EIN: 160743209
UEI: F27KDXZMF9Y8
Data as of August 20, 2026
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on March 29, 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 September 29, 2024, which was (690 days ago).
What is a management decision? →2023-001: (A) (B) Unallowed COVID-19 expenditures reported within the Health Resources Services Administration (HRSA) Provider Relief Fund (PRF) Portal, Program: COVID-19 - Provider Relief Fund and American Rescue Plan (ARP) Distribution, Assistance Listing Number: 93.498, Agency: Department of Health and Human Services (HHS), Award Year: 1/1/2020-6/30/2023, Award Number: Not available Criteria Law (Pub. L. No. 116-136, 134 Stat. 563 and Pub. L. No. 116-139, 134 Stat. 622 and 623) notes that PRFs should be used to prevent, prepare for, and respond to coronavirus, domestically or internationally, for necessary expenses to reimburse, through grants or other mechanisms, eligible health care providers for health care related expenses or lost revenues that are attributable to coronavirus. Additionally, these funds may not be used to reimburse expenses or losses that have been reimbursed from other sources or that other sources are obligated to reimburse. Condition The University of Rochester and Related Entities had 11 Period 4 submissions and 2 Period 5 submissions into the HRSA portal. Period 4 reporting was completed by the following entities: 1. University of Rochester, 2. UR Medicine Home Care, Certified Services, Inc., 3. St. James Hospital, 4. The Frederick Ferris Thompson Hospital, 5. MM Ewing Continuing Care Center, 6. Nicholas H. Noyes Memorial Hospital, 7. Memorial Hospital of William F and Gertrude F Jones Inc. 8. The Highlands Living Center Inc., 9. Highland Hospital of Rochester,10. Meadows at Westfall, Inc., and 11. FFT Senior Communities, Inc. Period 5 reporting was completed by the following entities: 1. UR Medicine Home Care, Certified Services, and 2. Highland Community Development Corp (d/b/a Highlands at Pittsford). From the detailed listing of expenses across the Period 4 HRSA submissions, we performed allowability testing of the “Unreimbursed Expenses Attributable to Coronavirus” in accordance with the Department of Health and Human Services (HHS) terms and conditions. The following table illustrates COVID-19 expenditures overstated (unallowable expenditure) in the Period 4 HRSA submissions by entity, by quarter and in total on a consolidated basis across the organization. Entities Other PRF Expenses Quarter 3 (July - September 2021) Quarter 4 (October - December 2021) Quarter 1 (January - March 2022) Total Overstated expenses UR Medicine Home Care Personnel 445 445 Nicholas H. Noyes Memorial Hospital Supplies 104,368 104,368 St. James Hospital Personnel 240 98,279 98,519 Total - Overstated expenses $ 240 $ 98,724 $ 104,368 $ 203,332 Cause The causes of the issues noted above were due to a lack of consistency in tracking and reviewing COVID-19 expenditures for inclusion in the Period 4 reporting across the organization. Effect University of Rochester and Related Entities’ Period 4 HRSA Reporting Portal submissions inaccurately captured total “Other PRF Expenses”. Questioned Costs UR Medicine Home Care had $445 of unallowable costs, however reported $1,362,892 million of unused lost revenues on the Phase 4 HRSA report. Nicholas H. Noyes Memorial Hospital had $104,368 of unallowable costs, however reported $1,818,103 of unused lost revenues on the Phase 4 HRSA report. St. James Hospital had $98,519 of unallowable costs, however reported lost revenue available to be used in the current reporting period was $203,524. As there were sufficient lost revenues for each entity, there are no questioned costs associated with this finding. Recommendation We recommend (should there be future funding) management ensure that the organization-wide policy for tracking and reviewing COVID-19 expenditures is implemented more consistently across entities. This will help ensure completeness and accuracy of future federal report and/or HRSA Reporting portal submissions. Additionally, we recommend management communicate the errors noted in the submissions to HRSA and request advice for how to correct this error.
