INOVA HEALTH SYSTEM

Federal Program Information Federal Agencies: Department of Health and Human Services (“HHS”) Pass-Through Entity: Virginia Department of Health; Not Applicable Pass-Through Entity Number: INORWB611-GY23; INORWB611-GY24; Not Applicable Awards: Assistance Listing 93.917 – HIV Emergency Relief Project Grants; Assistance Listing 93.918 – Grants to Provide Outpatient Early Intervention Services with Respect to HIV Disease Award Periods: April 1, 2023 to March 31, 2024; April 1, 2024 to March 31, 2025; May 1, 2023 to April 30, 2024; May 1, 2024 to April 30, 2025 Description: Timely Application of Program Income Prior to Requesting Additional Cash Payments   Criteria In accordance with Title 2 U.S. Code of Federal Regulations, Part 200.303, Internal controls, “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.” Per the terms and conditions of the notice of award (Assistance Listing 93.918) and the pass-through entity agreement between the Virginia Department of Health (the Department) (Assistance Listing 93.917) and the Inova Juniper Program (IJP), IJP is required to follow Health Resources and Services Administration (HRSA) guidelines related to the program. HRSA develops multiple policies to help grant recipients and subrecipients understand and carry out legislation applicable to Ryan White programs. Per the Policy Clarification Notice included on the official HRSA website for Ryan White, “Under the uniform administrative requirements, to the extent available, recipients and subrecipients must disburse funds available from program income, rebates, refunds, contract settlements, audit recoveries and interest earned on such funds before requesting additional cash payments.” As such, program income must be used for the purpose and subject to the conditions of the Federal award. The requirements within the pass-through entity agreement with the Virginia Department of Health are consistent with those required by the original Federal awarding agency, the Department of Health and Human Services (HHS), HRSA as included in the notice of award. Per the frequently asked questions (FAQs) presented by HRSA’s HIV/AIDS Bureau (HAB) for Policy Clarification Notice (PCN) 15-03, Clarification Regarding the Ryan White HIV/AIDS Program and Program Income, released on March 21, 2016, program income is gross income earned by the non-Federal entity that is directly generated by a supported activity or earned as a result of the Federal award during the period of performance (or grant period). Program Income includes the core medical and support services that HRSA considers allowable uses of Ryan White grant funds and the individuals eligible to receive those services. Condition IHS did not have appropriately designed internal controls in place to ensure that program income was applied to offset expenditures prior to requesting additional cash reimbursements each month during the grant period. Cause IJP has policies and procedures in place to ensure program income was applied to offset expenditures in its entirety prior to the end of the calendar and grant period. However, during the grant period, program income was not timely applied prior to cash reimbursement requests. Effect or potential effect Cash payments were being requested and reimbursed prior to application of program income. Questioned costs $109,290 of known questioned costs for Assistance Listing 93.917 $44,677 of known questioned costs for Assistance Listing 93.918 The costs questioned represent the amount of program income that should have been applied prior to requesting cash reimbursement. Identification of a repeat finding This is a repeat finding and relates to prior year finding 2023-002. Context Cash reimbursement requests under Assistance Listing 93.917 are submitted monthly. During our audit for Assistance Listing 93.917, we selected a sample of 4 months for testing and identified exceptions within 2 months where program income was not being applied timely to the cash reimbursement requests. The total amount of program income that should have been applied prior to requesting cash reimbursement was $32,843 for the 2 months selected. As a result, we obtained management’s summary of program income for the fiscal year and identified that a total of 7 months or a total of $109,290 did not apply program income prior to requesting cash reimbursements. Cash reimbursement requests under Assistance Listing 93.918 are submitted quarterly. During our audit for Assistance Listing 93.918, we selected a sample of 2 quarters for testing and identified that program income was not being applied timely to the first quarter cash reimbursement request. The cumulative program income not applied prior to the cash reimbursement for the first quarter was $44,677. As a result, we obtained management’s summary of program income for the fiscal year and identified that there were no other quarters impacted. Recommendation During the latter part of the fiscal year and as a result of prior year audit findings, IJP implemented various checkpoints in their processes to ensure that program income was applied prior to requesting cash reimbursements. IJP should continue to assess existing policies and procedures to ensure the program income balance is applied timely. HRSA recommends that recipients and subrecipients strive to proactively secure and estimate the extent to which program income will be accrued. View of responsible officials Management concurs with the finding and has implemented procedures to ensure the appropriate and timely application of program income.

Federal Program Information Federal Agencies: Department of Health and Human Services (“HHS”) Pass-Through Entity: Virginia Department of Health Pass-Through Entity Number: INORWB611-GY23; INORWB611-GY24 Awards: Assistance Listing Number 93.917 – HIV Emergency Relief Project Grants (Part B) Award Periods: April 1, 2023 to March 31, 2024; April 1, 2024 to March 31, 2025 Description: Timely Completion of the 24-month Eligibility Screening Criteria In accordance with Title 2 U.S. Code of Federal Regulations, Part 200.303, Internal controls, “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.” Per the terms and conditions of the pass-through entity agreement between the Virginia Department of Health (the Department) and the Inova Juniper Program (IJP), IJP is required to “conduct and complete a full RWHAP B eligibility screening for all clients for any allowable Ryan White services prior to enrollment in the RWHAP B program and every 24-months thereafter by following the procedure from the department” (INORWB611 – Scope of Services – Section G1). The procedure from the Department of the award requires the recipient to resubmit documents for residency, household income and proof of insurance before the 24-month eligibility period ends. Condition IHS did not have appropriately designed internal controls in place to ensure that the documentation is obtained and reviewed to verify eligibility prior to the end of the 24-month period. Cause IJP has policies and procedures in place to obtain the eligibility documents from all clients and retain in their files. IJP’s policies and procedures specify that an eligibility worker will meet with each client for an initial screening to verify residency, income, insurance status, and HIV status. The eligibility worker is required to meet with the client to update the required eligibility screening and include the required documentation in the client file by the 24-month period end. Additionally, an eligibility worker is required to periodically make inquiries of the patient as to any changes of income, address, or insurance coverage. If any changes are noted, submission of proper documentation is required. If the eligibility workers do not have access to the proper reassessment requirement date, the required documentation may not be obtained by the 24 month period end. Effect or potential effect Eligibility workers did not timely obtain the required documentation related to the 24-month eligibility screening for certain clients before the required date. Based on the terms and conditions of the pass-through agreement with the Department, the clients whose eligibility was not completed by the deadline would not be considered eligible and should be discharged from the program. Questioned costs Indeterminable Costs are not tracked by client. Identification of a repeat finding This is a repeat finding and relates to prior year finding 2023-001.   Context During our audit, we selected a sample of 60 clients for testing and noted that the 24-month eligibility screening was submitted to the Department after the eligibility expiration date for 5 clients. We further evaluated the 5 clients and noted that either no services were performed prior to obtaining full eligibility screening or if services were provided, the services were fully covered by insurance. Recommendation Management should continue to implement procedures to ensure completion of the eligibility screening prior to the end of the 24-month eligibility period including steps to ensure the eligibility date aligns with the supporting documentation. View of responsible officials Management concurs with the finding and will continue to implement further procedures to ensure that timely documentation is received with regard to eligibility.

