EIN: 310621866
UEI: CS1EU27WKUD5
237419897, 270712680, 310536662, 310564121, 310809436, 310886949, 310999724, 311051688, 311078381, 311127485, 311175717, 452036966 · unlinked EINs have no separate FAC filing
Audited by: EY
Oversight agency: 84 [Department of Education]
View federal awards & risk assessment →
Data as of August 28, 2026
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on September 26, 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 March 26, 2026 (156 days ago).
What is a management decision? →FAC accepted this audit on September 30, 2024 — management decision was due March 30, 2025.
FAC accepted this audit on September 10, 2023 — management decision was due March 10, 2024.
The System did not appropriately design or implement internal controls over the HRSA COVID-19 Uninsured Program T&Cs as of and for the year ended December 31, 2022. Cause: Though there are internal controls in place with respect to the System?s revenue cycle, the System did not specifically have internal controls in place to ensure compliance with the HRSA COVID-19 Uninsured Program T&Cs. Effect or potential effect: If adequate internal controls are not designed and implemented, the System may not be in compliance with the HRSA COVID-19 Uninsured Program T&Cs, or the System may not take necessary actions required to comply with the HRSA COVID-19 Uninsured Program related to Uniform Guidance compliance requirements A. Activities Allowed or Unallowed, B. Allowable Costs/Cost Principles, E. Eligibility, and N. Special Tests and Provisions Questioned costs: None. Kettering Health Schedule of Findings and Questioned Costs (continued) 2307-4310198 71 Section III ? Federal Award Findings and Questioned Costs (continued) Context: The HRSA COVID-19 Uninsured Program had federal expenditures of $1,105,658 for the year ended December 31, 2022 and was determined to be Type A major federal program. Identification as a repeat finding, if applicable: This is a repeat finding. The prior year finding reference is Finding 2021-001. Recommendation: Due to the nature of this program and the timing of the finding identified in the prior year, the System did not have the opportunity to remediate the prior year finding. While this program likely will not exist in future periods, the System should implement internal controls to document its review and compliance with future federal program T&Cs and the Uniform Guidance and ensure appropriate documentation is retained to support the operating effectiveness of the implemented internal controls. Views of responsible officials: Management agrees with the finding and has developed a plan to address the finding and will ensure appropriate internal controls and documentation are in place for future programs.
Show full finding ▾Hide full finding ▴Finding 2022-001 ? A. Activities Allowed or Unallowed, B. Allowable Costs / Cost Principles, E. Eligibility, and N. Special Tests and Provisions ? Material Weakness in Internal Controls Over Compliance Identification of the federal program: Assistance Listing 93.461 ? COVID-19 Claims Reimbursement to Health Care Providers and Facilities for Testing, Treatment, and Vaccine Administration for the Uninsured (U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA) (HRSA COVID-19 Uninsured Program) Criteria or specific requirement (including statutory, regulatory or other citation): Section 200.303 of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance), states the following regarding internal control: ?The non-federal entity must: 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 statues, 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 (also known as the Green Book) issued by the Comptroller General of the United States or the Internal Control ? Integrated Framework (COSO Framework) issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).? Kettering Health Schedule of Findings and Questioned Costs (continued) 2307-4310198 70 Section III ? Federal Award Findings and Questioned Costs (continued) Health and Human Services (HHS) ? (HRSA issued Terms and Conditions for Participation in the HRSA COVID-19 Claims Reimbursement to Health Care Providers and Facilities for Testing, Treatment, and Vaccine Administration for the Uninsured Program (T&Cs) outlining requirements that recipients of funding from the HRSA COVID-19 Uninsured Program must comply with including the following sections: Testing Services, Treatment Services and Vaccine Administration, and General Provisions in FY2020 Consolidated Appropriations. Condition: The System did not appropriately design or implement internal controls over the HRSA COVID-19 Uninsured Program T&Cs as of and for the year ended December 31, 2022. Cause: Though there are internal controls in place with respect to the System?s revenue cycle, the System did not specifically have internal controls in place to ensure compliance with the HRSA