EIN: 470379754
UEI: QBNXK4A795N7
Data as of August 24, 2026
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on September 28, 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 28, 2024 (880 days ago).
What is a management decision? →The Period 4 report submission applied $1,700,047 of ARPA distributions to expenditures, all of which were reported as expenditures incurred during Q1 2022. However, all of these expenditures were incurred in quarters Q1 2020 through Q4 2020. Cause: The Hospital interpreted Provider Relief Fund (PRF) reporting requirements in such a way that ARPA payments applied to expenditures did not need to be classified and reported by the quarterly period incurred. Effect: The Period 4 report submission reported $1,700,047 of ARPA payments as Q1 2022 expenses when all of the payments should have been reported in the Period 4 report in previous quarters. No findings were identified over the period of performance. Identification of Questioned Costs: None Repeat finding: Finding 2022-011 is not a repeat finding Recommendation: We recommend that the Hospital strengthen their system of internal controls around the review of HRSA guidance to ensure that all reporting is consistent with requirements and instructions as provided by regulatory agencies. View of Responsible Officials: Management agrees with the finding. Although reported in the incorrect quarter, the Hospital did incur expenses in excess of the amount of ARPA funds received. In addition, the Hospital also suffered lost revenues in excess of the ARPA funds received. Management will refine its review process of HRSA guidance and data entry into the portal to ensure appropriate designation between reporting periods.
Show full finding ▾Hide full finding ▴(3) Findings and Questioned Costs relating to Federal Awards Finding 2022-011 Compliance Requirement: Reporting Federal Agency: U.S. Department of Health and Human Services Federal Program: Covid-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution - AL No. 93.498 ALN Number: 93.498 Award Year: January 1, 2021 - December 31, 2021 Criteria: The reporting requirements for American Rescue Plan Act (ARPA) state that ARPA payments applied to expenditures should be reported by calendar year quarterly periods within the period of performance. Condition: The Period 4 report submission applied $1,700,047 of ARPA distributions to expenditures, all of which were reported as expenditures incurred during Q1 2022. However, all of these expenditures were incurred in quarters Q1 2020 through Q4 2020. Cause: The Hospital interpreted Provider Relief Fund (PRF) reporting requirements in such a way that ARPA payments applied to expenditures did not need to be classified and reported by the quarterly period incurred. Effect: The Period 4 report submission reported $1,700,047 of ARPA payments as Q1 2022 expenses when all of the payments should have been reported in the Period 4 report in previous quarters. No findings were identified over the period of performance. Identification of Questioned Costs: None Repeat finding: Finding 2022-011 is not a repeat finding Recommendation: We recommend that the Hospital strengthen their system of internal controls around the review of HRSA guidance to ensure that all reporting is consistent with requirements and instructions as provided by regulatory agencies. View of Responsible Officials: Management agrees with the finding. Although reported in the incorrect quarter, the Hospital did incur expenses in excess of the amount of ARPA funds received. In addition, the Hospital also suffered lost revenues in excess of the ARPA funds received. Management will refine its review process of HRSA guidance and data entry into the portal to ensure appropriate designation between reporting periods.
Finding 2022-001: Reporting Recommendation: The Hospital should strengthen their system of internal controls around the review of HRSA guidance to ensure that all reporting is consistent with requirements and instructions as provided by regulatory agencies. Views of Responsible Officials: Management agrees with the finding. Although reported in the incorrect quarter, the Hospital did incur expenses in excess of the amount of ARPA funds received. In addition, the Hospital also suffered lost revenues in excess of the ARPA funds received. Management will refine its review process of HRSA guidance and data entry into the portal to ensure appropriate designation between reporting periods. Children?s Hospital & Medical Center and Affiliates Corrective Action Plan: Management inadvertently reported expenses in the incorrect quarter of the Period 4 report submission. Although reported incorrectly, reported expenses were still above the total ARPA payments received. For future reporting, management will reinforce the reporting of activities in the proper quarter prior to submission. Completion Date: Completed Contact Person: Mindy Stetson 402-955-6765
FAC accepted this audit on September 29, 2022 — management decision was due March 29, 2023.