Federal Program Information Federal Agencies: Department of Health and Human Services (“HHS”) Pass-Through Entity: Virginia Department of Health Pass-Through Entity Number: INORWB611-GY22; INORPS611-FY23; INORWB611-GY23 Awards: Assistance Listing Number 93.917 – HIV Emergency Relief Project Grants (Part B) Award Periods: April 1, 2022 to March 31, 2023; July 1, 2022 to March 31, 2023; April 1, 2023 to March 31, 2024 Description: Timely Completion of the 24-month Eligibility Screening Type of Finding: Material Weakness in Internal Control Over Compliance Criteria In accordance with Title 2 U.S. Code of Federal Regulations, Part 200.303, Internal controls, “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.” Per the terms and conditions of the pass-through entity agreement between the Virginia Department of Health (the Department) and the Inova Juniper Program (IJP), IJP is required to “conduct and complete a full RWHAP B eligibility screening for all clients for any allowable Ryan White services prior to enrollment in the RWHAP B program and every 24-months thereafter by following the procedure from the department” (INORWB611-GY22 – Scope of Services – Section E, INORPS611-FY23 – Scope of Services – Section A, INORWB611-GY23 – Scope of Services – Section G1). The procedure from the department of the award requires the recipient to resubmit documents for residency, household income and proof of insurance before the 24-month eligibility period ends. Condition The System did not have appropriately designed internal controls in place to ensure that the documentation is obtained and reviewed to verify eligibility prior to the end of the 24-month period. Cause IJP has policies and procedures in place to obtain the eligibility documents from all clients and retain in their files. IJP’s policies and procedures specify that an eligibility worker will meet with each client for an initial screening to verify residency, income, insurance status, and HIV status. The eligibility worker is required to meet with the client to update the required eligibility screening and include the required documentation in the client file by the 24-month period end. Additionally, at each subsequent visit, the receptionist questions each client as to whether there have been any changes in their income or insurance status. If there are changes to the client’s eligibility status, another visit is scheduled with the eligibility worker. If there are delays with responses from the clients, the required documentation may not be obtained by the 24-month period end. Effect or potential effect Eligibility workers did not obtain and/or retain the required documentation related to the 24-month eligibility screening for certain clients before the required date. Based on the terms and conditions of the pass-through agreement with the Department, the clients whose eligibility was not completed by the deadline would not be considered eligible and should be discharged from the program. Questioned costs None. Identification of a repeat finding This is a repeat finding and relates to prior year finding 2022-002. Context During our audit, we selected a sample of 60 clients for testing and noted the following exceptions: • The 24-month eligibility screening was submitted to the Department after the eligibility expiration date for one client. For the exception identified, services were not provided prior to obtaining the full eligibility screening and therefore, there were no unallowable costs identified required for reimbursement from the Department. IJP has not completed a full review of all clients that could be impacted by the exception above. Recommendation Management should implement procedures to ensure completion of the eligibility screening prior to the end of the 24-month eligibility period. View of responsible officials Management concurs with the finding and will implement procedures to ensure that timely documentation is received with regard to eligibility.

Federal Program Information Federal Agencies: Department of Health and Human Services (“HHS”) Pass-Through Entity: Virginia Department of Health Pass-Through Entity Number: INORWB611-GY22; INORPS611-FY23; INORWB611-GY23 Awards: Assistance Listing Number 93.917 – HIV Emergency Relief Project Grants (Part B) Assistance Listing Number 93.918 – Grants to Provide Outpatient Early Intervention Services with Respect to HIV Disease (Part C) Award Periods: April 1, 2022 to March 31, 2023; July 1, 2022 to March 31, 2023; April 1, 2023 to March 31, 2024 May 1, 2022 to April 30, 2023; May 1, 2023 to April 30, 2024 Description: Timely Application of Program Income Prior to Requesting Additional Cash Payments Type of Finding: Material Weakness in Internal Control Over Compliance Criteria In accordance with Title 2 U.S. Code of Federal Regulations, Part 200.303, Internal controls, “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.” Per the terms and conditions of the pass-through entity agreement between the Virginia Department of Health (the Department) and the Inova Juniper Program (IJP), IJP is required to follow Health Resources and Services Administration (HRSA) guidelines related to the program. HRSA develops multiple policies to help grant recipients and subrecipients understand and carry out legislation applicable to Ryan White programs. Per the Policy Clarification Notice included on the official HRSA website for Ryan White, “Under the uniform administrative requirements, to the extent available, recipients and subrecipients must disburse funds available from program income, rebates, refunds, contract settlements, audit recoveries and interest earned on such funds before requesting additional cash payments.” As such, program income must be used for the purpose and subject to the conditions of the Federal award. The requirements within the pass-through entity agreement with the Virginia Department of Health are consistent with those required by the original Federal awarding agency, the Department of Health and Human Services (HHS), HRSA. Per the frequently asked questions (FAQs) presented by HRSA’s HIV/AIDS Bureau (HAB) for Policy Clarification Notice (PCN) 15-03, Clarification Regarding the Ryan White HIV/AIDS Program and Program Income, and PCN 15-04, Utilization and Reporting of Pharmaceutical Rebates, released on March 21, 2016, program income is gross income earned by the non-Federal entity that is directly generated by a supported activity or earned as a result of the Federal award during the period of performance (or grant period). Program Income, inclusive of program income derived from the 340B Drug Pricing Program, includes the core medical and support services that HRSA considers allowable uses of Ryan White grant funds and the individuals eligible to receive those services. Unallowable uses include PrEP/nPEP materials, which are designed to promote or encourage, directly, intravenous drug use or sexual activity. Condition The System did not have appropriately designed internal controls in place to ensure that program income was not applied to offset expenditures prior to requesting additional cash reimbursements each month and/or quarter during the grant period. The cash management submissions and financial reporting for Assistance Listing – 93.918 Grants to Provide Outpatient Early Intervention Services with Respect to HIV Disease (Part C), including the quarterly Federal Financial Reports and annual SF-425 Federal Financial Reports, included the incorrect 340B program income during the period, which included unallowable uses of PrEP/nPEP materials. Cause IJP has policies and procedures in place to ensure program income was not applied to offset expenditures in its entirety prior to the end of the grant period. However, during the grant period, program income is not timely applied prior to cash reimbursement requests. IJP accumulates 340B program income on a monthly basis inclusive of the pharmacy income and related costs. Through management review of the costs associated within the 340B program, it was identified that PrEP/nPEP materials were inappropriately being included within program income. Effect or potential effect IJP did not have policies in place to ensure that program income was applied timely prior to requesting additional cash payments. As such, cash payments were being requested and reimbursed prior to application of program income. Program income was not appropriately being calculated by including unallowable uses. Questioned costs None. Identification of a repeat finding This is not a repeat finding. Context During our audit, we selected a sample of 4 months for testing, which identified that program income was not timely being applied to the cash reimbursement requests. Management does ensure that program income is applied prior to the end of the grant period. As of December 31, 2023, for Assistance Listing Number 93.917 – HIV Emergency Relief Project Grants (Part B), the cumulative program income not applied prior to cash reimbursement was $109,593. This was not identified as questioned costs given this was subsequently applied by the end of the grant period. As of December 31, 2023, Assistance Listing Number 93.918 – Grants to Provide Outpatient Early Intervention Services with Respect to HIV Disease (Part C), for the cumulative program income not applied prior to cash reimbursement was $84,064. This was not identified as questioned costs given the program income was subsequently applied by the end of the grant period. As of December 31, 2023, the unallowable PrEP/nPEP materials caused an overstatement of 340B program income by $484,569. This amount was appropriately adjusted within the Schedule. As such, there were no identified question costs. Recommendation IJP’s existing policies and procedures are not designed to ensure the program income balance is spent timely. HRSA recommends that recipients and subrecipients strive to proactively secure and estimate the extent to which program income will be accrued. IJP should accrue for the anticipated program income to ensure it is disbursed timely. IJP should reconcile 304B expenditures to the 340B program income to ensure there are no additional expenditures reported over the amount for 340B program income allowable. View of responsible officials Management concurs with the finding and will implement procedures to ensure that the appropriate and timely application of program income.