Finding 2023-001: (A) (B) Unallowed COVID-19 expenditures reported within the Health Resources Services Administration (HRSA) Provider Relief Fund Portal Program: COVID-19 - Provider Relief Fund (PRF) and American Rescue Plan (ARP) Distribution Assistance Listing Number: 93.498 Agency: Department of Health and Human Services (HHS) Award Year: 1/1/2020-6/30/2023 Award Number: Not available Management’s Response to Finding: Management acknowledges that certain COVID-19 expenditures were overstated in the Period 4 Reporting period HRSA portal submissions by the University of Rochester and Related Entities (“the University”). Management’s Corrective Action Plan: As provided in HRSA’s FAQs regarding Auditing and Reporting Requirements for Provider Relief Fund Payments, a provider is allowed to replace its unallowable expenses with its unreimbursed lost revenues in the reporting period in question if a provider is not required to report in subsequent reporting periods. None of the related entities with findings have future required HRSA portal submission. Both UR Medicine Home Care and Nicholas H. Noyes Memorial Hospital had unreimbursed lost revenue that exceeded the identified unallowable expenses in Reporting Period 4. In accordance with HRSA’s guidance, UR Medicine Home Care and Nicholas H. Noyes Memorial Hospital will replace the unallowable expenses with unreimbursed lost revenue. St. James Hospital did not report enough unreimbursed lost revenue to replace the unallowable expenses. However, St. James Hospital has identified additional allowable expenses and a miscalculated lost revenue amount for Reporting Period 4 that would exceed the identified unallowable expenses. Further, enterprise-wide, the University had unreimbursed lost revenue that far exceeded the identified unallowable expenses. As the University is unable to amend Reporting Period 4 for St. James Hospital, the University will document the additional allowable expenses and miscalculated lost revenue amount in case of future inquiries. The URMC Office of the Chief Financial Officer, in support with the Office of University Audit, the Controller’s Office, and the University of Rochester Medical Center (URMC) Office of Integrity and Compliance, distributed enterprise-wide guidelines in FY23 to assist each entity with respect to allowable COVID-19 expenditures to help ensure reporting was complete and accurate. The University also conducted enterprise-wide reviews of the HRSA Reporting portal submissions of all University affiliates prior to submission to the HRSA. The University will continue to conduct enhanced reviews with respect to its future required portal submissions.
2023-002: (L) Reporting of Unreimbursed Expenses Attributable to Coronavirus and Lost Revenues, within the Health Resources Services Administration (HRSA) Provider Relief Fund Portal, Program: COVID-19 - Provider Relief Fund and American Rescue Plan (ARP) Distribution, Assistance Listing Number: 93.498, Agency: Department of Health and Human Services (HHS), Award Year: 1/1/2023-3/31/2023, Award Number: Not available Criteria Law (Pub. L. No. 116-136, 134 Stat. 563 and Pub. L. No. 116-139, 134 Stat. 622 and 623) notes that PRFs should be used to prevent, prepare for, and respond to coronavirus, domestically or internationally, for necessary expenses to reimburse, through grants or other mechanisms, eligible health care providers for health care related expenses or lost revenues that are attributable to coronavirus. Additionally, these funds may not be used to reimburse expenses or losses that have been reimbursed from other sources or that other sources are obligated to reimburse. Condition Through testing of Period 4 HRSA portal submissions, we identified the following: St James Hospital: • Personnel costs of $466,729 were all reported in quarter 3 of 2021 on the Phase 4 HRSA report. These costs related to incentive pay and were expensed from July 2021 through June 2022, and should have been allocated between Q3 2021 – Q2 2022 instead of all in Q3 2021. Costs were determined to be allowable, reporting error only. The reporting for the quarters noted below were over/under stated by the following amounts due to this: Quarter 3(July - September 2021) Quarter 4(October - December 2021) Quarter 1(January - March 2022) Quarter 2(April-June 2022) Total Over (Under) stated $376,523 $(184,184) $(108,609) $(83,730) $0 • Lost revenue calculation inaccurately overstated actual 2021 revenues