EIN: 470378779
UEI: F3VJDNCLM813
Data as of August 19, 2026
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on September 4, 2023. 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 4, 2024, which was (899 days ago).
What is a management decision? →Criteria: 2 CFR 200.303(a) establishes that the auditee must establish and maintain effective internal control over the federal award that provides assurance that the entity is managing the federal award in compliance with federal statutes, regulations, and conditions of the federal award. Condition: The Hospital inadvertently miskeyed a number when reporting ?2022 actuals (calendar year)? patient care revenue within the Period 4 Department of Health and Human Services report submission process. Cause: The Hospital did not have an internal control process in place to ensure the reporting portal input field for the revenue was correct. Effect: The amount of ?2022 actuals (calendar year)? patient care revenue reported by the Hospital was $200,434,563 instead of $207,434,563. Questioned Costs: None reported. The Hospital used expenses to justify amounts received under the Provider Relief Fund and ARP for period 4 and did not utilize lost revenue. The amount reported by the Hospital for ?2022 actuals (calendar year)? patient care revenue was for informational purposes only and had no impact on the amount of funds earned by the Hospital. Context: Key line items were tested on the Period 4 Department of Health and Human Services report. The amount of ?2022 actuals (calendar year)? patient care revenue reported by the Hospital was $200,434,563 instead of $207,434,563. Recommendation: We recommend that management continue to monitor and enhance its internal controls over federal award compliance to ensure proper reporting of revenue. Views of Responsible Officials: Management agrees with the noted finding.
Criteria: 2 CFR 200.303(a) establishes that the auditee must establish and maintain effective internal control over the federal award that provides assurance that the entity is managing the federal award in compliance with federal statutes, regulations, and conditions of the federal award. Condition: The Hospital inadvertently miskeyed a number when reporting ?2022 actuals (calendar year)? patient care revenue within the Period 4 Department of Health and Human Services report submission process. Previous Response for Finding: Management agrees with the noted finding. Corrective Action: Management will continue to monitor and enhance its internal controls over federal award compliance to ensure proper reporting of revenue. Planned Completion Date: Ongoing Person Responsible: Shawn Nordby, CFO
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on June 2, 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 December 2, 2022, which was (1357 days ago).
What is a management decision? →Criteria or Specific Requirement: 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 Health Resources and Services Administration (HRSA) provided guidance on how an organization was to report usage of PRF distributions received. Period 1 reporting required an organization to illustrate how PRF received between April 10 through June 30, 2020 was used. An organization was allowed to include eligible expenditures from January 1, 2020 through June 30, 2021. Condition: During the process of identifying expenses that were incurred to prevent, prepare for or respond to the coronavirus pandemic, management included insurance premiums where a portion thereof covered several months subsequent to June 30, 2021. 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 included in eligible expenses a portion of insurance premiums that covered several months subsequent to June 30, 2021. Effect or Potential 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 related to Federal Assistance Listing Number 93.498 amounted to $80,750 and were calculated based on the portion of the insurance premiums that were to be amortized to expense subsequent to June 30, 2021. Context: HRSA guidance for Period 1 reporting indicated expenditures were to be for the period of January 1, 2020 through June 30, 2021. Total insurance premiums paid were $413,921, of which $80,750 was related to months subsequent to June 30, 2021. 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 reporting periods defined by HRSA. Views of Responsible Officials and Planned Corrective Action: Management agrees with the noted finding. However, the Hospital also incurred and reported unreimbursed expenses attributable to coronavirus of $5,421,539 which could be used to replace the identified questioned costs. Management will continue to refine its processes to more diligently review expenditures to ensure only those costs incurred during the eligibility period are included in future reporting.
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 Health Resources and Services Administration (HRSA) provided guidance on how an organization was to report usage of PRF distributions received. Period 1 reporting required an organization to illustrate how PRF received between April 10 through June 30, 2020 was used. An organization was allowed to include eligible expenditures from January 1, 2020 through June 30, 2021. Condition: During the process of identifying expenses that were incurred to prevent, prepare for or respond to the coronavirus pandemic, management included insurance premiums where a portion thereof covered several months subsequent to June 30, 2021. Planned Corrective Action: Management will continue to refine processes to more diligently review reporting requirements and the accumulation of eligible expenditures, per the terms and conditions of the PRF and reporting guidance provided by HRSA. However, the Hospital also incurred and reported sufficient unreimbursed expenditures attributable to coronavirus in the PRF reporting portal that if the noted item were not to be reported, the Hospital would have satisfactorily incurred eligible expenses in excess of the PRF funds received, including interest earned on such funds. Planned Completion Date: Ongoing Person Responsible: Shawn Nordby, CFO
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 terms and conditions also requires the recipient to only use PRF distributions to reimburse expenditures that have not been reimbursed from other sources or that other sources are obligated to reimburse. Condition: During the process of identifying expenses that were incurred to prevent, prepare for or respond to the coronavirus pandemic, management included hazard pay to employees that had been claimed for another grant. 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 included in eligible expenses hazard pay to employees that had been claimed for another grant. Effect: Management included amounts in the PRF reporting portal which were not eligible based on the terms and conditions of the PRF distributions. Questioned Costs: Total questioned costs related to Federal Assistance Listing Number 93.498 amounted to $656,640 and was compiled from support of total hazard pay and benefits that totaled $1,095,215. Context: The terms and conditions of the PRF requires the recipient to exclude expenditures that have been reimbursed by other sources. Management did report the $656,640 as other assistance received then inadvertently included the associated expenditures as an eligible use of PRF distributions. 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. Views of Responsible Officials: Management agrees with the noted finding. However, the Hospital also incurred and reported unreimbursed expenses attributable to coronavirus of $5,421,539 which could be used to replace the identified questioned costs. Management will continue to refine its processes to more diligently review expenditures to ensure only those costs incurred and not reimbursed by other sources are included in future reporting.
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 terms and conditions also requires the recipient to only use PRF distributions to reimburse expenditures that have not been reimbursed from other sources or that other sources are obligated to reimburse. Condition: During the process of identifying expenses that were incurred to prevent, prepare for or respond to the coronavirus pandemic, management included hazard pay to employees that had been claimed for another grant. Planned Corrective Action: Management will continue to refine processes to more diligently review reporting requirements and the accumulation of eligible expenditures, per the terms and conditions of the PRF and reporting guidance provided by HRSA is followed. However, the Hospital also incurred and reported sufficient unreimbursed expenditures attributable to coronavirus in the PRF reporting portal that if the noted item were not to be reported, the Hospital would have satisfactorily incurred eligible expenses in excess of the PRF funds received, including interest earned on such funds. Planned Completion Date: Ongoing Person Responsible: Shawn Nordby, CFO
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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