Federal Program Information Federal Agencies: Department of Health and Human Services (“HHS”) Pass-Through Entity: Virginia Department of Health Pass-Through Entity Number: Not Applicable Awards: Assistance Listing Number 93.918 – Grants to Provide Outpatient Early Intervention Services with Respect to HIV Disease (Part C) Award Periods: May 1, 2022 to April 30, 2023; May 1, 2023 to April 30, 2024 Description: Documentation of Procurement and Suspension and Debarment Type of Finding: Material Weakness in Internal Control Over Compliance Criteria In accordance with Title 2 U.S. Code of Federal Regulations, Part 200.303, Internal controls, “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).” Part 200.320 Methods of procurement to be followed states the following: “The non-Federal entity must have and use documented procurement procedures, consistent with the standards of this section and §§ 200.317, 200.318, and 200.319” regarding the methods of procurement used for the acquisition of property or services required under a Federal award or sub-award. Condition As part of our testing over the operating effectiveness of internal controls over the Procurement, Suspension and Debarment assertion, we noted that the System had a procurement policy that included procedures for small purchases (i.e. purchases between $50,000-$250,000) in which management obtains one or more sources from suppliers or public websites in order to document justification for vendor approval. However, records were not maintained to document the rationale for the procurement method, contract type selection, contractor selection or rejection, and the basis for the contract price. Management also validates that vendors are reviewed on a monthly basis to ensure they are not included on the suspension and debarment list. There was no documentation to support completeness and accuracy of the vendor list for suspension and debarment. Cause The System did not retain documentation to support compliance with the procurement policy that conforms to the provisions required by the Uniform Guidance. The System did not retain documentation to support the completeness and accuracy of the vendor list for suspension and debarment. Effect or potential effect Purchasing of goods and/or servicing with the grant funds may not be in compliance with the Uniform Guidance. The vendor list for suspension and debarment may not be complete and accurate and therefore, federal funds may be used to pay a contractor that is suspended or debarred. Questioned costs None. Identification of a repeat finding This is not a repeat finding. Context Small purchases were $106,345, which represents approximately 3% of total federal expenditures of $3,589,730 reported on the Schedule for the year ended December 31, 2023. Management subsequently documented the rationale for the procurement method, contract type selection, contractor selection or rejection, and the basis for the contract price. As part of our testing for suspension and debarment, we did not identify any vendors that were excluded from the suspension and debarment list that were part of the grant. Recommendation The System should update its process to ensure documentation is retained consistent with the procurement policy and suspension and debarment for purchasing goods and/or services with federal funds. View of responsible officials Management concurs with the finding and will implement procedures to documentation is retained to support procurement and suspension and debarment.

Criteria In accordance with Title 2 U.S. Code of Federal Regulations, Part 200.303, Internal controls, ?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.? The terms and conditions of the award require the recipient to submit reports as the secretary of HHS determines are needed to ensure compliance with conditions that are imposed on the payment, and such reports shall be in such form, with such content, as specified by the secretary of HHS in future program instructions directed to all recipients. Condition The System did not have appropriately designed internal controls in place over the COVID 19 Provider Relief Fund (?PRF?) grant awards related to the review and approval of the expenditures included in the U.S. Health Resources and Services Administration (?HRSA?) portal submission. Cause Management did not design internal controls or retain evidence of review and approval of the allowability of expenditures submitted within the HRSA portal. Effect or potential effect The expenditures included in the HRSA portal submission could be inaccurate or information reported to HRSA portal may be incomplete or inaccurate. Questioned costs None. Identification of a repeat finding This is a repeat finding and relates to prior year finding 2021-002. Context The System submitted a total of 9 reports within the HRSA portal during Period 3 and Period 4. The total PRF payments received by the System was $12,424,630. We tested 5 HRSA portal submissions that had total payments from HRSA amount to $11,977,661. Management did not retain documentation to support review and approval of the allowability of the expenditures entered in the HRSA portal. Audit procedures identified no questioned costs as it related to expenditures included within the HRSA portal submission. F) grant awards related to the review and approval of the expenditures included in the HRSA portal submission. Cause: Management did not design internal controls or retain evidence of review and approval of the expenditures. Effect or potential effect The expenditures included in the HRSA portal submission could be inaccurate or information reported to HRSA portal may be incomplete or inaccurate. Questioned costs: None. Identification of a repeat finding: This is a repeat finding and relates to prior year finding 2021-002. Context: The System submitted a total of 9 reports within the HRSA portal during Period 3 and Period 4. The total PRF payments received by the System was $12,424,630. We tested 5 HRSA portal submissions that had total payments from HRSA amount to $11,977,661. Management did not retain documentation to support review and approval of the expenditures entered in the HRSA portal. Audit procedures identified no questioned costs as it related to expenditures included within the HRSA portal submission.

Federal Program Information Federal Agencies: Department of Health and Human Services (“HHS”) Awards: Assistance Listing Number 93.498 COVID 19 – Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Award Periods: Period 3 – January 1, 2021 to June 30, 2022 Period 4 – June 30, 2021 to December 31, 2022 Description: Review and Approval of the expenditures included in the HRSA portal submission Type of Finding: Significant Deficiency in Internal Control Over Compliance Criteria In accordance with Title 2 U.S. Code of Federal Regulations, Part 200.303, Internal controls, “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.” The terms and conditions of the award require the recipient to submit reports as the secretary of HHS determines are needed to ensure compliance with conditions that are imposed on the payment, and such reports shall be in such form, with such content, as specified by the secretary of HHS in future program instructions directed to all recipients. Condition The System did not have appropriately designed internal controls in place over the COVID 19 Provider Relief Fund (“PRF”) grant awards related to the review and approval of the expenditures included in the U.S. Health Resources and Services Administration (“HRSA”) portal submission. Cause Management did not design internal controls or retain evidence of review and approval of the allowability of expenditures submitted within the HRSA portal. Effect or potential effect The expenditures included in the HRSA portal submission could be inaccurate or information reported to HRSA portal may be incomplete or inaccurate. Questioned costs None. Identification of a repeat finding This is a repeat finding and relates to prior year finding 2021-002. Context The System submitted a total of 9 reports within the HRSA portal during Period 3 and Period 4. The total PRF payments received by the System was $12,424,630. We tested 5 HRSA portal submissions that had total payments from HRSA amount to $11,977,661. Management did not retain documentation to support review and approval of the allowability of the expenditures entered in the HRSA portal. Audit procedures identified no questioned costs as it related to expenditures included within the HRSA portal submission. Recommendation Management should design internal controls related to the review of the allowability of expenditures for the HRSA portal submission to ensure that the reported amounts are accurate and retain evidence of this review. View of responsible officials Management concurs with the finding and will implement procedures to ensure that HRSA reporting reports are prepared by individuals with HRSA reporting experience and reviewed by management prior to submission.