as management did not include actual revenue net of bad debt expense in the quarterly totals for calendar year 2021. The Phase 4 HRSA report included no eligible lost revenue for 2021, and using the corrected amount of revenue net of bad debt expense does not change this conclusion. The report was corrected to properly state actual 2021 revenue. Memorial Hospital of William F and Gertrude F Jones Inc.: • Supply costs related to COVID-19 tests were reported on an equal allocation across quarters verses in actual amounts across quarters on the Phase 4 HRSA report. These costs were aggregated in total and then reported per each quarter based on an equal allocation, and should have been reported per each quarter based on the actual expenditure amount incurred in the respective quarter. Costs were determined to be allowable, reporting error only. The reporting for the quarters noted below were over/under stated by the following amounts due to this: Quarter 3(July - September 2021) Quarter 4(October - December 2021) Quarter 1(January - March 2022) Quarter 2 (April-June 2022) Quarter 3(July – September 2022) Quarter 4 (October-December 2022) Total Over (Under) stated $83,130 $850 $21,930 $(105,910) $29,227 $(29,227) $0 Cause The causes of the issues noted above were due to a lack of consistency in tracking and reviewing COVID-19 expenditures for inclusion in the Period 4 reporting across the organization. Effect University of Rochester and Related Entities’ Period 4 HRSA Reporting Portal submissions inaccurately captured total “Personnel” and “Fringe Benefits” for PRF expenses, and inaccurately captured total revenues which are utilized to report lost revenues for the period. Questioned Costs None noted. Recommendation We recommend (should there be future funding) management ensure that the organization-wide policy for reviewing HRSA Reporting portal submissions is implemented more consistently across entities. This will help ensure completeness and accuracy of future federal report and/or HRSA Reporting portal submissions. Additionally, we recommend management communicate the errors noted in the submissions to HRSA and request advice for how to correct this error.
Finding 2023-002: (L) Reporting of Unreimbursed Expenses Attributable to Coronavirus and Lost Revenues within the Health Resources Services Administration (HRSA) Provider Relief Fund Portal Program: COVID-19 - Provider Relief Fund (PRF) and American Rescue Plan (ARP) Distribution Assistance Listing Number: 93.498 Agency: Department of Health and Human Services (HHS) Award Year: 1/1/2023-3/31/2023 Award Number: Not available Management’s Response to Finding: Management acknowledges the Period 4 HRSA Reporting portal submission errors noted. The personnel and supply costs identified at St. James Hospital and Memorial Hospital of William F and Gertrude F Jones Inc. were all allowable and reported in Period 4, but were over- or under-stated in a particular quarter. Management acknowledges that St. James Hospital understated its lost revenue in Reporting Period 4. Management’s Corrective Action Plan: The University is unable to amend the Reporting Period 4 submissions. HRSA has only provided guidance to providers with respect to how to account for unallowable expenses identified in prior reporting periods. The portal submission expense items identified were all allowable expenses, but under- or over- reported in a particular quarter of the Period 4 Reporting. The lost revenue calculation for St. James Hospital was an error in reporting. Since there is no ability to amend the Period 4 reporting for either of these entities, the University will ensure that it documents these corrections in case of future inquiries from the HRSA. As noted above, the URMC Office of the Chief Financial Officer, in support with the Office of University Audit, the Controller’s Office, and the University of Rochester Medical Center (URMC) Office of Integrity and Compliance, conducted enterprise-wide reviews of the HRSA Reporting portal submissions of all University affiliates in FY23 prior to submission to the HRSA. The University will continue to conduct enhanced reviews with respect to its future required portal submissions. Contact person: Adam Anolik, URMC Senior Vice President and CFO, Adam_Anolik@URMC.Rochester.edu
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on September 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 March 29, 2023, which was (1240 days ago).
