EIN: 376006885
UEI: GSA_MIGRATION
Data as of August 23, 2026
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on September 28, 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 28, 2023 (1244 days ago).
What is a management decision? →The Hospital?s internal controls over compliance related to covid expenditures were not effective as the Hospital reported patient revenue write-offs related to Covid-19 tests as expense. Questioned costs: N/A Context: The Hospital performed free testing for Covid-19 for various organizations within the community. Cause: Given the complexity associated with the rules and regulations of the program as well as the uncertainty given changing regulations management believed test write-offs to be an allowable expense. Effect: The Hospital?s internal controls around compliance were not effective in identifying allowable expenses associated with Covid-19. Repeat Finding: N/A Recommendation: We recommend the Hospital design controls to ensure that expenses are reported in accordance with latest HHS guidelines. Views of responsible officials: There is no disagreement with the audit finding. Management has identified additional Covid-19 expenses that were not included with the Period 1 submission that they believe would offset the issue identified above.
Show full finding ▾Hide full finding ▴2021 ? 001 Federal agency: U.S. Department of Health and Human Services Other Programs Federal program title: COVID-19 Provider Relief Funding Assistance Listing Number: 93.498 Pass-Through Agency: N/A Pass-Through Number(s): N/A Award Period: Period 1 Type of Finding: Material Weakness in Internal Control in and over Compliance Compliance Requirement: Allowable Costs Criteria or specific requirement: The Provider Relief Funds were provided under the Coronavirus Aid, Relief, and Economic Security Act (Pub. L. No. 116-136, 134 Stat. 563) and are to be used to prevent, prepare for, and respond to coronavirus and that the funds shall reimburse the recipient only for expenses or lost revenues that are attributable to coronavirus. Condition: The Hospital?s internal controls over compliance related to covid expenditures were not effective as the Hospital reported patient revenue write-offs related to Covid-19 tests as expense. Questioned costs: N/A Context: The Hospital performed free testing for Covid-19 for various organizations within the community. Cause: Given the complexity associated with the rules and regulations of the program as well as the uncertainty given changing regulations management believed test write-offs to be an allowable expense. Effect: The Hospital?s internal controls around compliance were not effective in identifying allowable expenses associated with Covid-19. Repeat Finding: N/A Recommendation: We recommend the Hospital design controls to ensure that expenses are reported in accordance with latest HHS guidelines. Views of responsible officials: There is no disagreement with the audit finding. Management has identified additional Covid-19 expenses that were not included with the Period 1 submission that they believe would offset the issue identified above.
COVID-19 Provider Relief Funding Recommendation: We recommend the Hospital design controls to ensure that expenses are reported in accordance with latest HHS guidelines. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Management has identified additional Covid-19 expenses that were not included with the Period 1 submission that they believe would offset the issue identified above. Action taken in response to finding: The Hospital will ensure that controls are put into place to capture Covid specific costs in accordance with HHS guidelines. Name of the contact person responsible for corrective action: Rikki Bonthron, CFO. Planned completion date for corrective action plan: October 1, 2022
During our testing, we identified the Hospital did not have internal controls in place to ensure reporting was completed in accordance with HHS guidelines. Questioned costs: $377,000 Context: During our testing, it was identified that the Hospital?s calculation of lost revenues was not measured consistently between budgeted and actual amounts. Cause: Management identified that error was made in the calculation of lost revenues as result of a final cost report settlement being completed and adjusted in the 2021 financial statement audit, however the calculated amount of lost revenues was not updated do to the timing of the deadline of reporting and provider relief funds. Effect: The calculation of lost revenues was not measured consistently as final settlement of reimbursable costs and Medicare revenue was not included in the calculation of lost revenues. The effect of this was to overstate the amount of lost revenues calculated and reported. Repeat Finding: N/A Recommendation: We recommend the Hospital design controls to ensure that reporting is completed in accordance with latest HHS guidelines. Views of responsible officials: There is no disagreement with the audit finding. Management has identified additional Covid-19 expenses that were not included with the Period 1 submission that they believe would offset the issue identified above.