Criteria In accordance with Title 2 U.S. Code of Federal Regulations, Part 200.303, Internal controls, ?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.? Per the terms and conditions of the pass-through entity agreement between the Virginia Department of Health (the Department) and the Inova Juniper Program (IJP), IJP ?is required to collect the following documentation for client eligibility: (a) Legible documentation for proof of residency in Virginia, (b) Legible documents for proof of a medical diagnosis of a HIV disease (required only once for each client), (c) Legible documentation or proof of household income no greater than 500% of the Poverty Level Guidelines, and (d) Legible documentation for proof that the client does not have insurance (including Medicaid) or other program coverage for the services that the client is seeking from the RW Part B Program. Medicaid-enrolled clients who have access to HIV medications are not eligible for VA MAP services.? (INORWB611-GY22 ? Client Eligibility Section E.1, INORPS611-FY23 Section A.1). IJP ?will maintain an eligibility checklist and required eligibility documentation in one place in each client file? (INORWB611-GY22 ? Client Eligibility Section E.3, INORPS611-FY23 Section A.2). Further, IJP ?will verify client eligibility status prior to providing services, including HIV medication services? (INORWB611-GY22 ? Client Eligibility Section E.4, INORPS611-FY23 Section A.3). IJP ?will not receive reimbursement by the Department for any services provided to clients whose eligibility was not current at the time of service? (INORWB611-GY22 ? Client Eligibility Section E.6, INORPS611-FY23 Section A.5). The requirements within the pass-through entity agreement with the Department are consistent with those required by the original Federal awarding agency, the Department of Health and Human Services (DHHS), U.S. Health Resources and Services Administration (HRSA). Per the National Monitoring Standards for Part B included on the official HRSA website, it is the provider/subgrantee?s responsibility to ?maintain client records that contain documentation of the client?s eligibility determination, including the following: Initial Eligibility Determination and Recertification Documentation Requirements: (1) HIV diagnosis (2) Proof of residency (3) Low Income (4) Uninsured or underinsured status.? HRSA aligns with the Public Service Health Act Section 2616 ? Provision of Treatment (b) (1-2) which states ?to be eligible to receive assistance from a State under this section an individual shall (1) have a medical diagnosis of HIV/AIDS; and (2) be a low-income individual, as defined by the State.? Per the National Monitoring Standards for Part B included on the official HRSA website, ?Income made from charges to RWHAP Part B clients or to insurance companies for services performed is considered program income.? Condition The System did not have appropriately designed internal controls in place to ensure that the documentation is obtained and reviewed to verify eligibility prior to providing services. Cause IJP has policies and procedures in place to obtain the eligibility documents from all clients and retain in their files. IJP?s policies and procedures specify that an eligibility worker will meet with each client for an initial screening to verify residency, income, insurance status, and HIV status. The eligibility worker is required to meet with the client to update the required eligibility screening and include the required documentation in the client file. Additionally, at each subsequent visit, the receptionist questions each client as to whether there have been any changes in their income or insurance status. If there are changes to the client?s eligibility status, another visit is scheduled with the eligibility worker. Management identified that these policies and procedures were not followed during the year due to lack of oversight and related under performance from various eligibility workers employed during the year. Effect or potential effect Eligibility workers did not obtain and/or retain the required documentation related to the eligibility screening for certain clients. Services continued to be provided and related costs were reimbursed by DHHS. Based on the terms and conditions of the pass-through agreement with DHHS, the clients whose eligibility was not current at the time of service would not be considered eligible and any reimbursed cost would represent unallowable costs. Furthermore, program income represents income made from charges to RW Part B eligible clients or to insurance companies for services performed. Program income was recognized on services and charges for clients whose eligibility was not current at the time of service. For clients that received services in 2022, IJP recognized $332,344 of program income during the year. Questioned costs Indeterminable. Identification of a repeat finding This is not a repeat finding. Context During our audit, we selected a sample of 60 clients for testing and noted the following 3 exceptions: ? There was no evidence of documentation obtained to prove that the client did not have insurance (including Medicaid) or other program coverage for the services provided for one client. ? There was no evidence of documentation obtained to prove that the client did not have household income no greater than 500% of the Poverty Level Guidelines for one client. ? The documentation for support proof that the client did not have household income no greater than 500% of the Poverty Level Guidelines was retained; however, for one client, the support indicated that they exceeded the Poverty Level Guidelines and services were provided. Section III ? Federal Award Findings and Questioned Costs (continued) IJP has not completed a full review of all clients that could be impacted by the exceptions above. Further, IJP does not track reimbursed costs at the individual client level. As such, the costs associated with this finding are indeterminable.

