EIN: 261938641
UEI: SVEFFMDEKK53
Audited by: DZA PLLC
Oversight agency: 10 [Department of Agriculture]
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Data as of September 2, 2026
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on February 17, 2025. Under 2 CFR 200.521(d), a pass-through entity that provided federal funds to this organization for this audit period must issue a management decision on these findings by August 17, 2025 (382 days ago).
What is a management decision? →FAC accepted this audit on January 24, 2024 — management decision was due July 24, 2024.
FAC accepted this audit on January 19, 2023 — management decision was due July 19, 2023.
FAC accepted this audit on January 23, 2022 — management decision was due July 23, 2022.
2021-001 Billing Patients with Presumptive or Actual Case of COVID-19 Federal Agency Department of Health and Human Services CFDA 93.498 ? Provider Relief Fund Award Numbers Not applicable Criteria [ ] Compliance Finding [X] Significant Deficiency [ ] Material Weakness Under the terms and conditions of the award, the recipient certifies it will not seek to collect from any patient out-of-pocket expenses in an amount greater than what the patient would have otherwise been required to pay if the care had been provided by an in-network provider, for patients with presumptive or actual case of COVID-19 from January 31, 2020, through the end of the Public Health Emergency. Condition The Hospital has not documented its policies and procedures to ensure that out-ofnetwork- patients with presumptive or actual cases of COVID-19 are not billed for out-of-pocket expenses greater than what the patient would have been required to pay if the patient had been provided services by an in-network provider. Context This finding appears to be a systemic issue. Cause The Hospital does not have documented internal controls in place to ensure compliance with the requirements of the program. Effect Without documented policies and procedures, there is risk a patient with presumptive or actual case of COVID-19 may be billed for out-of-pocket expenses in an amount greater than what the patient would have otherwise been required to pay if the care had been provided by an in-network provider. Recommendation We recommend management formalize and document its policies and procedures surrounding the billing of patients with presumptive or actual cases of COVID-19. Views of responsible officials and planned corrective actions Management is aware of the compliance requirement and the Hospital has been billing in network and out of network patients appropriately and is complying with the requirement. Management will formalize this with a policy that the board will approve at the board meeting on January 25, 2022.
Show full finding ▾Hide full finding ▴2021-001 Billing Patients with Presumptive or Actual Case of COVID-19 Federal Agency Department of Health and Human Services CFDA 93.498 ? Provider Relief Fund Award Numbers Not applicable Criteria [ ] Compliance Finding [X] Significant Deficiency [ ] Material Weakness Under the terms and conditions of the award, the recipient certifies it will not seek to collect from any patient out-of-pocket expenses in an amount greater than what the patient would have otherwise been required to pay if the care had been provided by an in-network provider, for patients with presumptive or actual case of COVID-19 from January 31, 2020, through the end of the Public Health Emergency. Condition The Hospital has not documented its policies and procedures to ensure that out-ofnetwork- patients with presumptive or actual cases of COVID-19 are not billed for out-of-pocket expenses greater than what the patient would have been required to pay if the patient had been provided services by an in-network provider. Context This finding appears to be a systemic issue. Cause The Hospital does not have documented internal controls in place to ensure compliance with the requirements of the program. Effect Without documented policies and procedures, there is risk a patient with presumptive or actual case of COVID-19 may be billed for out-of-pocket expenses in an amount greater than what the patient would have otherwise been required to pay if the care had been provided by an in-network provider. Recommendation We recommend management formalize and document its policies and procedures surrounding the billing of patients with presumptive or actual cases of COVID-19. Views of responsible officials and planned corrective actions Management is aware of the compliance requirement and the Hospital has been billing in network and out of network patients appropriately and is complying with the requirement. Management will formalize this with a policy that the board will approve at the board meeting on January 25, 2022.
Corrective action planned: Management has drafted a formal policy that the hospital will not seek to collect from any patient out-of-pocket expenses in an amount greater than what the patient would have otherwise been required to pay if the care had been provided by an in-network provider, for patients with presumptive or actual case of COVID-19 through the end of the Public Health Emergency. The policy will be presented to the board for approval at the next board meeting. Anticipated completion date: January 25, 2022 Contact person responsible for corrective action: J?Dee Adams, CEO
FAC accepted this audit on January 29, 2020 — management decision was due July 29, 2020.
FAC accepted this audit on January 23, 2019 — management decision was due July 23, 2019.
FAC accepted this audit on January 30, 2018 — management decision was due July 30, 2018.
FAC accepted this audit on January 22, 2017 — management decision was due July 22, 2017.
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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