EIN: 476000874
UEI: LLVQKMKLZQX1
Data as of August 22, 2026
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on August 9, 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 9, 2023 (1290 days ago).
What is a management decision? →During the process of identifying expenses that were incurred to prevent, prepare for or respond to the coronavirus pandemic, management included costs that were also reimbursed by other sources. 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 certain costs that were also reimbursed by other sources. 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 Financial Assistance Listing/CFDA #93.498 amounted to $84,656 and were calculated based off the underlying general ledger detail used by management to gather expenses to report in the PRF portal. Context: The PRF and HRSA guidance states that costs cannot be used to reimburse expenses or losses that have been or are obligated to be reimbursed by other sources. Certain supply and capital asset expenses were identified as being reimbursed by other sources included in the PRF reporting portal. 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 and that the same expenses are not used for multiple grant awards.
Show full finding ▾Hide full finding ▴Finding No. 2021-002 Federal Program: Federal Financial Assistance Listing/CFDA #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 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 coronavirus pandemic, management included costs that were also reimbursed by other sources. 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 certain costs that were also reimbursed by other sources. 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 Financial Assistance Listing/CFDA #93.498 amounted to $84,656 and were calculated based off the underlying general ledger detail used by management to gather expenses to report in the PRF portal. Context: The PRF and HRSA guidance states that costs cannot be used to reimburse expenses or losses that have been or are obligated to be reimbursed by other sources. Certain supply and capital asset expenses were identified as being reimbursed by other sources included in the PRF reporting portal. 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 and that the same expenses are not used for multiple grant awards.
Finding No. 2021-002 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 coronavirus pandemic, management included costs that were also reimbursed by other sources. Planned Corrective Action: Management will continue to refine processes to more diligently review expenses to ensure double dipping is excluded in future reporting. However, the Hospital also incurred and reported significant unreimbursed expenses in the PRF reporting portal that if the noted questioned costs had not been 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: Reba Burgett, Chief Financial Officer
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