Federal Program Information Federal Agencies: Department of Health and Human Services Pass-Through Entity: Virginia Department of Health Pass-Through Entity Number: INORWB611-GY21; INORWB611-GY22; INORPS611-FY22; INORPS611-FY23 Awards: Assistance Listing Number 93.917 HIV Care Formula Grants (Part B) Award Periods: April 1, 2021 to March 31, 2022: April 1, 2022 to March 31, 2023; July 1, 2021 to June 30, 2022; July 1, 2022 to March 31, 2023 Description: Review and Retention of Eligibility Required Documentation Type of Finding: Material Weakness in Internal Control Over Compliance Criteria In accordance with Title 2 U.S. Code of Federal Regulations, Part 200.303, Internal controls, “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.” Per the terms and conditions of the pass-through entity agreement between the Virginia Department of Health (the Department) and the Inova Juniper Program (IJP), IJP “is required to collect the following documentation for client eligibility: (a) Legible documentation for proof of residency in Virginia, (b) Legible documents for proof of a medical diagnosis of a HIV disease (required only once for each client), (c) Legible documentation or proof of household income no greater than 500% of the Poverty Level Guidelines, and (d) Legible documentation for proof that the client does not have insurance (including Medicaid) or other program coverage for the services that the client is seeking from the RW Part B Program. Medicaid-enrolled clients who have access to HIV medications are not eligible for VA MAP services.” (INORWB611-GY22 – Client Eligibility Section E.1, INORPS611-FY23 Section A.1). IJP “will maintain an eligibility checklist and required eligibility documentation in one place in each client file” (INORWB611-GY22 – Client Eligibility Section E.3, INORPS611-FY23 Section A.2). Further, IJP “will verify client eligibility status prior to providing services, including HIV medication services” (INORWB611-GY22 – Client Eligibility Section E.4, INORPS611-FY23 Section A.3). IJP “will not receive reimbursement by the Department for any services provided to clients whose eligibility was not current at the time of service” (INORWB611-GY22 – Client Eligibility Section E.6, INORPS611-FY23 Section A.5). The requirements within the pass-through entity agreement with the Department are consistent with those required by the original Federal awarding agency, the Department of Health and Human Services (DHHS), U.S. Health Resources and Services Administration (HRSA). Per the National Monitoring Standards for Part B included on the official HRSA website, it is the provider/subgrantee’s responsibility to “maintain client records that contain documentation of the client’s eligibility determination, including the following: Initial Eligibility Determination and Recertification Documentation Requirements: (1) HIV diagnosis (2) Proof of residency (3) Low Income (4) Uninsured or underinsured status.” HRSA aligns with the Public Service Health Act Section 2616 – Provision of Treatment (b) (1-2) which states “to be eligible to receive assistance from a State under this section an individual shall (1) have a medical diagnosis of HIV/AIDS; and (2) be a low-income individual, as defined by the State.” Per the National Monitoring Standards for Part B included on the official HRSA website, “Income made from charges to RWHAP Part B clients or to insurance companies for services performed is considered program income.” Condition The System did not have appropriately designed internal controls in place to ensure that the documentation is obtained and reviewed to verify eligibility prior to providing services. Cause IJP has policies and procedures in place to obtain the eligibility documents from all clients and retain in their files. IJP’s policies and procedures specify that an eligibility worker will meet with each client for an initial screening to verify residency, income, insurance status, and HIV status. The eligibility worker is required to meet with the client to update the required eligibility screening and include the required documentation in the client file. Additionally, at each subsequent visit, the receptionist questions each client as to whether there have been any changes in their income or insurance status. If there are changes to the client’s eligibility status, another visit is scheduled with the eligibility worker. Management identified that these policies and procedures were not followed during the year due to lack of oversight and related under performance from various eligibility workers employed during the year.  Effect or potential effect Eligibility workers did not obtain and/or retain the required documentation related to the eligibility screening for certain clients. Services continued to be provided and related costs were reimbursed by DHHS. Based on the terms and conditions of the pass-through agreement with DHHS, the clients whose eligibility was not current at the time of service would not be considered eligible and any reimbursed cost would represent unallowable costs. Furthermore, program income represents income made from charges to RW Part B eligible clients or to insurance companies for services performed. Program income was recognized on services and charges for clients whose eligibility was not current at the time of service. For clients that received services in 2022, IJP recognized $332,344 of program income during the year. Questioned costs Indeterminable. Identification of a repeat finding This is not a repeat finding. Context During our audit, we selected a sample of 60 clients for testing and noted the following 3 exceptions: • There was no evidence of documentation obtained to prove that the client did not have insurance (including Medicaid) or other program coverage for the services provided for one client. • There was no evidence of documentation obtained to prove that the client did not have household income no greater than 500% of the Poverty Level Guidelines for one client. • The documentation for support proof that the client did not have household income no greater than 500% of the Poverty Level Guidelines was retained; however, for one client, the support indicated that they exceeded the Poverty Level Guidelines and services were provided. IJP has not completed a full review of all clients that could be impacted by the exceptions above. Further, IJP does not track reimbursed costs at the individual client level. As such, the costs associated with this finding are indeterminable. Recommendation IJP’s existing policies and procedures are in line with the requirements of the pass-through agreement with DHHS; however, IJP should continue to evaluate whether appropriate oversight is performed to ensure that these policies and procedures are being followed with regard to eligibility verification including maintaining the requirement documentation for all clients. View of responsible officials Management concurs with the finding and will implement procedures to ensure that the appropriate oversight is performed with regard to eligibility.

Criteria In accordance with Title 2 U.S. Code of Federal Regulations, Part 200.303, Internal controls, ?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.? Condition The System did not have appropriately designed internal controls in place to determine the correct amount of COVID 19 Provider Relief Fund (PRF) grant awards on the Schedule of Expenditures of Federal Awards (the Schedule) for the year ended December 31, 2022. Cause The Schedule for the year ended December 31, 2022 continued to include a number of COVID 19 programs. These programs did not follow the historical grant process and therefore, various individuals in the System were involved and responsible for monitoring the terms and conditions of the federal awards and reporting of the federal expenditures. Management did not design internal controls to accurately report expenditures within the Schedule. Effect or potential effect The reporting and verification of the completeness and accuracy of the expenditures included in the Schedule is not sufficient. Questioned costs None. Identification of a repeat finding This is a repeat finding and relates to prior year finding 2021-001. Context We identified that the Schedule for the PRF grant awards did not include rural distributions of $1,483,532. Management reconciled the Schedule to the payments received as well as to the HHS Tracking Accountability in Government Grants System (TAGGS) database, which inappropriately excluded the rural distributions. Management subsequently corrected the amount and the federal expenditures reported on the Schedule include the rural distributions.

Federal Program Information Federal Agencies: Department of Health and Human Services Awards: Assistance Listing Number 93.498 COVID 19 – Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Award Periods: Period 3 – January 1, 2021 to June 30, 2022; Period 4 – June 30, 2021 to December 31, 2022 Description: Preparation of Schedule of Expenditures of Federal Awards Type of Finding: Significant Deficiency in Internal Control Over Compliance   Criteria In accordance with Title 2 U.S. Code of Federal Regulations, Part 200.303, Internal controls, “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.” Condition The System did not have appropriately designed internal controls in place to determine the correct amount of COVID 19 Provider Relief Fund (PRF) grant awards on the Schedule of Expenditures of Federal Awards (the Schedule) for the year ended December 31, 2022. Cause The Schedule for the year ended December 31, 2022 continued to include a number of COVID 19 programs. These programs did not follow the historical grant process and therefore, various individuals in the System were involved and responsible for monitoring the terms and conditions of the federal awards and reporting of the federal expenditures. Management did not design internal controls to accurately report expenditures within the Schedule. Effect or potential effect The reporting and verification of the completeness and accuracy of the expenditures included in the Schedule is not sufficient. Questioned costs None. Identification of a repeat finding This is a repeat finding and relates to prior year finding 2021-001.   Context We identified that the Schedule for the PRF grant awards did not include rural distributions of $1,483,532. Management reconciled the Schedule to the payments received as well as to the HHS Tracking Accountability in Government Grants System (TAGGS) database, which inappropriately excluded the rural distributions. Management subsequently corrected the amount and the federal expenditures reported on the Schedule include the rural distributions. Recommendation The System’s policy and procedures should be designed to ensure accurate reporting as required by the Uniform Guidance. View of responsible officials There is no disagreement with the audit finding.

Federal Program Information Federal Agencies: United States Department of Homeland Security Awards: Assistance Listing Number 97.036 – COVID-19 – Disaster Grants - Public Assistance (Presidentially Declared Disasters) Award Periods: January 20, 2020 – May 11, 2023 Description: Preparation of Schedule of Expenditures of Federal Awards Type of Finding: Material Weakness in Internal Control Over Compliance Criteria The Uniform Guidance 2 CFR section 200.303 states, “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 CFR section 200.510 states, “(b) Schedule of expenditures of Federal awards. The auditee must also prepare the Schedule for the period covered by the auditee’s financial statements which must include the total Federal awards expended as determined in accordance with §200.502 Basis for determining Federal awards expended.” Condition The System omitted the obligated expenditures related to the Assistance Listing Number 97.036 – COVID-19 – Disaster Grants - Public Assistance (Presidentially Declared Disasters) (“FEMA”) in the Schedule. Cause The System misinterpreted the FEMA Public Assistance Grant Program guidance for reporting Assistance Listing 97.036 expenditures in the Schedule, which is based on when (1) FEMA has approved (i.e., obligated) the non-federal entity’s project worksheet (PW), and (2) the non-federal entity has incurred the eligible expenditures. The System interpreted the date the PW is approved (i.e., obligated) as the date the Virginia Department of Emergency Management will authorize disbursement and appropriate of the funds from the Department of Planning and Budget rather than the date FEMA obligated the PW. Effect or potential effect The Schedule prepared by the System was misstated but was subsequently corrected. A misstated Schedule could result in the improper selection of federal award major programs or an incorrect percentage of coverage being calculated resulting in a restatement of a previously issued Uniform Guidance report. Questioned costs None. Identification of a repeat finding This is not a repeat finding. Context Expenditures for Assistance Listing 97.036 of $31,631,420 were excluded from the Schedule. These expenditures related to PWs obligated in 2022 and expenditures incurred in previous fiscal years and consequently should have been recorded in the 2022 Schedule. Recommendation The System should update its policies and procedures and internal controls, specifically the process to accumulate and report FEMA expenditures of federal awards to be in accordance with the FEMA Schedule requirements outlined above. View of responsible officials The System agrees with the comment and has developed a plan to correct the finding.

