EIN: 410991680
UEI: EA4PYMYAGJU3
Data as of August 19, 2026
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on June 24, 2026. Under 2 CFR 200.521(d), a pass-through entity that provided federal funds to this organization for this audit period must issue a management decision on these findings by December 24, 2026 (126 days from today).
What is a management decision? →Finding 2025-001 – Activities Allowed or Unallowed, Allowable Costs/Cost Principles Identification of the federal program: Federal Grantor: United States Department of Health and Human Services Assistance Listing No.: 93.817 Hospital Preparedness Program (HPP) Ebola Preparedness and Response Activities Criteria or specific requirement (including statutory, regulatory, or other citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) 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 statutes, 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” issued by the Comptroller General of the United States and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” Condition: Internal controls over payroll charged to the federal program were not sufficiently precise to ensure that payroll expenses were recorded using the correct authorized pay rates. Cause: Fairview did not have controls operating effectively, to review payroll calculations at a level of precision sufficient to detect discrepancies between applied pay rates and authorized rates prior to charging costs to the federal award. Effect or potential effect: Expenses may be charged to the federal award that are not in compliance with the federal grant agreements. Questioned costs: None. Context: Of the 23 payroll transactions sampled (totaling $67,035), two payroll transactions (totaling $404) were calculated using incorrect pay rates, resulting in inaccurate payroll charges to the federal program. For Assistance Listing No. 93.817, total payroll costs for Fairview were $537,540, representing 25.4% of total federal expenditures of $2,115,184 for the year ended December 31, 2025. Identification as a repeat finding, if applicable: The finding is not a repeat finding from the prior year. Recommendation: Management should enhance controls over payroll review processes to ensure payroll charges to federal programs are based on authorized pay rates and are reviewed at a sufficient level of precision to identify and correct errors prior to being charged to the award. Views of responsible officials: Management agrees with the finding and has developed a plan to correct the finding. To prevent recurrence, Fairview will enhance controls over payroll review processes to ensure accuracy prior to submission. These enhancements include reinforcing review expectations with project directors and including detailed review procedures for validating pay rate and wage calculations prior to reimbursement submissions.
Finding 2025-001 Federal Grantor: United States Department of Health and Human Services Planned Corrective Actions: Responsible Official – Dawn Ksepka, VP of Finance and System Controller Anticipated completion date – June 30, 2026 Management agrees with the finding. Remediation: Fairview has corrected the payroll reimbursement request for the inaccurate payroll charges identified in the finding. To prevent recurrence, Fairview will enhance controls over payroll review processes to ensure accuracy prior to submission. These enhancements include reinforcing review expectations with project directors and including detailed review procedures for validating pay rate and wage calculations prior to reimbursement submissions. Management believes these actions will improve the accuracy of payroll charges and ensure compliance with federal program requirements.
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on June 30, 2025. Under 2 CFR 200.521(d), a pass-through entity that provided federal funds to this organization for this audit period must issue a management decision on these findings by December 30, 2025, which was (233 days ago).
What is a management decision? →Finding 2024-001 Federal Funding Accountability and Transparency Act (FFATA) Reporting Identification of the federal program: Federal Grantor: United States Department of Health and Human Services Assistance Listing No.: 93.817 Hospital Preparedness Program (HPP) Ebola Preparedness and Response Activities Criteria or specific requirement (including statutory, regulatory, or other citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) 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 statutes, 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” issued by the comptroller General of the United States and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” Under the requirements of the Federal Funding Accountability and Transparency Act (Pub. L. No. 109-282) (Transparency Act) that are codified in 2 CFR Part 170, “unless the auditee is exempt as provided in paragraph d. of this award term, the auditee must report each action that equals or exceeds $30,000 in Federal funds for a subaward to a non-Federal entity or Federal agency no later than the end of the month following the month in which the obligation was made.” Recipients of grants or cooperative agreements are required to report first-tier subawards of $30,000 or more to the Federal Funding Accountability and Transparency Act Subaward Reporting System (FSRS) per submission instructions posted at http://www.fsrs.gov. Condition: During our testing of FFATA Report, it was identified that the report was not submitted by Fairview management within the time frame designated in 2 CFR 170 Appendix A. Cause: Policies and procedures and internal controls were not in place to ensure compliance with the FFATA reporting requirements. Effect or potential effect: Fairview Health Services did not report the necessary FFATA report for first-tier subawards over $30,000 to the FFATA Subaward Reporting System. Questioned costs: None. Context: Total subrecipient expenditures subject to FFATA reporting were $155,996 for the year ended December 31, 2024 and total Federal expenditures were $1,656,727 for the year ended December 31, 2024. Identification as a repeat finding, if applicable: The finding is not a repeat finding from the prior year. Recommendation: We recommend that Fairview Health Services management take immediate action to ensure compliance with the reporting requirements of the FFATA. Views of responsible officials: Management agrees with the finding. The FFATA report was filed on April 15, 2025. Fairview has established an internal control to ensure timely filing of FFATA reports in the future.
Finding 2024-001 Federal Grantor: United States Department of Health and Human Services Planned Corrective Actions: Responsible Official – Dawn Ksepka, VP of Finance and System Controller Anticipated completion date – April 15, 2025 Management agrees with the finding. Remediation: The FFATA report was filed on April 15, 2025. Fairview has established an internal control to ensure timely filing of FFATA reports in the future.