COVID-19 Uninsured Program T&Cs. Effect or potential effect: If adequate internal controls are not designed and implemented, the System may not be in compliance with the HRSA COVID-19 Uninsured Program T&Cs, or the System may not take necessary actions required to comply with the HRSA COVID-19 Uninsured Program related to Uniform Guidance compliance requirements A. Activities Allowed or Unallowed, B. Allowable Costs/Cost Principles, E. Eligibility, and N. Special Tests and Provisions Questioned costs: None. Kettering Health Schedule of Findings and Questioned Costs (continued) 2307-4310198 71 Section III ? Federal Award Findings and Questioned Costs (continued) Context: The HRSA COVID-19 Uninsured Program had federal expenditures of $1,105,658 for the year ended December 31, 2022 and was determined to be Type A major federal program. Identification as a repeat finding, if applicable: This is a repeat finding. The prior year finding reference is Finding 2021-001. Recommendation: Due to the nature of this program and the timing of the finding identified in the prior year, the System did not have the opportunity to remediate the prior year finding. While this program likely will not exist in future periods, the System should implement internal controls to document its review and compliance with future federal program T&Cs and the Uniform Guidance and ensure appropriate documentation is retained to support the operating effectiveness of the implemented internal controls. Views of responsible officials: Management agrees with the finding and has developed a plan to address the finding and will ensure appropriate internal controls and documentation are in place for future programs.
Finding 2022-001 ? A. Activities Allowed or Unallowed, B. Allowable Costs / Cost Principles, E. Eligibility, and N. Special Tests and Provisions ? Material Weakness in Internal Controls Over Compliance Federal Program: COVID-19 Claims Reimbursement to Health Care Providers and Facilities for Testing Treatment, and Vaccine Administration for the Uninsured, Assistance Listing No. 93.461 (COVID-19 Uninsured Program) Federal Agency: U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA) Pass-Through Award Period: January 1, 2022 through December 31, 2022 Views of responsible officials and planned corrective actions: Management agrees with the finding as reported. It is noteworthy that the COVID-19 Uninsured Program (the Program) ceases to accept claims for testing and treatment effective March 22, 2022. Claims for vaccinations were no longer accepted after April 5, 2022. Should HRSA funding be re-instated, the Network is committed to ensure proper internal controls over compliance are established to fully comply with the Program?s set terms and conditions.
2021-001
The System did not appropriately design, implement, or retain documentation for internal controls over the PRF Program for the year ended December 31, 2022 to ensure compliance with requirements of the Uniform Guidance. Management also did not retain its documentation over the review and approval of the PRF Program terms and conditions (T&Cs). Cause: Though there are internal controls in place with respect to purchasing and revenue within the System, the System did not specifically have internal controls in place or operating effectively to ensure, or retain documentation to demonstrate compliance, with the PRF Program T&Cs and the Uniform Guidance. Effect or potential effect: If adequate internal controls are not designed, implemented, and documented the System may not be in compliance with the PRF Program T&Cs, or the System may not take necessary actions required to comply with the PRF Program related to all applicable Uniform Guidance compliance requirements. Questioned costs: None. Context: Total federal expenditures for Assistance Listing 93.498 totaled $27,741,256 for the year ended December 31, 2022. Kettering Health Schedule of Findings and Questioned Costs (continued) 2307-4310198 74 Section III ? Federal Award Findings and Questioned Costs (continued) Identification as a repeat finding, if applicable: This is a repeat finding. The prior year finding reference is Finding 2021-003. Recommendation: Due to the nature of this program and the timing of the finding identified in the prior year, the System did not have the opportunity to remediate the prior year finding. While this program likely will not exist in future periods, the System should implement internal controls to document its review and compliance with future federal program T&Cs and the Uniform Guidance and ensure appropriate documentation is retained to support the operating effectiveness of the implemented internal controls. Views of responsible officials: Management agrees with the finding and has developed a plan to address the finding and will ensure appropriate internal controls and documentation are in place for future programs.