Criteria In accordance with Title 2 U.S. Code of Federal Regulations, Part 200.303, Internal controls, ?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.? Condition The System had not finalized the Schedule of Expenditures of Federal Awards (the ?Schedule?) for the year ended December 31, 2021 in a timely manner. Cause The Schedule for the year ended December 31, 2021 included a number of COVID 19 programs. These programs did not follow the historical grant process and therefore, various individuals in the System were involved and responsible for monitoring the terms and conditions of the federal awards and reporting of the federal expenditures. COVID 19 also impacted a number of resources within the System causing various constraints. Effect or potential effect The reporting and verification of the completeness and accuracy of the expenditures required more time than expected due to the COVID 19 nature of the funds. Questioned costs None. Identification of a repeat finding This is not a repeat finding. Context The audit was not completed and the reporting submitted within the earlier of 30 calendar days after receipt of the auditor?s report(s), or nine months after the end of the audit period as required by the Uniform Guidance.

In accordance with Title 2 U.S. Code of Federal Regulations, Part 200.303, Internal controls, ?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.? The terms and conditions of the award require the recipient to submit reports as the secretary of HHS determines are needed to ensure compliance with conditions that are imposed on the payment, and such reports shall be in such form, with such content, as specified by the secretary of HHS in future program instructions directed to all recipients. The Provider Relief Programs: Provider Relief Fund and ARP Rural Payments Frequently Asked Questions states the following: ?If funds were held in an interest-bearing account, they would be considered a reportable revenue. If interest is earned on PRF disbursements that the Reporting Entity expended in full, the interest amounts may be retained and applied toward a reportable use of funds. If interest is earned on funds that are only partially expended, the interest on remaining unused funds must be calculated, reported and returned.? Condition The System did not have appropriately designed internal controls in place over the COVID 19 Provider Relief Fund (?PRF?) grant awards related to the review and approval of the reportable interest earned on PRF payments and expenditures included in the HRSA portal submission. Cause Management did not design internal controls or retain evidence of review and approval of the interest income calculation and expenditures. Effect or potential effect The interest earned and expenditures included in the HRSA portal submission could be inaccurate or information reported to HRSA portal may be incomplete or inaccurate. Questioned costs None. Identification of a repeat finding This is not a repeat finding. Context The System submitted a total of 20 reports within the HRSA portal during period 1 and period 2. The total PRF payments received by the System was $211,583,107. We tested 14 HRSA portal submissions that had total payments from HRSA amount to $166,568,914. For Inova Health Care Services, the System included $863,991 of interest earned within the HRSA portal submission for period 2. However, the System deposited the applicable PRF payments received for Inova Health Care Services in a non-interest bearing account. The related interest earned included in the HRSA portal was inaccurate. For the related HRSA portal submission, management did not retain documentation to support review and approval of the interest earned and expenditures entered in the HRSA portal. For lost revenues reported, the System reconciled the actual revenues compared to the general ledger for each reporting entity. As a result of their reconciliation, they did identify a difference of $88,568 in which lost revenues were overstated on the Inova Health Care Services report submission. The overstatement of the interest earned and lost revenue had no impact on meeting the requirement to retain the funding received.

Criteria or Specific Requirement In accordance with Title 2 U.S. Code of Federal Regulations, Part 200.303, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards, Inova Health System ?must establish and maintain effective internal controls over Federal awards 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.? Per the terms and conditions of the pass-through entity agreement between the Virginia Department of Health (the Department) and the Inova Juniper Program (IJP), IJP ?is required to collect the following documentation for client eligibility (a) Proof of HIV/AIDS medical diagnosis, (b) proof and verification of low-income status (at or below 500% FPL), (c) proof of Virginia residency; and (d) insurance status? (INOMAI611GY19 ? Client Eligibility Section 1). IJP ?will conduct and complete a full Ryan White HIV/AIDS Program (RWHAP) Part B eligibility screening for all clients prior to enrollment in the Ryan White Part B program and annually thereafter. IJP is required to recertify client eligibility every six months (eligibility expires six months from the date the client signs the initial and annual eligibility). If there has been no changes in client income, residency, or insurance at the time of the six-month recertification, IJP will ask client to sign a self-attestation of no changes form. If there have been changes, IJP will obtain needed documentation from the client to verify eligibility? (INOMAI611GY19/20 ? Client Eligibility Section). Additionally, IJP ?will maintain required eligibility documentation in one place in each client file? (INOMAI611GY19/20 ? Client Eligibility Section 2). Further, IJP ?will verify client eligibility status prior to providing Ryan White Part B Services? (INOMAI611GY19/20 ? Client Eligibility Section 3). IJP ?will not be reimbursed by the Department for any services provided to clients whose Ryan White Part B eligibility was not current at the time of service? (INOMAI611GY19/20 ? Client Eligibility Section 6). The requirements within the pass-through entity agreement with the Department are consistent with those required by the original Federal awarding agency, the Department of Health and Human Services (DHHS), U.S. Health Resources and Services Administration (HRSA). Per the National Monitoring Standards for Part B included on the official HRSA website, it is the provider/subgrantee?s responsibility to ?maintain client records that contain documentation of the client?s eligibility determination, including the following: Initial Eligibility Determination and once a year/12 Month Period Recertification Documentation Requirements: (1) HIV/AIDS diagnosis (2) Proof of residence (3) Low Income (4) Uninsured or underinsured status. At the six-month recertification one of the following is acceptable: full application and documentation, self-attestation of no change, or self-attestation of change with documentation.? HRSA aligns with the Public Service Health Act Section 2616 ? Provision of Treatment (b) (1-2) which states ?to be eligible to receive assistance from a State under this section an individual shall (1) have a medical diagnosis of HIV/AIDS; and (2) be a low-income individual, as defined by the State.? Section III ? Federal Award Findings and Questioned Costs (continued) Per the National Monitoring Standards for Part B included on the official HRSA website, ?Income made from charges to RWHAP Part B clients or to insurance companies for services performed is considered program income.? Condition As described in the prior year finding 2019-001, management identified instances of noncompliance regarding missing client documentation to verify eligibility including the annual full Ryan White HIV/AIDS Program Part B eligibility screening (annual eligibility screening) and the required timely six-month recertification. Management determined that in some cases, the annual eligibility screening and six-month recertification was being performed; however, the required documentation was not being retained in the client file. In other cases, there was no evidence that procedures were being performed in accordance with the grant terms and conditions to obtain the required documentation. The clients whose annual eligibility screening and/or six-month recertification was not current continued to receive services that were subsequently reimbursed by the Department. During our 2020 audit, we selected a sample of 60 clients for testing in which services were performed during the period and noted the following: ? There was no evidence that the six-month recertification occurred for five clients. ? There were no exceptions noted for annual eligibility screening documentation. The annual eligibility included the five client exceptions related to the six-month recertification Cause IJP has appropriate policies and procedures in place to ensure eligibility documents are obtained from all clients in a timely manner and retained in their files. IJP?s policies and procedures specify that an eligibility worker will meet with each client for an initial screening to verify residency, income, insurance status, and HIV status. The eligibility worker is required to meet with the client annually and every six-months thereafter to update the required annual eligibility screening and/or the six-month recertification and include the required documentation in the client file. Additionally, at each subsequent visit, the receptionist questions each client as to whether there have been any changes in their income or insurance status. If there are changes to the client?s eligibility status, another visit is scheduled with the eligibility worker. Management identified that these policies and procedures were not followed during 2019 due to lack of oversight and related negligence from various eligibility workers employed during 2019. This was corrected in 2020; however, prior to the correction and completion of the full review of clients, there was noncompliance with the required documentation related to the six-month recertification. Effect Prior to the completion of the full review of clients, eligibility workers did not perform and/or retain the required documentation related to the six-month recertification for certain clients. Services continued to be provided and related costs were reimbursed by the Department. Based on the terms and conditions of the pass-through agreement with the Department, the clients whose eligibility was not current at the time of service would not be considered eligible and any reimbursed cost would represent unallowable costs. Furthermore, program income represents income made from charges to RWHAP Part B eligible clients or to insurance companies for services performed. Program income was recognized on services and charges for clients whose eligibility was not current at the time of service. Section III ? Federal Award Findings and Questioned Costs (continued) Questioned Costs Indeterminable. Identification of a repeat finding This is a repeat finding and relates to prior year finding 2019-001. Context The IJP has completed a full review of all clients that did not have the required annual eligibility screening and/or a six-month recertification documentation. IJP does not track reimbursed costs at the individual client level. As such, the costs associated with this finding are indeterminable. Recommendation IJP?s existing policies and procedures are in line with the requirements of the pass-through agreement with the Department. However, IJP should continue to evaluate whether appropriate oversight is performed to ensure that these policies and procedures are being followed with regard to eligibility verification for all clients. View of Responsible Officials Management became aware of gaps in the eligibility documentation of certain clients in December 2019. There is no disagreement with this audit finding.