Finding 2024-002 Procurement and Suspension and Debarment Federal Grantor: United States Department of Health and Human Services Assistance Listing No.: 93.817 Hospital Preparedness Program (HPP) Ebola Preparedness and Response Activities Criteria or specific requirement (including statutory, regulatory, or other citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) 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 statutes, 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” issued by the comptroller General of the United States and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” Uniform Guidance 2 CFR Section 200.320 (a)(2) states regarding the applicability of simplified acquisition procedures: “The aggregate dollar amount of the procurement transaction is higher than the micro-purchase threshold but does not exceed the simplified acquisition threshold. If simplified acquisition procedures are used, price or rate quotations must be obtained from an adequate number of qualified sources. Unless specified by the Federal agency, the recipient or subrecipient may exercise judgment in determining what number is adequate. “ Section V.A.1.a.ii of the procurement policy of Fairview Health Services requires that for procurements by small purchase ($10,000–$249,000), where the aggregate dollar amount is higher than the micro-purchase threshold but does not exceed the simplified acquisition threshold, price or rate quotations must be obtained from three qualified sources. If three separate qualified sources cannot be obtained the reason needs to be formally documented. Condition: For one procurement transaction tested, we noted that Fairview Health Services did not complete a sole-source justification form timely to support the vendor that was selected. Cause: Management does not have sufficient internal controls in place to ensure that Fairview Health Services’ procurement policies are followed for all procurement transactions prior to entering the procurement. Effect or potential effect: Fairview Health Services entered into a procurement that did not go through a competitive solicitation process. Questioned costs: None Context: Total Federal expenditures subject to procurement for HPP were $616,107 for the year ended December 31, 2024. Total expenditures related to the procurement at issue were $29,041. Total Federal expenditures were $1,656,727 for the year ended December 31, 2024. Identification as a repeat finding, if applicable: The finding is not a repeat finding from the prior year. Recommendation: Management should review its policies and procedures to ensure all procurement transactions are in accordance with Fairview Health Services’ procurement policies and have the appropriate supporting documentation. Views of responsible officials: Management agrees with the finding and has developed a plan to correct the finding. Fairview updated its internal control processes to better retain and document sole source procurement justification before entering vendor agreements. A standard form for sole source justification will be implemented to enhance documentation.
Finding 2024-002 Federal Grantor: United States Department of Health and Human Services Planned Corrective Actions: Responsible Official – Dawn Ksepka, VP of Finance and System Controller Anticipated completion date – July 31, 2025 Management agrees with the finding. Remediation: Fairview updated its internal control processes to better retain and document sole source procurement justification before entering vendor agreements. A standard form for sole source justification will be implemented to enhance documentation.
Finding 2024-003 Procurement and Suspension and Debarment Identification of the federal program: Federal Grantor: United States Department of Health and Human Services Assistance Listing No.: 93.817 Hospital Preparedness Program (HPP) Ebola Preparedness and Response Activities Criteria or specific requirement (including statutory, regulatory, or other citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) 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 statutes, 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” issued by the comptroller General of the United States and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” Uniform Guidance 2 CFR Section 200.320 (a)(2) states regarding the applicability of simplified acquisition procedures: “The aggregate dollar amount of the procurement transaction is higher than the micro-purchase threshold but does not exceed the simplified acquisition threshold. If simplified acquisition procedures are used, price or rate quotations must be obtained from an adequate number of qualified sources. Unless specified by the Federal agency, the recipient or subrecipient may exercise judgment in determining what number is adequate. “ Section V.A.1.a.ii of the procurement policy of Fairview Health Services requires that for procurements by small purchase ($10,000-$249,000), where the aggregate dollar amount is higher than the micro-purchase threshold but does not exceed the simplified acquisition threshold, price or rate quotations must be obtained from three qualified sources. If three separate qualified sources cannot be obtained the reason needs to be formally documented. Condition: The data used in evaluating the vendors for suspension and debarment was not reviewed and approved. Cause: Management does not have internal controls in place to require the review and approval of the data used in evaluation of vendors for suspension and debarment. Effect or potential effect: Suspension and debarment results may not be accurate. As a result, federal funds may be used to pay a contractor that is suspended or debarred. Questioned costs: None Context: Total Federal expenditures subject to suspension and debarment were $947,686, representing 57% of total federal expenditures of $1,656,727 for the year ended December 31, 2024. Identification as a repeat finding, if applicable: The finding is not a repeat finding from the prior year. Recommendation: Management should implement internal controls over the review and approval of the data used in suspension and debarment analysis. Views of responsible officials: Management agrees with the finding and has developed a plan to correct the finding. Starting June 2025, the monthly suspension and debarment file will be reviewed. A signed statement confirming its accuracy will be included post-review. The accounts payable standard work document will be updated accordingly.
Finding 2024-003 Federal Grantor: United States Department of Health and Human Services Planned Corrective Actions: Monthly Suspension and Debarment files will be reviewed, and documented approval will be retained within the monthly files. Responsible Official – Dawn Ksepka, VP of Finance and System Controller Anticipated completion date –June 30, 2025 Management agrees with the finding. Remediation: Starting June 2025, the monthly suspension and debarment file will be reviewed. A signed statement confirming its accuracy will be included post-review. The accounts payable standard work document will be updated accordingly.
Finding 2024-004 Internal Controls over Allowability Identification of the federal program: Federal Grantor: United States Department of Health and Human Services Assistance Listing No.: 93.817 Hospital Preparedness Program (HPP) Ebola Preparedness and Response Activities Criteria or specific requirement (including statutory, regulatory, or other citation): 2 CFR 200.303 requires that the non-Federal entity must “(a) 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 statutes, 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” issued by the comptroller General of the United States and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” Condition: Fairview management did not retain documentation of review and approval of the fringe benefit rate calculation. In addition, Fairview management did not retain documentation of review and approval of supplies expenses for allowability. Cause: Fairview Health Services did not have internal controls in place that require supporting documentation of review and approval of the fringe benefit rate calculation and review and approval of supplies expenses for allowability. Effect or potential effect: Expenses may be charged to the federal award that are not in compliance with the federal grant agreements. Questioned costs: None. Context: For Assistance Listing No. 93.817, total fringe benefit expenses were $104,506, representing 6% of total federal expenditures of $1,656,727 for the year ended December 31, 2024. For Assistance Listing No. 93.817, total supplies expenses were $85,328, representing 5% of total federal expenditures of $1,656,727 for the year ended December 31, 2024. Identification as a repeat finding, if applicable: The finding is not a repeat finding from the prior year. Recommendation: Management should enhance internal controls to require the review and approval of the fringe benefit rate calculation and review and approval of supplies expenses for allowability. Views of responsible officials: Management agrees with the finding and has developed a plan to correct the finding. The accounting manager reviewed and approved the updated 2025 fringe benefit analysis with 2024 actuals on February 28, 2025. Upon finalization of the 2025 budget, the analysis will be revised and reviewed again. Accounting will collect evidence of review and approval of supply expenditure throughout the year to ensure proper retention of the documentation.