What is a management decision? →Condition The University of Rochester and Related Entities had 10 Period 1 submissions into the HRSA portal. Period 1 reporting was completed by the following entities: 1. University of Rochester, 2. UR Medicine Home Care, Certified Services, Inc., 3. St. James Hospital, 4. The Frederick Ferris Thompson Hospital, 5. MM Ewing Continuing Care Center, 6. Nicholas H. Noyes Memorial Hospital, 7. Memorial Hospital of William F and Gertrude F Jones Inc. 8. The Highlands Living Center Inc., 9. Highland Hospital of Rochester, and 10. Meadows at Westfall, Inc. From the detailed listing of expenses across the Period 1 HRSA submissions, we performed allowability testing of the ?Unreimbursed Expenses Attributable to Coronavirus? in accordance with the Department of Health and Human Services (HHS) terms and conditions. The following table illustrates COVID-19 expenditures either overstated, unallowable expenditure, or (understated), there are incremental COVID-19 expenditures not reported, in the Period 1 HRSA submissions by entity, by quarter and in total on a consolidated basis across the organization. Entities Other PRF Expenses Quarter 1 (January - March 2020) Quarter 2 (April-June 2020) Quarter 3 (July-Sept 2020) Quarter 4 (Oct-Dec 2020) Quarter 1 (January - March 2021) Total Overstated (understated) expenses The Frederick Ferris Thompson Hospital Personnel $ 30,370 $ 30,370 The Frederick Ferris Thompson Hospital Supplies (4,711) 20,247 (28,895) (13,359) Nicholas H. Noyes Memorial Hospital Personnel 10,999 10,999 Finger Lakes Visiting Nurse Service & UR Medicine Home Care, Certified Services, Inc. Personnel 1,071 6,123 2,210 2,883 12,287 Finger Lakes Visiting Nurse Service & UR Medicine Home Care, Certified Services, Inc. Supplies 100 100 Memorial Hospital of William F and Gertrude F Jones Inc Personnel (54) (486) (69) 29 (580) Memorial Hospital of William F and Gertrude F Jones Inc Overall listing to HRSA report 2,432 7,297 9,729 St. James Hospital Personnel (241) (241) University of Rochester Personnel 1,158 3,722 4,880 Total - Overstated (understated) expenses $ 1,934 $ 42,295 $ 24,889 $ (14,962) $ 29 $ 54,185 Criteria Law (Pub. L. No. 116-136, 134 Stat. 563 and Pub. L. No. 116-139, 134 Stat. 622 and 623) notes that PRFs should be used to prevent, prepare for, and respond to coronavirus, domestically or internationally, for necessary expenses to reimburse, through grants or other mechanisms, eligible health care providers for health care related expenses or lost revenues that are attributable to coronavirus. Additionally, these funds may not be used to reimburse expenses or losses that have been reimbursed from other sources or that other sources are obligated to reimburse. Cause The causes of the issues noted above were due to a lack of consistency in tracking and reviewing COVID-19 expenditures for inclusion in the Period 1 reporting across the organization. Effect University of Rochester and Related Entities? Period 1 HRSA Reporting Portal submissions inaccurately captured total ?Other PRF Expenses?. Questioned Costs The Frederick Ferris Thompson Hospital had $17,011 of unallowable costs and did not report any lost revenues in their Period 1 submission. The other entities noted in the table above have unallowable costs of $37,174 and did report lost revenues as part of their Period 1 submissions. Recommendation We recommend management design and implement an organization-wide policy for tracking and reviewing COVID-19 expenditures. This will help ensure completeness and accuracy of future federal report and/or HRSA Reporting portal submissions. Additionally, we recommend management communicate the errors noted in the submissions to HRSA and request advice for how to correct this error. Management's View and Corrective Action Plan Management?s view and corrective action plan is included at the end of this report.