Criteria or Specific Requirement In accordance with Title 2 U.S. Code of Federal Regulations, Part 200.303, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards, Inova Health System ?must establish and maintain effective internal controls over Federal awards 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.? The uniform administrative requirements cost principles and audit requirements for Department of Health and Human Services (HHS), Title 45 Code of Federal Regulations (CFR) 75.305(b)(5) provides that ?to the extent available, recipients and subrecipients must disburse funds available from program income, rebates, refunds, contract settlements, audit recoveries, and interest earned on such funds before requesting additional cash payments.? As such, program income must be used for the purpose and subject to the conditions of the Federal award. The requirements within the pass-through entity agreement with the Virginia Department of Health are consistent with those required by the original Federal awarding agency, the Department of Health and Human Services (the Department), U.S. Health Resources and Service Administration (HRSA). Per the frequently asked questions (FAQs) presented by HRSA?s HIV/AIDS Bureau (HAB) for Policy Clarification Notice (PCN) 15-03, Clarification Regarding the Ryan White HIV/AIDS Program and Program Income, and PCN 15-04, Utilization and Reporting of Pharmaceutical Rebates, released on March 21, 2016, program income is gross income earned by the non-Federal entity that is directly generated by a supported activity or earned as a result of the Federal award during the period of performance (or grant period). Program Income includes the difference between the third-party reimbursement and the 340B drug purchase price, and funds received by billing health insurance for services provided to eligible Ryan White HIV/AIDS Program clients. Program income does not include rebates, credits, discounts, and interest earned including the reduced 340B price a covered entity received on the purchase of a medication. Condition The cash management submissions and financial reporting for Assistance Listing ? 93.917 HIV Care Formula Grants (Part B) and Assistance Listing ? 93.918 Grants to Provide Outpatient Early Intervention Services with Respect to HIV Disease (Part C), including the quarterly Federal Financial Reports and annual SF-425 Federal Financial Reports for Assistance Listing ? 93.918 Grants to Provide Outpatient Early Intervention Services with Respect to HIV Disease (Part C), included the incorrect 340B program income and/or excluded 340B program income during the period. The annual SF-425 Federal Financial Report inappropriately excluded 340B program income. For the three quarterly Federal Financial Reports, 340B program income was calculated using the 340B purchase price inclusive of a discount and incorrectly allocated among the Inova Juniper Program (IJP) federal funding sources. The schedule of expenditures of federal awards inappropriately reported program income for Assistance Listing ? 93.917 HIV Care Formula Grants (Part B) and Assistance Listing ? 93.918 Grants to Provide Outpatient Early Intervention Services with Respect to HIV Disease (Part C). Cause As a result of training provided during the year, management was provided clarity of the cash management and reporting requirements as it relates to the 340B program income. Due to the complexity of the 340B program income, management was unaware of the requirement to exclude discounts, and that 340B program income should only be reported for programs that have an eligible registration, resulting in errors in the reporting of program income for the identified programs. In order to gather the information needed to calculate the 340B program income, Inova Health System did not finalize the schedule of expenditures of federal awards for the year ended in a timely manner. Effect Subsequent to the PCN releases noted above, management tracked the 340B program income and related expenditures for IJP and used it to support the HIV services covered in excess of the federal funding sources. Management implemented modified reporting beginning with the April 2020 monthly cash management submission for Assistance Listing ? 93.917 HIV Care Formula Grants (Part B) and Assistance Listing ? 93.918 Grants to Provide Outpatient Early Intervention Services with Respect to HIV Disease (Part C) in which the 340B program income was initially allocated to both programs. The direct award Assistance Listing ? 93.918 Grants to Provide Outpatient Early Intervention Services with Respect to HIV Disease (Part C) is the only program that has eligible registration and therefore, should be the only program to include the 340B program income. As such, the schedule of expenditures of federal awards has been updated to include the 340B program income only under the Part C program. In addition, management recalculated the 340B program income removing the 340B purchase price discount for the related period of performance for the schedule of expenditures of federal awards. As a result, the related cash management submissions and financial reporting (including the quarterly Federal Financial Reports and annual SF-425 Federal Financial Reports) for Assistance Listing ? 93.918 Grants to Provide Outpatient Early Intervention Services with Respect to HIV Disease (Part C) were inaccurate during the period. Although the program income was internally allocated to Assistance Listing ? 93.917 HIV Care Formula Grants (Part B), the requirements under Assistance Listing ? 93.917 HIV Care Formula Grants (Part B) are more stringent than Assistance Listing ? 93.918 Grants to Provide Outpatient Early Intervention Services with Respect to HIV Disease (Part C). Therefore, the expenditures were allowed and allowable under the Assistance Listing ? 93.918 Grants to Provide Outpatient Early Intervention Services with Respect to HIV Disease (Part C) and finding did not result in any known questioned costs. Due to the updates required to appropriately calculate the 340B program income, the reporting and verification of the completeness and accuracy of the expenditures were not performed timely. Questioned Costs None Context Federal funding related to 340B expenditures continued to be requested from the Department. Based on the terms and conditions of the Department, these funds should be expended and included on financial reporting prior to the request of additional funds. Although the related amounts associated with 340B program income expenditures were excluded from reporting and cash management submissions for the year ended December 31, 2020, Inova Health System expended funds in excess of the federal funding for the period of performance. The 340B program income expended during the period was $1,151,541, which was initially excluded from the schedule of expenditures of federal awards for Assistance Listing ? 93.918 Grants to Provide Outpatient Early Intervention Services with Respect to HIV Disease (Part C). Management updated the schedule of expenditures of federal awards for the year ended December 31, 2020 to appropriately include the 340B program income expenditures, and the accompanying Schedule presents all program income appropriately. Recommendation IJP should implement policies and procedures that strengthen internal control over compliance in relation to program income. The policy and procedures should be designed to ensure timely monitoring and reporting in accordance with the compliance requirements and expending program income. View of Responsible Officials There is no disagreement with this audit finding.