Finding 2024-004 Federal Grantor: United States Department of Health and Human Services Planned Corrective Actions: Management will improve internal controls to include the documentation and retention of approval on all supply expenditures and the annual fringe benefit analysis. Responsible Official – Dawn Ksepka, VP of Finance and System Controller Anticipated completion date –August 2025 Management agrees with the finding. Remediation: The accounting manager reviewed and approved the updated 2025 fringe benefit analysis with 2024 actuals on February 28, 2025. Upon finalization of the 2025 budget, the analysis will be revised and reviewed again. Accounting will collect evidence of review and approval of supply expenditure throughout the year to ensure proper retention of the documentation.
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on September 13, 2024. Under 2 CFR 200.521(d), a pass-through entity that provided federal funds to this organization for this audit period must issue a management decision on these findings by March 13, 2025, which was (525 days ago).
What is a management decision? →Finding 2023-001 Identification of the federal program: Federal Grantor: United States Department of Homeland Security Assistance Listing No.: 97.036, COVID-19 Disaster Grants – Public Assistance (Presidentially Declared Disasters) Pass-Through Grantor: State of Minnesota Pass-Through Award Period: 01/20/2020 – 05/11/2023 Criteria or specific requirement (including statutory, regulatory, or other citation): Section 200.303 of the Uniform Guidance states the following regarding internal control: “The non-Federal entity must: (a) 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 statutes, 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” issued by the Comptroller General of the United States or the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” The Uniform Guidance 2 CRF Subpart E Section 200.403 states the following: “Costs must meet the following general criteria in order to be allowable under Federal awards: (c) be consistent with policies and procedures that apply uniformly to both federally financed and other activities of the non-Federal entity; and (g) be adequately documented.” Condition: Fairview Health Services (the Company) did not retain sufficient documentation of its review of the allowability lab percentage calculation (which represents the total unreimbursed lab revenue as a percentage of total lab revenue to address duplication of benefits) used in determining lab supplies expense to be charged to FEMA. Cause: The Company did not have internal controls in place to formally document its review of the allowability percentage calculation applied to the lab supplies. Effect or potential effect: Lab supplies expenses may be charged to the federal award that are not consistent with the methodology adopted by the Company. Questioned costs: None. Context: We selected a sample of five of eight allowability percentage calculations for lab supplies and noted that for four of the calculations, there was no supporting documentation of the review and approval performed of the allowability percentage calculation. For Assistance Listing No. 97.036, total lab supplies to which the allowability percentage was applied were $8,432,353, representing 17% of total federal expenditures of $49,821,059 for the year ended December 31, 2023. Identification as a repeat finding, if applicable: The finding is not a repeat finding from the prior year. Recommendation: The Company should retain formal documentation of review and approval controls related to the lab supplies calculation. Views of responsible officials: “Management agrees with the finding. In May 2023, the COVID-19 emergency ended and, therefore, remediation of internal controls specific to allowability of costs for the FEMA program is no longer applicable. However, remediation steps were taken to improve documentation of review of internal controls over all federal expenditures, not limited to the FEMA program.” Fairview revised its internal control processes to improve the retention and documentation of the review and approval of inputs to the calculation of federal expenditures.
Finding 2023-001 Federal Grantor: United States Department of the Homeland Security Planned Corrective Actions: Responsible Official – Dawn Ksepka, VP of Finance and System Controller Anticipated completion date – August 31, 2024 Management agrees with the finding. In May 2023, the COVID-19 emergency was ended and therefore remediation of internal controls specific to allowability of costs for the FEMA program are no longer applicable. However, remediation steps were taken to improve documentation of review of internal controls over all federal expenditures, not limited to the FEMA program. Remediation: Fairview revised its internal control processes to improve the retention and documentation of the review and approval of inputs to the calculation of federal expenditures.
Finding 2023-002 Identification of the federal program: Federal Grantor: United States Department of Homeland Security Assistance Listing No.: 97.036, COVID-19 Disaster Grants – Public Assistance (Presidentially Declared Disasters) Pass-Through Grantor: State of Minnesota Pass-Through Award Period: 01/20/2020 – 05/11/2023 Criteria or specific requirement (including statutory, regulatory, or other citation): Section 200.303 of the Uniform Guidance states the following regarding internal control: “The non-Federal entity must: (a) 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 statutes, 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” issued by the Comptroller General of the United States or the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” The Uniform Guidance 2 CRF Subpart E Section 200.403 states the following: “Costs must meet the following general criteria in order to be allowable under Federal awards: (c) be consistent with policies and procedures that apply uniformly to both federally financed and other activities of the non-Federal entity; and (g) be adequately documented.” Condition: Management did not maintain supporting documentation to demonstrate how it validated the completeness and accuracy of the internal labor data used in the contract labor allowability percentage calculation (which represents the variance between internal labor cost and contract labor cost). In addition, supporting documentation was not retained to demonstrate that the contract labor allowability percentage calculation was reviewed and approved. The methodology used to calculate the labor allowability percentage to be applied to contract labor was based on assessing financial information for one pay period vs. assessing the two years to which the labor allowability percentage was applied. Cause: The Company did not have internal controls in place to formally document its review of the allowability percentage calculation applied to the contract labor. The review of the contract labor allowability percentage performed by management was not precise enough to challenge the appropriateness of the methodology. Effect or potential effect: Contract labor expenses may be charged to the federal award that are greater than the contract labor allowability percentage. Questioned costs: None. Context: For Assistance Listing No. 97.036, total contract labor expenses calculated with the allowability percentage were $17,856,115, representing 36% of total federal expenditures of $49,821,059 for the year ended December 31, 2023. Identification as a repeat finding, if applicable: The finding is not a repeat finding from the prior year. Recommendation: The Company should retain formal documentation of review and approval controls related to the contract labor allowability percentage calculation. The Company should reinforce the importance of applying the adopted methodology consistently related to the contract labor calculation. Views of responsible officials: “Management agrees with the finding. In May 2023, the COVID-19 emergency ended and, therefore, remediation of internal controls specific to allowability of costs for the FEMA program is no longer applicable. However, remediation steps were taken to improve documentation of review of internal controls over all federal expenditures, not limited to the FEMA program.” Fairview revised its internal control processes to improve the retention and documentation of the review and approval of inputs to the calculation of federal expenditures, as well as ensure that the review is precise enough to challenge the appropriateness of the methodology utilized.