Management?s Response to Finding: Management agrees that certain COVID-19 expenditures were either overstated or understated in the Period 1 Reporting period HRSA portal submissions by the University of Rochester and Related Entities (?the University?). Management?s Corrective Action Plan: The University will correct these over-/under- statements of $54,185 in the Period 3 and Period 4 Reporting periods, as applicable, depending on the filing requirements of each Related Entity. Enterprise-wide, the University reported total lost revenues of ($290,471,417) for Reporting Period 1, which exceeded the total payments received during the period ($118,193,895) by $172,277,524. The University and Related Entities also reported total eligible expenditures of $57,223,137 for Reporting Period 1. The overstated amount ($54,185) is far exceeded by the amount of lost revenues reported, which is far in excess of the funding received from the Provider Relief Fund, such that this finding does not impact the total Provider Relief Program funding received by the University from the federal government. The Office of University Audit and the University of Rochester Medical Center (URMC) Office of Integrity and Compliance reviewed a sampling of expenses and lost revenue calculations for the University and Related Entities as part of each entity?s Period 1 Reporting portal submission. These Offices will continue to do these reviews and to support alignment and adherence of the University?s processes from one entity to the next in terms of tracking and reviewing for expense allowability in future HRSA Reporting portal submissions. Additionally, in the second quarter (October ? December 2022) of the University?s fiscal year 2023, the URMC Office of the Chief Financial Officer, supported by the Office of University Audit, the URMC Office of Integrity and Compliance and the University Controller?s Office, will distribute enterprise-wide additional guidelines, based on the findings of this audit, which enhance previous instructions provided with respect to allowable COVID-19 expenditures, and highlight expense scenarios that may require additional review by each entity prior to the submission of Period 4 and later Reporting portal submission to the HRSA.
Condition Through testing of Period 1 HRSA portal submissions, we identified the following: ? Finger Lakes Visiting Nurse Service (FLVNS) ceased operating and transferred service of all patients to UR Medicine Home Care, Certified Services, Inc. (URHC) in November 2019. FLVNS ultimately merged into URHC and ceased to exist in November 2020. FLVNS received PRF payments based on their TIN?s Medicare reimbursement for the previous year. For the Period 1 submission, URHC allocated a portion of its total expenses and lost revenue to FLVNS based on the ratio of former FLVNS patients served by URHC to total patients served by URHC in 2020. As a result, FLVNS reported expenses and lost revenue when FLVNS did not have any operating activities in 2020. FLVNS Period 1 reporting should have shown a transfer to URHC, as allowed under the HHS terms and conditions, with URHC reporting total expenses and lost revenue on its Phase 1 submission. The amount reported on the FLVNS Period 1 HHS report erroneously was $322,723. ? University of Rochester management identified 5 equipment records submitted for Period 1 reporting that were later discovered to have also been previously reimbursed by other grants. The 5 equipment records submitted on both Period 1 reporting to HRSA and other grants totaled $87,265. ? Highland Hospital of Rochester management identified nursing agency expenditures that were not appropriately captured in the Period 1 reporting?s quarterly reporting. This resulted in an overstatement of nursing agency costs in Quarter 2 (April ? June 2021). However, in totality Highland Hospital of Rochester understated these COVID-19 expenditures. ? At our request, Nicholas H. Noyes Memorial Hospital management assessed their reporting of COVID-19 lab tests within the Period 1 reporting to HRSA. As a result of their review, management identified that they overstated COVID-19 lab tests in Quarter 1 (January ? March 2020) by $930 and in Quarter 2 (April ? June 2020) by $13,346. However, underreport the full expenditures of COVID-19 lab tests in Period 1 reporting by $25,506 if assessing across all allowable quarters from January 2020 ? June 2021. Criteria Law (Pub. L. No. 116-136, 134 Stat. 563 and Pub. L. No. 116-139, 134 Stat. 622 and 623) notes that PRFs should be used to prevent, prepare for, and respond to coronavirus, domestically or internationally, for necessary expenses to reimburse, through grants or other mechanisms, eligible health care providers for health care related expenses or lost revenues that are attributable to coronavirus. Additionally, these funds may not be used to reimburse expenses or losses that have been reimbursed from other sources or that other sources are obligated to reimburse. Cause The causes of the issues noted above were due to a lack of consistency in tracking and reviewing COVID-19 expenditures for inclusion in the Period 1 reporting across the organization. Effect University of Rochester and Related Entities? Period 1 HRSA Reporting Portal submissions inaccurately captured total ?Other PRF Expenses?. Questioned Costs None noted Recommendation We recommend management design and implement an organization-wide policy for reviewing HRSA Reporting portal submissions. This will help ensure completeness and accuracy of future federal report and/or HRSA Reporting portal submissions. Additionally, we recommend management communicate the errors noted in the submissions to HRSA and request advice for how to correct this error. Management's View and Corrective Action Plan Management?s view and corrective action plan is included at the end of this report.