Section III ? Federal Award Findings and Questioned Costs Finding Reference Number: 2019-001 Federal Program Information Federal Agency: U.S. Department of Health and Human Services Pass-Through Entity: Virginia Department of Health Award: CFDA- 93.917 HIV Care Formula Grants (Part B) Pass-Through Entity No.: INOMAI611GY18, INOMAI611GY19 Period of Performance: April 1, 2018 to March 31, 2019, April 1, 2019 to March 31, 2020 Award: CFDA-93.917 HIV Care Formula Grants (HIV/AIDS Resources and Linkages for Inmates) Pass-Through Entity No.: INORLI611FY19, INORLI611FY20 Period of Performance: July 1, 2018 to June 30, 2019, July 1, 2019 to June 30, 2020 Criteria or Specific Requirement In accordance with Title 2 U.S. Code of Federal Regulations, Part 200.303, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards, Inova Health System ?must establish and maintain effective internal controls over Federal awards 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.? Per the terms and conditions of the pass-through entity agreement between the Virginia Department of Health (the Department) and the Inova Juniper Program (IJP), IJP ?is required to collect the following documentation for client eligibility (a) Proof of HIV/AIDS medical diagnosis, (b) proof and verification of low-income status (at or below 500% FPL), (c) proof of Virginia residency; and (d) insurance status? (INOMAI611GY19 ? Client Eligibility Section 1). IJP ?will conduct and complete a full Ryan White HIV/AIDS Program (RWHAP) Part B eligibility screening for all clients prior to enrollment in the Ryan White Part B program and annually thereafter. IJP is required to recertify client eligibility every six months (eligibility expires six months from the date the client signs the initial and annual eligibility). If there has been no changes in client income, residency, or insurance at the time of the six-month recertification, IJP will ask client to sign a self-attestation of no changes form. If there have been changes, IJP will obtain needed documentation from the client to verify eligibility? (INOMAI611GY19 ? Client Eligibility Section). Additionally, IJP ?will maintain required eligibility documentation in one place in each client file? (INOMAI611GY19 ? Client Eligibility Section 2). Further, IJP ?will verify client eligibility status prior to providing Ryan White Part B Services? (INOMAI611GY19 ? Client Eligibility Section 3). IJP ?will not be reimbursed by the Department for any services provided to clients whose Ryan White Part B eligibility was not current at the time of service? (INOMAI611GY19 ? Client Eligibility Section 6). The requirements within the pass-through entity agreement with the Department are consistent with those required by the original Federal awarding agency, the Department of Health and Human Services (DHHS), U.S. Health Resources and Services Administration (HRSA). Per the National Monitoring Standards for Part B included on the official HRSA website, it is the provider/subgrantee?s responsibility to ?maintain client records that contain documentation of the client?s eligibility determination, including the following: Initial Eligibility Determination and once a year/12 Month Period Recertification Documentation Requirements: (1) HIV/AIDS diagnosis (2) Proof of residence (3) Low Income (4) Uninsured or underinsured status. At the six-month recertification one of the following is acceptable: full application and documentation, self-attestation of no change, or self-attestation of change with documentation.? HRSA aligns with the Public Service Health Act Section 2616 ? Provision of Treatment (b) (1-2) which states ?to be eligible to receive assistance from a State under this section an individual shall (1) have a medical diagnosis of HIV/AIDS; and (2) be a low-income individual, as defined by the State.? Per the National Monitoring Standards for Part B included on the official HRSA website, ?Income made from charges to RWHAP Part B clients or to insurance companies for services performed is considered program income.? Condition In 2019, management identified instances of noncompliance regarding missing client documentation to verify eligibility including the annual full Ryan White HIV/AIDS Program Part B eligibility screening (annual eligibility screening) and the required timely six-month recertification. Management determined that in some cases, the annual eligibility screening and six-month recertification was being performed; however, the required documentation was not being retained in the client file. In other cases, there was no evidence that procedures were being performed in accordance with the grant terms and conditions to obtain the required documentation. The clients whose annual eligibility screening and/or six-month recertification was not current continued to receive services that were subsequently reimbursed by the Department. During our audit, we selected a sample of 60 clients for testing and noted the following: ? There was no evidence that the annual eligibility screening or six-month recertification occurred for 6 clients. ? There was no evidence that the annual eligibility screening occurred for 7 clients. ? There was no evidence that the six-month recertification occurred for 1 client. None of the exceptions noted above applied specifically to the HIV/AIDS Resources and Linkages for Inmates (INORLI611FY19 and INORLI611FY20) for 2019, which represents $153,584 of the total $3,427,902 recorded for CFDA 93.917 on the schedule of expenditures of federal and state awards. Cause IJP has appropriate policies and procedures in place to ensure eligibility documents are obtained from all clients in a timely manner and retained in their files. IJP?s policies and procedures specify that an eligibility worker will meet with each client for an initial screening to verify residency, income, insurance status, and HIV status. The eligibility worker is required to meet with the client annually and every six-months thereafter to update the required annual eligibility screening and/or the six-month recertification and include the required documentation in the client file. Additionally, at each subsequent visit, the receptionist questions each client as to whether there have been any changes in their income or insurance status. If there are changes to the client?s eligibility status, another visit is scheduled with the eligibility worker. Management identified that these policies and procedures were not followed during the year due to lack of oversight and related negligence from various eligibility workers employed during 2019. Effect During 2019, eligibility workers did not perform and/or retain the required documentation related to the annual eligibility screening and/or a six-month recertification for certain clients. Services continued to be provided and related costs were reimbursed by the Department. Based on the terms and conditions of the pass-through agreement with the Department, the clients whose eligibility was not current at the time of service would not be considered eligible and any reimbursed cost would represent unallowable costs. Furthermore, program income represents income made from charges to RWHAP Part B eligible clients or to insurance companies for services performed. Program income was recognized on services and charges for clients whose eligibility was not current at the time of service. For clients that received services in 2019, IJP recognized $188,861 of program income during the year. Questioned Costs Indeterminable. Context The IJP has not completed a full review of all clients that did not have the required annual eligibility screening and/or a six-month recertification documentation. Further, IJP does not track reimbursed costs at the individual client level. As such, the costs associated with this finding are indeterminable. Recommendation IJP?s existing policies and procedures are in line with the requirements of the pass-through agreement with the Department; however, IJP should continue to evaluate whether appropriate oversight is performed to ensure that these policies and procedures are being followed with regard to eligibility verification for all clients. View of Responsible Officials Management became aware of gaps in the eligibility documentation of certain clients in December 2019.

GSA_MIGRATION