Finding 2023-002 Federal Grantor: United States Department of the Homeland Security Planned Corrective Actions: Responsible Official – Dawn Ksepka, VP of Finance and System Controller Anticipated completion date – August 31, 2024 Management agrees with the finding. In May 2023, the COVID-19 emergency was ended and therefore remediation of internal controls specific to allowability of costs for the FEMA program are no longer applicable. However, remediation steps were taken to improve documentation of review of internal controls over all federal expenditures, not limited to the FEMA program. Remediation: Fairview revised its internal control processes to improve the retention and documentation of the review and approval of inputs to the calculation of federal expenditures, as well as ensure that the review is precise enough to challenge the appropriateness of the methodology utilized.
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on September 20, 2022. Under 2 CFR 200.521(d), a pass-through entity that provided federal funds to this organization for this audit period must issue a management decision on these findings by March 20, 2023, which was (1249 days ago).
What is a management decision? →Finding 2021-001 Identification on the federal program: Federal Grantor: United States Department of Health and Human Services, Health Resources and Services Administration (HRSA) Assistance Listing No.: 93.461, COVID-19 HRSA COVID-19 Claims Reimbursement for the Uninsured Program and the COVID-19 Coverage Assistance Fund (COVID-19 Uninsured Program) Award Period: January 1, 2021 through December 31, 2021 Criteria or specific requirement (including statutory, regulatory, or other citation): Section 200.303 of the Uniform Guidance states the following regarding internal control: ?The non-Federal entity must: (a) 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 statutes, 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? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework,? issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).? Health and Human Services (HHS) ? Health Resources and Services and Administrative (HRSA) issued Terms and Conditions for Participation in HRSA COVID-19 Claims Reimbursement for the Uninsured Program and the COVID-19 Coverage Assistance Fund (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. Per the HRSA COVID-19 Uninsured Award T&Cs and further clarified in the HRSA FAQs for HRSA COVID-19 Claims Reimbursement for the Uninsured Program and the COVID-19 Coverage Assistance Fund, the FAQ states the following: ?If a provider tests for COVID-19 as part of pre-operative or other medical treatment unrelated to COVID-19, is the test eligible for reimbursement? For the HRSA COVID-19 Uninsured Program, COVID-19 testing is eligible for reimbursement if one of the following diagnoses codes is included in any position on the claim: Z03.818 ? Encounter for observation for suspected exposure to other biological agents ruled out (possible exposure to COVID-19) Z11.59 ? Encounter for screening for other viral diseases (asymptomatic) Z20.828 ? Contact with and (suspected) exposure to other viral communicable (confirmed exposure to COVID-19) Z11.52 ? Encounter for screening for COVID-19 (asymptomatic) Z20.822 ? Contact with and (suspected) exposure to COVID-19 Z86.16 ? Personal history of COVID-19 Related treatment visits and services are not eligible for reimbursement given the primary reason for treatment is not COVID-19.? Per the HRSA T&Cs (for Uninsured Program Fund Payments): ?The Recipient certifies that it will not use the Payment to reimburse expenses or losses that have been reimbursed from other sources or that other sources are obligated to reimburse. If the Recipient subsequently receives reimbursement for any items or services for which the Recipient requested Payment from the Uninsured Program Fund, the Recipient will return to HHS that portion of the Payment which duplicates payment or reimbursement from another source. The Recipient will not include costs for which Payment was received in cost reports or otherwise seek uncompensated care reimbursement through federal or state programs for items or services for which Payment was received.? Condition: Fairview Health Services did not document its compliance with the HRSA COVID-19 Uninsured Program T&Cs. For certain emergency department, inpatient claims, and physician office visits that included COVID-19 testing, but COVID-19 was not the primary reason for the related treatment visit and services, Fairview Health Services erroneously billed the HRSA COVID-19 Uninsured Program for the entire encounter, which was not in compliance with the HRSA COVID-19 Uninsured Program regulations. Furthermore, a risk exists that the data relevant to the HRSA COVID-19 Uninsured Program stored within the patient accounting system may be inappropriately created or modified. Evidence of the operation of controls identified to address this risk during the fiscal period under audit was not retained. Cause: Fairview Health Services did not have internal controls in place to formally document its compliance with the HRSA COVID-19 Uninsured Program T&Cs. Fairview Health Services did not have internal controls in place to monitor the Program T&Cs and underlying HRSA COVID-19 Uninsured Program regulations during the COVID-19 pandemic. Fairview Health Services did not have internal controls in place to formally document its compliance with the HRSA COVID-19 Uninsured Program?s allowability requirements. Patient encounters that included a COVID-19 testing diagnosis code, where the primary treatment diagnosis code was not COVID-19 related, were not reviewed prior to submission to HRSA to verify treatment costs were allowable under the HRSA COVID-19 Uninsured Program. Management did not retain sufficient supporting documentation to support that the information technology general controls (ITGCs) and ITDM controls were designed effectively and placed in operation during the period under audit. Effect or potential effect: Certain claims submitted to the HRSA COVID-19 Uninsured Program were for unallowable activities and were, therefore, not eligible for reimbursement under the HRSA COVID-19 Uninsured Program. Evidence of controls addressing the risk that data within the patient accounting system may be inappropriately created or modified was not retained. Potential effects of ineffective controls related to this risk include ineligible patients could be inappropriately identified as eligible, services could be reimbursed by HRSA for unallowable charges, or patients could be inappropriately billed for services that HRSA reimbursed under this program. Questioned costs: Assistance Listing 93.461 ? $297,926 Context: During 2022, management performed an analysis over claims submitted to HRSA related to services with 