Show full finding ▾Hide full finding ▴Finding 2022-002 ? A. Activities Allowed or Unallowed and B. Allowable Costs / Cost Principles ? Material Weakness in Internal Controls Over Compliance Identification of the federal program: Assistance Listing 93.498 ? COVID-19 Provider Relief Fund (PRF) and American Rescue Plan (ARP) Rural Distribution (PRF Program) Criteria or specific requirement (including statutory, regulatory or other citation): Section 200.303 of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance), states the following regarding internal control: ?The non-federal entity must: 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 statues, 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 (also known as the Green Book) issued by the Comptroller General of the United States or the Internal Control ? Integrated Framework (COSO Framework) issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).? Kettering Health Schedule of Findings and Questioned Costs (continued) 2307-4310198 73 Section III ? Federal Award Findings and Questioned Costs (continued) Condition: The System did not appropriately design, implement, or retain documentation for internal controls over the PRF Program for the year ended December 31, 2022 to ensure compliance with requirements of the Uniform Guidance. Management also did not retain its documentation over the review and approval of the PRF Program terms and conditions (T&Cs). Cause: Though there are internal controls in place with respect to purchasing and revenue within the System, the System did not specifically have internal controls in place or operating effectively to ensure, or retain documentation to demonstrate compliance, with the PRF Program T&Cs and the Uniform Guidance. Effect or potential effect: If adequate internal controls are not designed, implemented, and documented the System may not be in compliance with the PRF Program T&Cs, or the System may not take necessary actions required to comply with the PRF Program related to all applicable Uniform Guidance compliance requirements. Questioned costs: None. Context: Total federal expenditures for Assistance Listing 93.498 totaled $27,741,256 for the year ended December 31, 2022. Kettering Health Schedule of Findings and Questioned Costs (continued) 2307-4310198 74 Section III ? Federal Award Findings and Questioned Costs (continued) Identification as a repeat finding, if applicable: This is a repeat finding. The prior year finding reference is Finding 2021-003. Recommendation: Due to the nature of this program and the timing of the finding identified in the prior year, the System did not have the opportunity to remediate the prior year finding. While this program likely will not exist in future periods, the System should implement internal controls to document its review and compliance with future federal program T&Cs and the Uniform Guidance and ensure appropriate documentation is retained to support the operating effectiveness of the implemented internal controls. Views of responsible officials: Management agrees with the finding and has developed a plan to address the finding and will ensure appropriate internal controls and documentation are in place for future programs.
Finding 2022-002 A. Activities Allowed or Unallowed and B. Allowable Costs/Cost Principles ? Material Weakness in Internal Controls Over Compliance Federal Program: COVID-19 Provider Relief Fund (PRF) and American Rescue Plan (ARP) Rural Distribution (PRF Program), Assistance Listing No. 93.498 (PRF Program) Federal Agency: U.S. Department of Health and Human Services Pass-Through Award Period: January 1, 2021 through December 31, 2022 Views of responsible officials and planned corrective actions: Management agrees with the findings as reported. The Network is committed to ensuring internal controls are implemented to ensure compliance with Section 200.303 of the Uniform Guidance. The following steps have been implemented Spring 2023: 1. Design and implement controls over compliance to ensure terms and conditions are adhered to, including retaining proper documentation to support the effectiveness of the controls. 2. Utilize Internal Audit to perform testing on the PRF program 3. Established procedures for Internal Audit to test quarterly reporting related to the Health and Human Services (HHS) portal as it relates to Provider Relief Funds. After, Internal Audit?s testing of the data, Executive Director of Finance and Executive Director of Internal Audit will review the information with the Executive Director of Decision Support and Reimbursement prior to finalizing the quarterly reporting in the HHS portal.
2021-003
FAC accepted this audit on September 29, 2022 — management decision was due March 29, 2023.