During the process of identifying expenses that were incurred to prevent, prepare for or respond to the coronorvirus pandemic, the Hospital included $661,131 of Other PRF Expenses that were reimbursed by other sources on the Period 2 report submission that covered the period June 30, 2020 through December 31, 2020. There were no Other PRF Expenses reported on the Period 1 report submission. Cause: The Hospital interpreted PRF reporting requirements in such a way that ?Other PRF Expenses? should include direct expenditures that were reimbursed through other funding sources. Effect: The Hospital applied expenses of $661,131 against PRF payments but had already been reimbursed by other funding sources. These expenses were not eligible to be applied to PRF payments based on the terms and conditions of the PRF distributions. Identification of Questioned Costs: Total known questioned costs for ALN 93.498 amounted to $661,181 and were calculated based off total ?Other PRF expenses? reported on the Period 2 report submission. Repeat finding: Finding 2021-001 is not a repeat finding Recommendation: We recommend that the Hospital ensure appropriate review of PRF portal reporting is conducted by a person familiar with the reporting requirements to ensure correct amounts are presented in the PRF portal. View of Responsible Officials: Management agrees with the noted finding. The Hospital, however, also incurred and reported significant lost revenues in the PRF reporting portal such that if the noted questioned costs had not been reported, the Hospital would have satisfactorily incurred lost revenues in excess of the PRF funds received. Management will continue to refine processes to more diligently review expenses to ensure that expenses are not being utilized for reimbursement from multiple sources.
Show full finding ▾Hide full finding ▴(3) Findings and Questioned Costs relating to Federal Awards Finding 2021 001 Compliance Requirement: Allowability Federal Agency: U.S. Department of Health and Human Services Federal Program: Provider Relief Fund ALN Number: 93.498 Award Year: January 1, 2020 ? December 31, 2020 Criteria: The terms and conditions of the CARES Act Provider Relief Fund (PRF) distributions state that funds are not to be used to reimburse expenses or losses that have 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 coronorvirus pandemic, the Hospital included $661,131 of Other PRF Expenses that were reimbursed by other sources on the Period 2 report submission that covered the period June 30, 2020 through December 31, 2020. There were no Other PRF Expenses reported on the Period 1 report submission. Cause: The Hospital interpreted PRF reporting requirements in such a way that ?Other PRF Expenses? should include direct expenditures that were reimbursed through other funding sources. Effect: The Hospital applied expenses of $661,131 against PRF payments but had already been reimbursed by other funding sources. These expenses were not eligible to be applied to PRF payments based on the terms and conditions of the PRF distributions. Identification of Questioned Costs: Total known questioned costs for ALN 93.498 amounted to $661,181 and were calculated based off total ?Other PRF expenses? reported on the Period 2 report submission. Repeat finding: Finding 2021-001 is not a repeat finding Recommendation: We recommend that the Hospital ensure appropriate review of PRF portal reporting is conducted by a person familiar with the reporting requirements to ensure correct amounts are presented in the PRF portal. View of Responsible Officials: Management agrees with the noted finding. The Hospital, however, also incurred and reported significant lost revenues in the PRF reporting portal such that if the noted questioned costs had not been reported, the Hospital would have satisfactorily incurred lost revenues in excess of the PRF funds received. Management will continue to refine processes to more diligently review expenses to ensure that expenses are not being utilized for reimbursement from multiple sources.
Finding 2021-001: Allowability Recommendation: The Hospital should ensure appropriate review of PRF portal reporting is conducted by a person familiar with the reporting requirements to ensure correct amounts are presented in the PRF portal. Views of Responsible Officials Management agrees with the noted finding. The Hospital, however, also incurred and reported significant lost revenues in the PRF reporting portal such that if the noted questioned costs had not been reported, the Hospital would have satisfactorily incurred lost revenues in excess of the PRF funds received. Management will continue to refine processes to more diligently review expenses to ensure that expenses are not being utilized for reimbursement from multiple sources. Children?s Hospital & Medical Center and Affiliates Corrective Action Plan: Management inadvertently reported expenses reimbursed from other sources in the Other PRF Expenses section of the Period 2 report submission. Although reported incorrectly, reported lost revenues were still above the total PRF payments, even after taking into account the expenses reported from other sources. For future reporting, management will reinforce the reporting of activities allowed or unallowed from other sources and ensure specific review prior to submission. Completion Date: Completed Contact Person: Mindy Stetson 402-955-6765
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