2021 discharge dates, indicating that patient accounts totaling $296,804 were inappropriately billed to HRSA related to ineligible services. This amount was refunded to HRSA during 2022. This amount has been deducted from the amount presented on the schedule of federal awards. We sampled 60 patient claims (totaling $378,899 in federal expenditures) for services occurring during the award period that were billed to the COVID-19 Uninsured Program from the claims that were not refunded. We noted no allowability exceptions as a result of this testing. During our testing, we identified a patient account totaling $1,122 that had been paid by HRSA as well as by other insurance and HRSA had not been refunded. Total federal expenditures for Assistance Listing 93.461 totaled $4,955,833 for the year ended December 31, 2021. Identification as a repeat finding: This is a repeat finding and is related to finding 2020-004 from the prior year. Recommendation: The Uninsured Program ended in the first quarter of 2022. Therefore, no further changes are required to the current internal controls over this program or the related documentation of the operation of internal controls. If the program were to be reinstated, Fairview Health Services should implement sufficiently precise internal controls to review changes to the HRSA COVID-19 Uninsured Program to ensure it is administering the program in compliance with the HRSA COVID-19 Uninsured Program regulations. In addition, internal controls should be implemented to ensure claims submitted to the HRSA COVID-19 Uninsured Program meet the allowability criteria established by the HRSA COVID-19 Uninsured Program regulations before claims are submitted to HRSA for reimbursement. Management should retain documentation of the operation of controls responsive to risks related to the data stored in its IT systems as evidence of control activities. Credit balances should be resolved on a timely basis to ensure the HRSA COVID-19 Uninsured Program is refunded timely if third-party insurance is subsequently identified. Views of responsible officials: Management agrees with this finding and performed a review of claims submitted to the HRSA COVID-19 Uninsured Program for potential payments for ineligible services and has resubmitted any claims that require reprocessing due to overpayment. In March 2022, HRSA announced the discontinuance of the HRSA COVID-19 Uninsured Program and therefore remediation of internal controls is no longer applicable.
Finding 2021-001 Federal Agency: United States Department of Health and Human Services, Health Resources and Services Administration (HRSA) Planned Corrective Actions: Responsible Official ? Dawn Ksepka, VP of Finance and System Controller Anticipated completion date ? July 31, 2022 Management performed a review of claims submitted to the HRSA COVID-19 Uninsured Program for potential payments for ineligible services and has resubmitted any claims that require reprocessing due to overpayment. In March 2022, HRSA announced the discontinuance of the HRSA COVID-19 Uninsured Program and therefore remediation of internal controls is no longer applicable.
2020-004
Finding 2021-002 Identification on the federal program: Federal Grantor: United States Department of Health and Human Services (HHS), Health Resources and Services Administration (HRSA) Assistance Listing No.: 93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Award Period: January 1, 2021 through December 31, 2021 Criteria or specific requirement (including statutory, regulatory, or other citation): 2 CFR Section 200.303 of the Uniform Guidance states the following regarding internal control: ?The non-Federal entity must: (a) 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 statutes, 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? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).? Provider Relief Fund General and Targeted Distribution Post-Payment Notice of Reporting Requirements June 11, 2021 indicates that: ? Allowable equipment expenses include, ?Expenses paid for purchase of equipment used for infection control, such as updates to HVAC systems or sanitizing equipment.? ? ?The Reporting Entity will report on unreimbursed expenses attributable to coronavirus (net after other assistance received and PRF payments are applied).? ? ?Expenses that are paid for with General and Targeted PRF payments must be those that are unreimbursed by other sources and that other sources are not eligible to reimburse.? Condition: Management did not retain supporting documentation over its approval of certain expenses reported to HRSA in the HHS portal related to Grand Itasca Clinic and Hospital (GICH), a subsidiary within Fairview Health Services. While management had a robust process to identify and review expenses for allowability under the Provider Relief Fund (PRF) program, sufficient supporting documentation was not retained to support the process. GICH created a process to capture COVID-19 related payroll expenses by establishing COVID-19 pay codes. For the period from March 2020 through June 2021, certain payroll expenses recorded were charged to the PRF that did not have the appropriate COVID-19 pay codes and management did not retain supporting documentation to support that the payroll expenses were allowable under the PRF program. Cause: Management did not have suitably designed internal controls over the review and approval of PRF expenses for allowability related to GICH. Effect or potential effect: Unallowable expenses were charged to the PRF program related to GICH. Questioned Costs: $265,261 ? Assistance Listing 93.498 Context: We selected a sample of 40 expenses charged to the PRF program totaling $28,370. We identified 15 expense transactions totaling $2,379 for which sufficient supporting documentation was not retained. We noted these expenses were all related to one subsidiary within Fairview Health Services. Total expense related to this subsidiary lacking sufficient supporting documentation totaled $2,963,949. As a result of our observations in the above paragraph, management performed a detail review of all expenses charged to the PRF program for GICH and identified $265,261 of payroll costs that were unallowable. Total expenses reported in the HHS portal are $21,531,030. Total PRF lost revenue and expenditures reported on the SEFA are $200,901,082 for the year ended December 31, 2021. Identification as a repeat finding: This finding is not a repeat finding from the prior year. Recommendation: Management should reassess its internal controls over the review and approval of allowability of expenditures. Views of responsible officials: Management agrees with this finding and has developed a corrective action plan to remediate internal controls over the review and approval of allowability of expenditures at GICH in future periods.