Show full finding ▾Hide full finding ▴2021 ? 002 Federal agency: U.S. Department of Health and Human Services Other Programs Federal program title: COVID 19 Provider Relief Funding Assistance Listing Number: 93.498 Pass-Through Agency: N/A Pass-Through Number(s): N/A Award Period: Period 1 Type of Finding: Material Weakness in Internal Control in and over Compliance Compliance Requirement: Reporting Criteria or specific requirement: The Provider Relief Funds were provided under the Coronavirus Aid, Relief, and Economic Security Act (Pub. L. No. 116-136, 134 Stat. 563) and are to be used to prevent, prepare for, and respond to coronavirus and that the funds shall reimburse the recipient only for expenses or lost revenues that are attributable to coronavirus. Condition: During our testing, we identified the Hospital did not have internal controls in place to ensure reporting was completed in accordance with HHS guidelines. Questioned costs: $377,000 Context: During our testing, it was identified that the Hospital?s calculation of lost revenues was not measured consistently between budgeted and actual amounts. Cause: Management identified that error was made in the calculation of lost revenues as result of a final cost report settlement being completed and adjusted in the 2021 financial statement audit, however the calculated amount of lost revenues was not updated do to the timing of the deadline of reporting and provider relief funds. Effect: The calculation of lost revenues was not measured consistently as final settlement of reimbursable costs and Medicare revenue was not included in the calculation of lost revenues. The effect of this was to overstate the amount of lost revenues calculated and reported. Repeat Finding: N/A Recommendation: We recommend the Hospital design controls to ensure that reporting is completed in accordance with latest HHS guidelines. Views of responsible officials: There is no disagreement with the audit finding. Management has identified additional Covid-19 expenses that were not included with the Period 1 submission that they believe would offset the issue identified above.
COVID-19 Provider Relief Funding Recommendation: We recommend the Hospital design controls to ensure that reporting is completed in accordance with latest HHS guidelines. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Management has identified additional Covid-19 expenses that were not included with the Period 1 submission that they believe would offset the issue identified above. Action taken in response to finding: The Hospital will ensure that controls are put into place to ensure lost revenue reporting is completed in accordance with HHS guidelines. Name of the contact person responsible for corrective action: Rikki Bonthron, CFO. Planned completion date for corrective action plan: October 1, 2022
During our testing, we identified the Hospital did not have internal controls in place to ensure reporting was completed in accordance with HHS guidelines. Questioned costs: $714,000 Context: During our testing, it was identified the Hospital included certain Covid-19 related costs which were dated subsequent to the June 30, 2021 deadline on the use of the funds. Cause: Management identified that supply chain issues, contractor availability and access to the required capital items delayed the receipt and purchase of the items prior to the deadline on the use of the funds. Effect: The calculation of Covid-19 expenses included costs incurred subsequent to the June 30, 2021 reporting deadline. Repeat Finding: N/A Recommendation: We recommend the Hospital design controls to ensure that reporting is completed in accordance with latest HHS guidelines. Views of responsible officials: There is no disagreement with the audit finding. Management has identified additional Covid-19 expenses that were not included with the Period 1 submission that they believe would offset the issue identified above.
Show full finding ▾Hide full finding ▴2021 ? 003 Federal agency: U.S. Department of Health and Human Services Other Programs Federal program title: COVID 19 Provider Relief Funding Assistance Listing Number: 93.498 Pass-Through Agency: N/A Pass-Through Number(s): N/A Award Period: Period 1 Type of Finding: Material Weakness in Internal Control in and over Compliance Compliance Requirement: Period of Performance Criteria or specific requirement: The Provider Relief Funds were provided under the Coronavirus Aid, Relief, and Economic Security Act (Pub. L. No. 116-136, 134 Stat. 563) and are to be used to prevent, prepare for, and respond to coronavirus and that the funds shall reimburse the recipient only for expenses or lost revenues that are attributable to coronavirus. Condition: During our testing, we identified the Hospital did not have internal controls in place to ensure reporting was completed in accordance with HHS guidelines. Questioned costs: $714,000 Context: During our testing, it was identified the Hospital included certain Covid-19 related costs which were dated subsequent to the June 30, 2021 deadline on the use of the funds. Cause: Management identified that supply chain issues, contractor availability and access to the required capital items delayed the receipt and purchase of the items prior to the deadline on the use of the funds. Effect: The calculation of Covid-19 expenses included costs incurred subsequent to the June 30, 2021 reporting deadline. Repeat Finding: N/A Recommendation: We recommend the Hospital design controls to ensure that reporting is completed in accordance with latest HHS guidelines. Views of responsible officials: There is no disagreement with the audit finding. Management has identified additional Covid-19 expenses that were not included with the Period 1 submission that they believe would offset the issue identified above.
COVID-19 Provider Relief Funding Recommendation: We recommend the Hospital design controls to ensure that expenses are reported during the period of eligibility. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Management has identified additional Covid-19 expenses that were not included with the Period 1 submission that they believe would offset the issue identified above. Action taken in response to finding: The Hospital will ensure that controls are put into place to capture Covid specific costs during period of eligibility. Name of the contact person responsible for corrective action: Rikki Bonthron, CFO. Planned completion date for corrective action plan: October 1, 2022
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 compliance status.
Start monitoring →© 2026 Single Audit Intelligence. All data is public domain.