Management?s Response to Finding: Management agrees with the Period 1 HRSA Reporting portal submission errors noted and will continue to take proactive action to correct these portal submission errors. Management?s Corrective Action Plan: The University will take the following corrective action with respect to this finding: ? With respect to Finger Lakes Visiting Nurse Service ((FLVNS), the University acknowledges that FLVNS?s Period 1 Reporting portal submission should have shown a transfer of PRF funds to UR Medicine Home Care, Certified Services, Inc. (URMHC), with URMHC reporting total expenses and lost revenue for all PRF payments received by FLVNS. Importantly, there are no overstated amounts enterprise-wide with respect to this finding, as it is a matter of how PRF payments were allocated by the University to an entity (FLVNS) that was merged into another University entity (URMHC). The Vice President of Financial Services at URMHC will notify HRSA of this error in the second quarter of fiscal year 2023 (October ? December 2022) and inquire whether an amended/corrected submission is required. ? With respect to the 5 equipment records submitted for the University?s Period 1 reporting that were later discovered to have also been previously reimbursed by other grants, the University identified and self-reported this error as a correction in the University?s Period 2 Reporting portal submission. ? With respect to the nursing agency costs for Highland Hospital of Rochester (HH) that were not appropriately captured in HH?s Period 1 HRSA submission, HH identified the error and self-reported this error as a correction in HH?s Period 2 Reporting portal submission. Importantly, in totality, HH understated its COVID-19 expenditures such that this finding does not impact the total Provider Relief Program funding received by HH. ? With respect to the COVID-19 lab tests for Nicholas H. Noyes Memorial Hospital (Noyes) that were not appropriately captured in Noyes?s Period 1 HRSA submission, Noyes identified the error and will correct the expense in Noyes? Period 4 Reporting portal submission which will be filed in the third quarter of fiscal year 2023 (January ? March 2023). Importantly, in totality, Noyes understated its COVID-19 expenditures such that this finding does not impact the total Provider Relief Program funding received by Noyes. Additionally, in the second quarter of the University?s fiscal year 2023, the URMC Office of the Chief Financial Officer will formalize an organization-wide process, supported by the Office of University Audit, the URMC Office of Integrity and Compliance and the University Controller?s Office, to review future HRSA Reporting portal submissions of all University affiliates prior to submission to the HRSA to ensure that future HRSA Reporting portal submissions are complete and accurate. Contact person: Adam Anolik, URMC Senior Vice President and CFO, Adam_Anolik@URMC.Rochester.edu
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on February 17, 2019. 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 August 17, 2019, which was (2560 days ago).
What is a management decision? →GSA_MIGRATION
GSA_MIGRATION
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on March 12, 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 September 12, 2018, which was (2899 days ago).
What is a management decision? →GSA_MIGRATION
GSA_MIGRATION
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on March 30, 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 September 30, 2017, which was (3246 days ago).
What is a management decision? →GSA_MIGRATION
GSA_MIGRATION
2015-002
GSA_MIGRATION
GSA_MIGRATION
2015-004
GSA_MIGRATION
GSA_MIGRATION
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