Finding 2021-002 Federal Agency: United States Department of Health and Human Services, Health Resources and Services Administration (HRSA) Planned Corrective Actions: Planned Responsible Official ? Dawn Ksepka, VP of Finance and System Controller Anticipated completion date ? September 30, 2022 Management agrees with this finding and has developed a corrective action plan to remediate internal controls over the review and approval of allowability of expenditures at all Fairview subsidiaries.
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on March 29, 2022. Under 2 CFR 200.521(d), a pass-through entity that provided federal funds to this organization for this audit period must issue a management decision on these findings by September 29, 2022, which was (1421 days ago).
What is a management decision? →Information on the federal program: Federal Grantor: United States Department of Health Pass-Through Entity: Minnesota Department of Health Assistance Listing No.: 93.817 Hospital Preparedness Program (HPP) Ebola Preparedness and Response Activities Pass-Through Entity Assigned Number: 108180; 108184 Criteria or specific requirement (including statutory, regulatory, or other citation): Section 200.303(a) Internal Controls, of the Uniform Guidance states the following regarding the auditee and internal control: ?The non-Federal entity must: (a) 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 statutes, 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? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework,? issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO)? Condition: Fairview Health Services? internal controls over the review of cash draws was not designed at a sufficiently precise enough level to adequately validate the underlying support used to prepare the cash reimbursement requests was complete and accurate. We tested the two cash reimbursement submitted during fiscal 2020 and noted two instances where the review was not performed at a sufficiently precise level to identify mathematical errors in the underlying support. As a result of the errors, there was an immaterial understatement of the cash draw. Cause: Fairview Health Services? internal controls over the review of cash draws was not designed at a sufficiently precise enough level to adequately validate the underlying support used to prepare the cash reimbursement requests was complete and accurate. The supporting documentation for the cash reimbursement request contained formula errors that were not identified during the review process. Effect or potential effect: The amount of cash drawn down for reimbursement was not based on allowable costs of the program. Questioned Costs: None. Context: We tested the total fiscal year 2020 cash draw population, which represented two cash draws totaling $124,783. Federal expenditures reported in the SEFA for the major program totaled $2,176,241 for the year ended December 31, 2020. Identification as a repeat finding: This is not a repeat finding. Recommendation: Fairview Health Services should review its internal controls over cash draw down process to ensure the review is sufficiently precise to identify errors. Views of Responsible officials: Management concurs with the finding and has developed a plan to correct the finding.
Finding 2020-001 Federal Agency: U.S. Department of Health and Human Services - Centers for Disease Control and Prevention Planned Corrective Actions: Responsible Official ? Dawn Ksepka, VP of Finance and System Controller Anticipated completion date ? June 30, 2022 Management will review and modify its internal controls over the cash draw down process to ensure the review is sufficiently precise to validate support and identify errors.
Information on the federal program: Federal Grantor: United States Department of Health Pass-Through Entity: Minnesota Department of Health Assistance Listing No.: 93.817 Hospital Preparedness Program (HPP) Ebola Preparedness and Response Activities Pass-Through Entity Assigned Number: 108180 Criteria or specific requirement (including statutory, regulatory, or other citation): Section 200.303(a) Internal Controls, of the Uniform Guidance states the following regarding the auditee and internal control: ?The non-Federal entity must: (a) 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 statutes, 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? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework,? issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO)? 2 CFR Section 200.33 of the Uniform Guidance states the following regarding the definition of equipment: ?Equipment means tangible personal property, including information technology systems, having a useful life of more than one year and a per-unit acquisition cost, which equals or exceeds the lesser of the capitalization level established by the non-federal entity for financial statement purposes or $5,000.? 2 CFR Section 200.313 of the Uniform Guidance states the following regarding management?s responsibilities for managing equipment until disposition takes place: ?2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. 3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. 4) Adequate maintenance procedures must be developed to keep the property in good condition.? Condition: Fairview Health Services did not capitalize equipment purchased with federal monies between the federal capitalization threshold of $5,000 and $10,000. Fairview did not conduct a physical inventory of the property at least once in the last two years. Cause: Management does not have suitably designed internal controls over equipment in accordance with the federal register. In addition, Fairview Health Service?s policies and procedures related to the capitalization of federal equipment has a minimum threshold of a useful life of more than one year and a per-unit acquisition cost of $10,000, which exceeds the federal capitalization threshold of $5,000 outlined in 2 CFR Section 200.33. Effect or potential effect: Fairview Health Services did not capitalize federal equipment in accordance with the 2 CFR Section 200.33 and, therefore, had not indicated these assets were federal equipment within the fixed asset subledger. As a result, Fairview Health Services could dispose of a federal asset without following the appropriate federal standards. Additionally, management was unable to confirm the existence of the equipment through the performance of an inventory observation. Questioned Costs: None. Context: Total federal equipment for Assistance Listing 93.817 based on a useful life of more than one year and a per-unit acquisition cost of $5,000 totaled $2,004,327 for the year ended December 31, 2020. Fairview Health Service?s equipment records only included federal equipment of $1,840,217 as a result of higher capitalization thresholds used by management. The difference of $164,110 was recorded as an expense for the year ended December 2021. Total federal expenditures for Assistance Listing 93.817 were $2,176,241. Identification as a repeat finding: This is not a repeat finding. Recommendation: Management should update their internal controls and policies to lower the capitalization of federal equipment to $5,000 in accordance with 2 CFR Section 200.33 and complete a physical inventory of its federal assets. Views of responsible officials: Management agrees with the finding and has developed a plan to correct the finding.
