequate compliance and control testing on the federal expenditures. Recommendation - We recommend the Organization implement controls, including levels of review, to ensure expenses and lost revenue submitted to the portal are supportable and allowable. Views of Responsible Officials and Corrective Action Plan - We recognize the challenges that arose during the audit of the $858,046 in COVID 19 relief funds and want to provide our views. As an ambulance provider and first responders, our commitment to the community during the pandemic never wavered. The audit period coincided with our transition to a new payroll provider, which unfortunately resulted in the loss of access to certain payroll records. This limited our ability to provide Plante Moran with complete documentation of specific expenses. Even so, the full scope audit reflects the extraordinary impact of the pandemic on our operations. While payroll levels remained stable because reducing staffing was not an option, our transport volume was significantly reduced. The result was a sharp loss in revenue of approximately $12 million, while personnel hours and costs remained constant or increased. These hours included extended service time nearly double the historic average time required on individual transports, extended time on scene providing treatment without transport (or revenue) staffing federal COVID hospitals, and supporting non traditional and unfunded services requested by our public health and hospital partners. In addition, our teams were called on to transport patients to and from hospitals and, at times, to morgues, often under extremely difficult circumstances and not reimbursed. We also deployed personnel to administer monoclonal antibody treatments, a vital service in the community’s fight against COVID 19. Each of these missions required us to maintain a fully staffed workforce despite a steep decline in billable transport volume. Although gaps in payroll documentation presented challenges during the audit, the evidence of our financial losses and operational commitments during the pandemic clearly demonstrates the necessity and appropriateness of the relief funds received. We remain committed to transparency, accountability, and our mission of serving the community, especially in times of crisis. The Organization changed payroll providers in June 2022 at which point we were unable to access the payroll registers by personnel name from the old provided. The Organization has full access to payroll registers through the new payroll provider