The Network did not appropriately design or implement internal controls over the HRSA COVID-19 Uninsured Program T&Cs as of and for the year ended December 31, 2021. Cause: Though there are internal controls in place with respect to the Network?s revenue cycle, the Network did not specifically have internal controls in place to ensure compliance with the HRSA COVID-19 Uninsured Program T&Cs. Effect or potential effect: If adequate internal controls are not designed and implemented, the Network may not be in compliance with the HRSA COVID-19 Uninsured Program T&Cs, or the Network may not take necessary actions required to comply with the HRSA COVID-19 Uninsured Program related to Uniform Guidance compliance requirements A. Activities Allowed or Unallowed, B. Allowable Costs/Cost Principles, E. Eligibility, and N. Special Tests and Provisions. Questioned costs: None. Context: Total federal expenditures for Assistance Listing 93.461 totaled $2,637,247 for the year ended December 31, 2021. Identification as a repeat finding, if applicable: This is a repeat finding. The prior year finding reference is Finding 2020-001. Recommendation: The Network should implement and document internal controls to demonstrate its review and compliance with the HRSA COVID-19 Uninsured Program T&Cs and the Uniform Guidance compliance requirements A. Activities Allowed, B. Allowable Costs / Cost Principles, E. Eligibility, and N. Special Tests and Provisions. The Network should implement and document sufficiently precise internal controls to review changes to the HRSA COVID-19 Uninsured Program to ensure it is administering the program in compliance with the HRSA COVID-19 Uninsured Program regulations. In addition, internal controls should be implemented and documented to ensure claims submitted to the HRSA COVID-19 Uninsured Program meet the allowability criteria established by the HRSA COVID-19 Uninsured Program regulations before claims are submitted to HRSA for reimbursement. Standard policies, procedures, and documented internal controls over the review for patient insurance coverage and review of credit balances should be updated to address the unique aspects of the HRSA COVID-19 Uninsured Program. Views of responsible officials: Management agrees with the finding and has developed a plan to address the finding.
Show full finding ▾Hide full finding ▴Finding 2021-001 ? A. Activities Allowed or Unallowed, B. Allowable Costs / Cost Principles, E. Eligibility, and N. Special Tests and Provisions ? Material Weakness in Internal Controls Over Compliance Identification of the federal program: Assistance Listing 93.461 - COVID-19 Claims Reimbursement to Health Care Providers and Facilities for Testing, Treatment, and Vaccine Administration for the Uninsured (U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA) (HRSA COVID-19 Uninsured Program) Criteria or specific requirement (including statutory, regulatory or other citation): Section 200.303 of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) states the following regarding internal control: ?The non-federal entity must: 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 statues, 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 (also known as the Green Book) issued by the Comptroller General of the United States or the Internal Control ? Integrated Framework (COSO Framework) issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).? Health and Human Services (HHS) ? (HRSA issued Terms and Conditions for Participation in the HRSA COVID-19 Claims Reimbursement to Health Care Providers and Facilities for Testing, Treatment, and Vaccine Administration for the Uninsured Program (T&Cs) outlining requirements that recipients of funding from the HRSA COVID-19 Uninsured Program must comply with including the following sections: Testing Services, Treatment Services and Vaccine Administration, and General Provisions in FY2020 Consolidated Appropriations. Condition: The Network did not appropriately design or implement internal controls over the HRSA COVID-19 Uninsured Program T&Cs as of and for the year ended December 31, 2021. Cause: Though there are internal controls in place with respect to the Network?s revenue cycle, the Network did not specifically have internal controls in place to ensure compliance with the HRSA COVID-19 Uninsured Program T&Cs. Effect or potential effect: If adequate internal controls are not designed and implemented, the Network may not be in compliance with the HRSA COVID-19 Uninsured Program T&Cs, or the Network may not take necessary actions required to comply with the HRSA COVID-19 Uninsured Program related to Uniform Guidance compliance requirements A. Activities Allowed or Unallowed, B. Allowable Costs/Cost Principles, E. Eligibility, and N. Special Tests and Provisions. Questioned costs: None. Context: Total federal expenditures for Assistance Listing 93.461 totaled $2,637,247 for the year ended December 31, 2021. Identification as a repeat finding, if applicable: This is a repeat finding. The prior year finding reference is Finding 2020-001. Recommendation: The Network should implement and document internal controls to demonstrate its review and compliance with the HRSA COVID-19 Uninsured Program T&Cs and the Uniform Guidance compliance requirements A. Activities Allowed, B. Allowable Costs / Cost Principles, E. Eligibility, and N. Special Tests and Provisions. The Network should implement and document sufficiently precise internal controls to review changes to the HRSA COVID-19 Uninsured Program to ensure it is administering the program in compliance with the HRSA COVID-19 Uninsured Program regulations. In addition, internal controls should be implemented and documented to ensure claims submitted to the HRSA COVID-19 Uninsured Program meet the allowability criteria established by the HRSA COVID-19 Uninsured Program regulations before claims are submitted to HRSA for reimbursement. Standard policies, procedures, and documented internal controls over the review for patient insurance coverage and review of credit balances should be updated to address the unique aspects of the HRSA COVID-19 Uninsured Program. Views of responsible officials: Management agrees with the finding and has developed a plan to address the finding.