Finding 2020-002 Federal Agency: U.S. Department of Health and Human Services - Centers for Disease Control and Prevention Planned Corrective Actions: Planned Responsible Official ? Dawn Ksepka, VP of Finance and System Controller Anticipated completion date ? September 30, 2022 Management identified and corrected the capitalization of federal assets between $5,000 - $10,000. Management will update our internal controls and policies to lower the capitalization of federal equipment to $5,000 in accordance with 2 CFR Section 200.33. An inventory observation was not able to be performed due to the assets being within a unit actively caring for COVID-19 patients. Management will conduct a physical inventory of its federal assets during 2022, and then update our internal controls and policies to require physical inventory of federal assets at least once every two years going forward.
Information on the federal program: Federal Grantor: United States Department of Health Pass-Through Entity: Minnesota Department of Health Assistance Listing No.: 93.817 Hospital Preparedness Program (HPP) Ebola Preparedness and Response Activities and COVID-19 Coronavirus Preparedness and Response Supplemental Appropriations Pass-Through Entity Assigned Number: 108180; 108184, 181093 Criteria or specific requirement (including statutory, regulatory, or other citation): Section 200.303(a) Internal Controls, of the Uniform Guidance states the following regarding the auditee and internal control: ?The non-Federal entity must: (a) 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 statutes, 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? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework,? issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO)? Section 200.319(d) says ?The non-Federal entity must have written procedures for procurement transactions. These procedures must ensure that all solicitations: 1. Incorporate a clear and accurate description of the technical requirements for the material, product, or service to be procured. Such description must not, in competitive procurements, contain features which unduly restrict competition. The description may include a statement of the qualitative nature of the material, product, or service to be procured and, when necessary, must set forth those minimum essential characteristics and standards to which it must conform if it is to satisfy its intended use. Detailed product specifications should be avoided if at all possible. When it is impractical or uneconomical to make a clear and accurate description of the technical requirements, a ?brand name or equivalent? description may be used as a means to define the performance or other salient requirements of procurement. The specific features of the named brand which must be met by offers must be clearly stated; and 2. Identify all requirements which the offerors must fulfill and all other factors to be used in evaluating bids or proposals.? Section 200.319(e) says ?The non-Federal entity must ensure that all prequalified lists of persons, firms, or products, which are used in acquiring goods and services, are current and include enough qualified sources to ensure maximum open and free competition. Also, the non-federal entity must not preclude potential bidders from qualifying during the solicitation period.? Section 200.320(a) and (b) of the Uniform Guidance states, micro-purchases may be awarded without soliciting competitive quotations if the non-federal entity considers the price to be reasonable. If small purchase procedures are used, price or rate quotations must be obtained from an adequate number of qualified sources. ?For acquisitions exceeding the simplified acquisition threshold, the non-federal entity must use one of the following procurement methods: the sealed bid method if the acquisition meets the criteria in 2 CFR section 200.320(c); the competitive proposals method under the conditions specified in 2 CFR section 200.320(d); or the noncompetitive proposals method (i.e., solicit a proposal from only one source) but only when one or more of four circumstances are met, in accordance with 2 CFR section 200.320(f).? Condition: Fairview Health Services does not have adequate documentation supporting their procurements were made in accordance with federal procurement requirements outlined in Section 200.320 in fiscal 2020. Cause: Management does not have suitably designed internal controls and policies and procedures over federal procurements to ensure that they are made in accordance with the appropriate procurement threshold as outlined in Section 200.320 (a), (b), (c), and (d) and that supporting documentation is maintained to corroborate their procurement decisions. Effect or potential effect: An adequate number of quotes or bids was not obtained for procurements above the small purchase threshold. Purchases over the simplified acquisition threshold used the sole source method without providing support in accordance with the procurement standards. Purchases may have been entered into without obtaining the most reasonable price. Questioned Costs: $784,765 (Pass-Through: 108180) ? Assistance Listing 93.817 Context: We selected a sample of five procurement for fiscal 2020. Two of our procurement samples were above the small acquisition threshold (>$3,500); however, an adequate number of quotes and bids were not obtained. Additionally, two of our procurement samples were above the simplified acquisition threshold; however, Fairview Health Services did not obtain a competitive bid or document the rationale for a noncompetitive bid. Total federal procurements for the major program based on vendor expenses procured totaled $2,131,058 for the year ended December 31, 2020. Total federal expenditures for Assistance Listing 93.817 were $2,176,241. Identification as a repeat finding: This is not a repeat finding. Recommendation: Management should update their internal controls and policies to ensure procured transactions are appropriately entered into based on the Uniform Guidance standards and maintain sufficient evidence to support their conclusions related to these procurements. Views of responsible officials: Management agrees with the finding and has developed a plan to correct the finding.
Finding 2020-003 Federal Agency: U.S. Department of Health and Human Services - Centers for Disease Control and Prevention Planned Corrective Actions: Responsible Official ? Dawn Ksepka, VP of Finance and System Controller Anticipated completion date ? September 30, 2022 Management agrees that it could not produce documentation to support that an adequate number of bids or quotes were obtained, or of the rational for a noncompetitive bid. Management will implement internal controls, policies, and procedures over federal procurements in accordance with the federal regulations. This will include steps to ensure that they are made in accordance with the appropriate procurement threshold(s) as outlined in Section 200.320 (a), (b), (c) and (d) and that supporting documentation is maintained to corroborate procurement decisions.
