EIN: 072956642
UEI: EL8YKMPUCPC8
Audited by: Forvis Mazars, LLP
Oversight agency: 21 [Department of the Treasury]
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Data as of August 31, 2026
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on May 20, 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 November 20, 2026 (80 days from today).
What is a management decision? →FAC accepted this audit on November 13, 2024 — management decision was due May 13, 2025.
FAC accepted this audit on November 12, 2024 — management decision was due May 12, 2025.
2022-001 Finding: Activities Allowed or Unallowed Costs/Cost Principles Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Assistance Listing Number 93.498 U.S. Department of Health and Human Services Criteria or Specific Requirement – Activities Allowed/Unallowed and Cost Principles (Pub. L. No. 116-136, 134 Stat. 563 and Pub.. L. No. 116-139, 134 Stat. 622 and 623) Condition – The District is required to only use funds on costs associated with items and services outlined in the terms and conditions for “Infection Control Expenses” that are not reimbursed by other types of funding. Questioned Costs – $13,839 Context – The District had several staff working on administering COVID-19 tests to residents of the nursing home. As such, the expenditures related to these employee’s time used for testing were estimated using an average of wages for the employees focused on administering the tests and the estimated number of hours each day it took to perform the tests. Additionally, tests were included in allowable expenditures which were reimbursed by third-party payors. Cause – The district controls were not functioning for review of allowable costs. Effect – The auditor was unable to substantiate the estimated amount. Additionally, immaterial amounts of expenditures were reimbursed by multiple parties. Identification as a repeat finding – Not a repeat finding. Recommendation - Policies and procedures over federal grant spending should be modified to ensure support is reviewed and maintained for all expenditures. Views of responsible officials and planned corrective actions – The District agrees with the finding. See separate auditee document for planned correction action.
Show full finding ▾Hide full finding ▴2022-001 Finding: Activities Allowed or Unallowed Costs/Cost Principles Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Assistance Listing Number 93.498 U.S. Department of Health and Human Services Criteria or Specific Requirement – Activities Allowed/Unallowed and Cost Principles (Pub. L. No. 116-136, 134 Stat. 563 and Pub.. L. No. 116-139, 134 Stat. 622 and 623) Condition – The District is required to only use funds on costs associated with items and services outlined in the terms and conditions for “Infection Control Expenses” that are not reimbursed by other types of funding. Questioned Costs – $13,839 Context – The District had several staff working on administering COVID-19 tests to residents of the nursing home. As such, the expenditures related to these employee’s time used for testing were estimated using an average of wages for the employees focused on administering the tests and the estimated number of hours each day it took to perform the tests. Additionally, tests were included in allowable expenditures which were reimbursed by third-party payors. Cause – The district controls were not functioning for review of allowable costs. Effect – The auditor was unable to substantiate the estimated amount. Additionally, immaterial amounts of expenditures were reimbursed by multiple parties. Identification as a repeat finding – Not a repeat finding. Recommendation - Policies and procedures over federal grant spending should be modified to ensure support is reviewed and maintained for all expenditures. Views of responsible officials and planned corrective actions – The District agrees with the finding. See separate auditee document for planned correction action.
Finding: Unable to support $13,395 of estimated salaries for SJH employees administering nursing home COVID testing. Corrective Action: Since the employees administering tests are primarily exempt employees and do not clock in to track specific tasks, St. John’s Health created a sign in sheet which indicates when an employee is engaged in manning a testing station. The employee fills in their name, date, time in, time out, and a description of what they were doing during that time. The sign in sheet is reviewed by someone who is familiar with the grant conditions and the reviewer also signs off on the sheet verifying that the time spent would meet the intent of the grant reimbursement. The corrective action plan is fully implemented as of September 2024. The contact person at the Hospital responsible for the plan is Alisa Lane, alane@stjohns.health.
FAC accepted this audit on November 12, 2024 — management decision was due May 12, 2025.
Data source: This information comes from the Federal Audit Clearinghouse, the official repository of Single Audit data. All data is public domain. Verify this organization's audit history at fac.gov.
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