Finding 2021-001 ? A. Activities Allowed or Unallowed, B. Allowable Costs / Cost Principles, E. Eligibility, and N. Special Tests and Provisions ? Material Weakness in Internal Controls Over Compliance Federal Program: COVID-19 Claims Reimbursement to Health Care Providers and Facilities for Testing Treatment, and Vaccine Administration for the Uninsured, Assistance Listing No. 93.461 (COVID-19 Uninsured Program) Federal Agency: U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA) Pass-Through Award Period: January 1, 2021 through December 31, 2021 Views of responsible officials and planned corrective actions: Management agrees with the finding as reported. It is noteworthy that the COVID-19 Uninsured Program (the Program) ceases to accept claims for testing and treatment effective March 22, 2022. Claims for vaccinations were no longer accepted after April 5, 2022. Should HRSA funding be re-instated, the Network is committed to ensure proper internal controls over compliance are established to fully comply with the Program?s set terms and conditions.
2020-001
Management did not have sufficiently designed internal controls to review the supporting documentation used in the lost revenue calculation and the data submitted in the HHS PRF Reporting Portal. The Network submitted lost revenue inclusive of entities that did not receive federal funding from PRF Program and understated expense totals for personnel and fringe benefits. Cause: There was no supporting documentation to evidence that the internal controls were sufficiently designed and operating effectively as it relates to the lost revenue calculation, COVID-19 related expenses, and HHS portal submission. Management entered the incorrect information into the HHS PRF Reporting Portal. Management?s internal controls over the review and approval of the HHS PRF Reporting Portal submission was not sufficiently robust to identify data input errors. Effect or potential effect: A lack of internal controls over the review the lost revenue calculation, COVID-19 related expenses, and the data submitted in the HHS PRF Reporting Portal could (and did) result in a misstatement of the amounts reported in the HHS PRF Reporting Portal. Questioned costs: None. Context: Total federal expenditures for Assistance Listing 93.498 totaled $46,712,073 for the year ended December 31, 2021. Identification as a repeat finding, if applicable: The finding is not a repeat finding. Recommendation: Management should correct any reporting errors in the next PRF reporting period. In addition, management should implement and document internal controls over the review and approval of the data used to calculate lost revenue, COVID-19 related expenses, and the data submitted in the HHS PRF Reporting Portal. Views of responsible officials: Management agrees with the finding and has developed a plan to address finding.