Information on the federal program: Federal Grantor: United States Department of Health Pass-Through Entity: Health Resources and Services Administration CFDA No.: 93.461, COVID-19 Claims Reimbursement to Health Care Providers and Facilities for Testing, Treatment, and Vaccine Administration for the Uninsured (COVID-19 Uninsured Program) Grant/Contract Number: UIT20200001 Criteria or Specific Requirement (Including Statutory, Regulatory, or Other Citation): Section 200.303 of the Uniform Guidance states the following regarding internal control: ?The non-Federal entity must: (a) 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 statutes, 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? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework,? issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).? Health and Human Services (HHS) ? Health Resources and Services and Administrative (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. Per the HRSA COVID-19 Uninsured Award T&Cs and further clarified in the HRSA FAQs for COVID-19 Claims Reimbursement to Health Care Providers and Facilities for Testing, Treatment, and Vaccine Administration, the FAQ states the following: ?If a provider tests for COVID-19 as part of pre-operative or other medical treatment unrelated to COVID-19, is the test eligible for reimbursement? For the HRSA COVID-19 Uninsured Program, COVID-19 testing is eligible for reimbursement if one of the following diagnoses codes is included in any position on the claim: Z03.818 ? Encounter for observation for suspected exposure to other biological agents ruled out (possible exposure to COVID-19) Z11.59 ? Encounter for screening for other viral diseases (asymptomatic) Z20.828 ? Contact with and (suspected) exposure to other viral communicable (confirmed exposure to COVID-19) Z11.52 ? Encounter for screening for COVID-19 (asymptomatic) Z20.822 ? Contact with and (suspected) exposure to COVID-19 Z86.16 ? Personal history of COVID-19 Related treatment visits and services are not eligible for reimbursement given the primary reason for treatment is not COVID-19.? Condition: For certain patient visits that included COVID-19 testing and treatment, but COVID-19 was not the primary reason for the related visit and services, Fairview erroneously billed the COVID-19 Uninsured Program for the entire encounter, which was not in compliance with the COVID-19 Uninsured Program regulations. In addition, Fairview did not document its compliance with the COVID-19 Uninsured Program T&Cs. Furthermore, a risk exists that the data relevant to the COVID-19 Uninsured Program stored within the patient accounting system may be inappropriately created or modified. Evidence of the operation of controls identified to address this risk during the fiscal period under audit was not retained. Fairview Health Services did not have suitably designed controls in place to ensure that the COVID-19 Uninsured Program is reimbursed for services provided to patients that have retroactively been approved for alternate insurance coverage. Cause: Fairview Health Services did not have internal controls in place to monitor the T&Cs and underlying COVID-19 Uninsured Program regulations during the COVID-19 pandemic. Fairview did not have internal controls in place to formally document its compliance with the COVID-19 Uninsured Program T&Cs. Management did not retain sufficient supporting documentation to support that the information technology general controls (ITGCs) and ITDM controls were designed effectively and placed in operation during the period under audit. Finally, management was unable to provide a complete population of patients with credit balances that existed as a part of the HRSA Uninsured Program. Effect or potential effect: Potential effects include ineligible patients were inappropriately identified as eligible, services reimbursed by HRSA were not allowable, or patients were inappropriately billed for services that HRSA reimbursed under this program. Fairview could be in noncompliance with the COVID-19 Uninsured Program T&Cs. Certain claims submitted to the COVID-19 Uninsured Program were for unallowable activities and were, therefore, not eligible for reimbursement under the COVID-19 Uninsured Program. Credit balances may not be resolved timely and refunds to the Uninsured Program may not be identified or refunded on a timely basis. Questioned Costs: Assistance Listing 93.461 ? $231,283 Context: We sampled 40 claims (totaling $615,186 in federal expenditures) for services occurring during the award period that were billed to the COVID-19 Uninsured Program and noted $231,283 claims that were inappropriately billed to HRSA because the primary reason for the visit was not COVID-19. Total federal expenditures for Assistance Listing 93.461 totaled $4,962,359 for the year ended December 31, 2020. Identification as a repeat finding: This is not a repeat finding. Recommendation: Fairview should implement internal controls to document its review and compliance with the T&Cs. Fairview should implement sufficiently precise internal controls to review changes to the COVID-19 Uninsured Program to ensure it is administering the program in compliance with the COVID-19 Uninsured Program regulations. In addition, internal controls should be implemented to ensure claims submitted to the COVID-19 Uninsured Program meet the allowability criteria established by the COVID-19 Uninsured Program regulations before claims are submitted to HRSA for reimbursement. Management should retain documentation of the operation of ITGC and ITDM controls as evidence of control operations sufficient to test internal control over compliance. Internal controls over credit balances related to the uninsured program should be implemented. Views of responsible officials: Management agrees with the finding and has developed a plan to correct the finding.
Finding 2020-004 Federal Agency: U.S. Department of Health and Human Services - Centers for Disease Control and Prevention Assistance Listing: No. 93.461, COVID-19 Claims Reimbursement to Health Care Providers and Facilities for Testing, Treatment, and Vaccine Administration for the Uninsured (COVID-19 Uninsured Program) Planned Corrective Actions: Responsible Official ? Dawn Ksepka, VP of Finance and System Controller Anticipated completion date ? September 30, 2022 Management is in the process of reviewing claims submitted to the HRSA COVID-19 Uninsured Program for potential payments for ineligible services and will timely resubmit any claims that require reprocessing due to overpayment. In March 2022, HRSA announced the discontinuance of the HRSA COVID-19 Uninsured program and therefore remediation of internal controls in no longer applicable.
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on September 24, 2018. Under 2 CFR 200.521(d), a pass-through entity that provided federal funds to this organization for this audit period must issue a management decision on these findings by March 24, 2019, which was (2706 days ago).
What is a management decision? →GSA_MIGRATION
GSA_MIGRATION
2016-001
GSA_MIGRATION
GSA_MIGRATION
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on September 29, 2017. Under 2 CFR 200.521(d), a pass-through entity that provided federal funds to this organization for this audit period must issue a management decision on these findings by March 29, 2018, which was (3066 days ago).
What is a management decision? →GSA_MIGRATION
GSA_MIGRATION
GSA_MIGRATION
GSA_MIGRATION
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