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III-A-21 Segregation of Duties - The Organization did not properly segregate custody, record-keeping and reconciling functions for revenues and expenditures, including those related to federal programs. See II-A-21.

III-B-21 Policies and Procedures Criteria ? Title 2, U.S. Code of Federal Regulations Part 200 Uniform Administrative Requirements, Cost Principles and Audit Requirements for Federal Awards (Uniform Guidance) requires the Organization to have certain formal/written policies and procedures in place. Condition ? The Organization has not established all policies required under the Uniform Guidance Part 200. Cause ? Although the Organization has a good understanding of the rules and regulations, there were never formal policies written as required under Uniform Guidance Part 200. Effect ? The Organization is not in compliance with Federal regulations pertaining to policies as required by the Uniform Guidance. Recommendation ? The Organization should establish written policies to ensure compliance with the Uniform Guidance Part 200. Response ? We will establish written policies to be in compliance with the Uniform Guidance Part 200. Conclusion - Response accepted.

III-C-21 Dual Signature Check Policy - The Organization did not always comply with their policy that required dual signatures for all disbursements in excess of $5,000. This could potentially effect disbursements related to federal programs. See II-C-21.

III-D-21 Reporting Criteria ? The terms and conditions of the CARES Act Provider Relief Fund (PRF) distributions state the funds are to only be used to prevent, prepare for and respond to the coronavirus, and that funds may only be used for healthcare related expenses or lost revenue that is attributable to the coronavirus. Period 1 reporting required an Organization to illustrate how funds received between April 10, 2020 through June 30, 2020 were used. Period 2 reporting required to illustrate how funds received between July 1, 2020 through December 31, 2020 were used. Condition ? During the process of reviewing the expenses that were reported it was noted that some expenses were reported in the incorrect period, however the total amount of expenses reported were correct. Cause ? Managements procedures in place to track expenses were not detailed enough to ensure qualified expenses were recorded in the proper reporting period. Effect ? Management included amounts in the PRF reporting portal which were not eligible for the specified period that was being reported on. Recommendation ? We recommend that management continue to monitor and enhance its internal controls over federal award compliance to ensure that only eligible costs are included in the reporting periods defined by HRSA. Response ? We will take steps to ensure all expenses are recorded in the correct period for future reporting as defined by HRSA. Conclusion - Response accepted.