Show full finding ▾Hide full finding ▴Finding 2021-002 ? L. Reporting ? Material Weakness in Internal Control Over Compliance and Material Noncompliance Identification of the federal program: Assistance Listing 93.498 - COVID-19 Provider Relief Fund (PRF) and American Rescue Plan (ARP) Rural Distribution (PRF Program) Criteria or specific requirement (including statutory, regulatory or other citation): Section 200.303 of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) states the following regarding internal control: ?The non-federal entity must: 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 statues, 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 (also known as the Green Book) issued by the Comptroller General of the United States or the Internal Control ? Integrated Framework (COSO Framework) issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).? The terms and conditions of the PRF Program require the recipient to submit reports to the secretary of the U.S. Department of Health and Human Services (HHS) for each reporting period to ensure compliance with conditions that are imposed on the federal award, and such report shall be in such form, with such content, as specified by the sectary of HHS in program instructions directed to all recipients. Condition: Management did not have sufficiently designed internal controls to review the supporting documentation used in the lost revenue calculation and the data submitted in the HHS PRF Reporting Portal. The Network submitted lost revenue inclusive of entities that did not receive federal funding from PRF Program and understated expense totals for personnel and fringe benefits. Cause: There was no supporting documentation to evidence that the internal controls were sufficiently designed and operating effectively as it relates to the lost revenue calculation, COVID-19 related expenses, and HHS portal submission. Management entered the incorrect information into the HHS PRF Reporting Portal. Management?s internal controls over the review and approval of the HHS PRF Reporting Portal submission was not sufficiently robust to identify data input errors. Effect or potential effect: A lack of internal controls over the review the lost revenue calculation, COVID-19 related expenses, and the data submitted in the HHS PRF Reporting Portal could (and did) result in a misstatement of the amounts reported in the HHS PRF Reporting Portal. Questioned costs: None. Context: Total federal expenditures for Assistance Listing 93.498 totaled $46,712,073 for the year ended December 31, 2021. Identification as a repeat finding, if applicable: The finding is not a repeat finding. Recommendation: Management should correct any reporting errors in the next PRF reporting period. In addition, management should implement and document internal controls over the review and approval of the data used to calculate lost revenue, COVID-19 related expenses, and the data submitted in the HHS PRF Reporting Portal. Views of responsible officials: Management agrees with the finding and has developed a plan to address finding.
Finding 2021-002 L. Reporting Federal Program: COVID-19 Provider Relief Fund (PRF) and American Rescue Plan (ARP) Rural Distribution (PRF Program), Assistance Listing No. 93.498 (PRF Program) Federal Agency: U.S. Department of Health and Human Services Pass-Through Award Period: July 1, 2020 through December 31, 2020 Views of responsible officials and planned corrective actions: Management agrees with the findings as reported. The Network is committed to ensuring internal controls are implemented to ensure compliance with Section 200.303 of the Uniform Guidance. The following steps have been or will be implemented Spring 2023: 1. Design and implement controls over compliance to ensure terms and conditions are adhered to, including retaining proper documentation to support the effectiveness of the controls. 2. Utilize Internal Audit to perform testing on the PRF program 3. Established procedures for Internal Audit to test quarterly reporting related to the Health and Human Services (HHS) portal as it relates to Provider Relief Funds. After, Internal Audit?s testing of the data, Executive Director of Finance and Executive Director of Internal Audit will review the information with the Executive Director of Decision Support and Reimbursement prior to finalizing the quarterly reporting in the HHS portal. 4. Reporting within in HHS portal will be corrected by September 30, 2022, before the reporting portal closes.
The Network did not appropriately design, implement, or retain documentation for internal controls over the PRF Program for the year ended December 31, 2021 to ensure compliance with requirements of the Uniform Guidance. Management also did not retain its documentation over the review and approval of the PRF Program terms and conditions (T&Cs). Cause: Though there are internal controls in place with respect to purchasing and revenue within the Network, the Network did not specifically have internal controls in place or operating effectively to ensure, or retain documentation to demonstrate compliance, with the PRF Program T&Cs and the Uniform Guidance. Effect or potential effect: If adequate internal controls are not designed, implemented, and documented the Network may not be in compliance with the PRF Program T&Cs, or the Network may not take necessary actions required to comply with the PRF Program related to all applicable Uniform Guidance compliance requirements (compliance requirement L. Reporting is further discussed in Finding 2021-002). Questioned costs: None. Context: Total federal expenditures for Assistance Listing 93.498 totaled $46,712,073 for the year ended December 31, 2021. Identification as a repeat finding, if applicable: The finding is not a repeat finding. Recommendation The Network should implement internal controls to document its review and compliance with the PRF Program T&Cs and the Uniform Guidance and ensure appropriate documentation is retained to support the operating effectiveness of the implemented internal controls. Views of responsible officials: Management agrees with the finding and has developed a plan to address the finding
