EIN: 440629397
UEI: GSA_MIGRATION
Audited by: SEIM JOHNSON, LLP
Oversight agency: 93 [Department of Health and Human Services]
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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 August 10, 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 February 10, 2023 (1301 days ago).
What is a management decision? →During the process of identifying expenses and capital costs that were incurred to prevent, prepare for or respond to the coronavirus pandemic, management inadvertently claimed patient discounts. Cause: Due to the amount of detailed information that was required to be compiled by management in order to enter data into the PRF reporting portal, management inadvertently claimed patient discounts. Effect: Management included amounts in the PRF reporting portal which were not eligible based on the terms and conditions of the PRF distributions and subsequent HRSA guidance. Questioned Costs: Total questioned costs amounted to $244,866 and were calculated based off amounts related to patient discounts, but which were claimed as eligible expenses in the PRF reporting portal. Context: Certain costs were included on the PRF submission were not allowable under the PRF terms and conditions. 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 amounts expended.
Show full finding ▾Hide full finding ▴Finding No. 2021-002 Significant Deficiency Federal Program: Federal Financial Assistance Listing #93.498 US Department of Health and Human Services Provider Relief Fund Criteria: The terms and conditions of the CARES Act Provider Relief fund (PRF) distributions state that funds are to only be used to prevent, prepare for and respond to coronavirus, and that funds may only be used for healthcare related expenses or lost revenue that is attributable to the coronavirus. Subsequent guidance issued by the Health Resources and Services Administration (HRSA) states that recipients may use payments for eligible expenses incurred prior to the receipt of PRF distributions dating back to January 1, 2020, so long as they are to prevent, prepare for, and respond to coronavirus. Condition: During the process of identifying expenses and capital costs that were incurred to prevent, prepare for or respond to the coronavirus pandemic, management inadvertently claimed patient discounts. Cause: Due to the amount of detailed information that was required to be compiled by management in order to enter data into the PRF reporting portal, management inadvertently claimed patient discounts. Effect: Management included amounts in the PRF reporting portal which were not eligible based on the terms and conditions of the PRF distributions and subsequent HRSA guidance. Questioned Costs: Total questioned costs amounted to $244,866 and were calculated based off amounts related to patient discounts, but which were claimed as eligible expenses in the PRF reporting portal. Context: Certain costs were included on the PRF submission were not allowable under the PRF terms and conditions. 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 amounts expended.
Finding No. 2021-002 Criteria: The terms and conditions of the CARES Act Provider Relief fund (PRF) distributions state that funds are to only be used to prevent, prepare for and respond to coronavirus, and that funds may only be used for healthcare related expenses or lost revenue that is attributable to the coronavirus. Subsequent guidance issued by the Health Resources and Services Administration (HRSA) states that recipients may use payments for eligible expenses incurred prior to the receipt of PRF distributions dating back to January 1, 2020, so long as they are to prevent, prepare for, and respond to coronavirus. Condition: During the process of identifying expenses and capital costs that were incurred to prevent, prepare for or respond to the coronavirus pandemic, management inadvertently claimed patient discounts. Planned Corrective Action: Management will continue to refine processes to more diligently review expense to ensure only those costs exist and properly inputted in future reporting. However, the Hospital also incurred and reported sufficient lost revenue in the PRF reporting portal that if the noted expenses were not to be reported, the Hospital would have satisfactorily incurred eligible expenses and lost revenue in excess of the PRF funds received, including interest earned on such funds. Planned Completion Date: Ongoing Person Responsible: Lesley Delaney, CFO
The calculation of lost revenue was not in accordance with the terms of the award as patient revenue was not properly reconciled to the audited financial statements. Cause: Due to the amount of detailed information that was required to be compiled by management in order to enter data into the PRF reporting portal, amounts were not properly reconciled to the audited financial statements. Effect: Management?s calculation of lost revenue was not in accordance with the terms and conditions of the PRF distributions and subsequent HRSA guidance. Questioned Costs: Total questioned costs amounted to $487,907 and were determined based off a recalculation of lost revenue in accordance with the PRF guidance. Context: Management did not reconcile to the audited financial statements in its calculation of lost revenue. Recommendation: We recommend that management continue to monitor and enhance its internal controls over federal award compliance to ensure that federal award terms and conditions are properly being followed.
Show full finding ▾Hide full finding ▴Finding No. 2021-003 Significant Deficiency Federal Program: Federal Financial Assistance Listing #93.498 US Department of Health and Human Services Provider Relief Fund Criteria: The terms and conditions of the CARES Act Provider Relief fund (PRF) distributions state that funds are to only be used to prevent, prepare for and respond to coronavirus, and that funds may only be used for healthcare related expenses or lost revenue that is attributable to the coronavirus. The PRF guidance for calculations of lost revenue requires patient revenue to be reported net of all adjustments including bad debt expense and charity care. Condition: The calculation of lost revenue was not in accordance with the terms of the award as patient revenue was not properly reconciled to the audited financial statements. Cause: Due to the amount of detailed information that was required to be compiled by management in order to enter data into the PRF reporting portal, amounts were not properly reconciled to the audited financial statements. Effect: Management?s calculation of lost revenue was not in accordance with the terms and conditions of the PRF distributions and subsequent HRSA guidance. Questioned Costs: Total questioned costs amounted to $487,907 and were determined based off a recalculation of lost revenue in accordance with the PRF guidance. Context: Management did not reconcile to the audited financial statements in its calculation of lost revenue. Recommendation: We recommend that management continue to monitor and enhance its internal controls over federal award compliance to ensure that federal award terms and conditions are properly being followed.
Finding No. 2021-003 Criteria: The terms and conditions of the CARES Act Provider Relief fund (PRF) distributions state that funds are to only be used to prevent, prepare for and respond to coronavirus, and that funds may only be used for healthcare related expenses or lost revenue that is attributable to the coronavirus. The PRF guidance for calculations of lost revenue requires patient revenue to be reported net of all adjustments, including bad debt expense and charity care and amounts reimbursed by other sources. Condition: The calculation of lost revenue was not in accordance with the terms and conditions of the award, as patient revenue was not properly reduced by certain revenue adjustments and reimbursed amounts by other sources. Planned Corrective Action: Management will continue to refine processes to more diligently review lost revenue calculations to ensure such amounts are in accordance with the terms and conditions of the award. However, the Hospital also incurred and reported sufficient eligible expenses and lost revenue in the PRF reporting portal that if lost revenue had been properly calculated, the Hospital would have satisfactorily incurred eligible expenses and lost revenue in excess of the PRF funds received, including interest earned on such funds. Planned Completion Date: Ongoing Person Responsible: Lesley Delaney, CFO
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