Show full finding ▾Hide full finding ▴Finding 2021-003 ? A. Activities Allowed or Unallowed and B. Allowable Costs / Cost Principles - Material Weakness in Internal Controls Over Compliance Identification of the federal program: Assistance Listing 93.498 - COVID-19 Provider Relief Fund (PRF) and American Rescue Plan (ARP) Rural Distribution (PRF Program) Criteria or specific requirement (including statutory, regulatory or other citation): Section 200.303 of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) states the following regarding internal control: ?The non-federal entity must: 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 statues, 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 (also known as the Green Book) issued by the Comptroller General of the United States or the Internal Control ? Integrated Framework (COSO framework) issued by the Committee of Sponsoring Organizations of the Treadway Commission(COSO).? Condition: The Network did not appropriately design, implement, or retain documentation for internal controls over the PRF Program for the year ended December 31, 2021 to ensure compliance with requirements of the Uniform Guidance. Management also did not retain its documentation over the review and approval of the PRF Program terms and conditions (T&Cs). Cause: Though there are internal controls in place with respect to purchasing and revenue within the Network, the Network did not specifically have internal controls in place or operating effectively to ensure, or retain documentation to demonstrate compliance, with the PRF Program T&Cs and the Uniform Guidance. Effect or potential effect: If adequate internal controls are not designed, implemented, and documented the Network may not be in compliance with the PRF Program T&Cs, or the Network may not take necessary actions required to comply with the PRF Program related to all applicable Uniform Guidance compliance requirements (compliance requirement L. Reporting is further discussed in Finding 2021-002). Questioned costs: None. Context: Total federal expenditures for Assistance Listing 93.498 totaled $46,712,073 for the year ended December 31, 2021. Identification as a repeat finding, if applicable: The finding is not a repeat finding. Recommendation The Network should implement internal controls to document its review and compliance with the PRF Program T&Cs and the Uniform Guidance and ensure appropriate documentation is retained to support the operating effectiveness of the implemented internal controls. Views of responsible officials: Management agrees with the finding and has developed a plan to address the finding
2021-003 A. Activities Allowed or Unallowed and B. Allowable Costs/Cost Principles ? Material Weakness in Internal Controls Over Compliance Federal Program: COVID-19 Provider Relief Fund (PRF) and American Rescue Plan (ARP) Rural Distribution (PRF Program), Assistance Listing No. 93.498 (PRF Program) Federal Agency: U.S. Department of Health and Human Services Pass-Through Award Period: July 1, 2020 through December 31, 2020 Views of responsible officials and planned corrective actions: Management agrees with the findings as reported. The Network is committed to ensuring internal controls are implemented to ensure compliance with Section 200.303 of the Uniform Guidance. The following steps have been or will be implemented Spring 2023: 1. Design and implement controls over compliance to ensure terms and conditions are adhered to, including retaining proper documentation to support the effectiveness of the controls. 2. Utilize Internal Audit to perform testing on the PRF program 3. Established procedures for Internal Audit to test quarterly reporting related to the Health and Human Services (HHS) portal as it relates to Provider Relief Funds. After, Internal Audit?s testing of the data, Executive Director of Finance and Executive Director of Internal Audit will review the information with the Executive Director of Decision Support and Reimbursement prior to finalizing the quarterly reporting in the HHS portal. 4. Reporting within in HHS portal will be corrected by September 30, 2022, before the reporting portal closes.
FAC accepted this audit on December 16, 2021 — management decision was due June 16, 2022.
GSA_MIGRATION
Show full finding ▾Hide full finding ▴GSA_MIGRATION
GSA_MIGRATION
GSA_MIGRATION
Show full finding ▾Hide full finding ▴FAC accepted this audit on June 28, 2020 — management decision was due December 28, 2020.
FAC accepted this audit on September 25, 2019 — management decision was due March 25, 2020.
FAC accepted this audit on September 26, 2018 — management decision was due March 26, 2019.
FAC accepted this audit on September 26, 2017 — management decision was due March 26, 2018.
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.
Track your findings and corrective action plans across audit cycles.
Start tracking findings →Monitor subrecipient audit findings and filing records.
Start monitoring →© 2026 Single Audit Intelligence. All data is public domain.
