Adventist Health System Sunbelt Healthcare Corporation

Finding 2023-001 Identification of the Federal Program: Federal Grantor: United States Department of Health and Human Services and Department of Defense Assistance Listing No.: Various; Research and Development Cluster Period of Performance: January 1, 2023 – December 31, 2023 Criteria or Specific Requirement (Including Statutory, Regulatory or Other Citation): 2 CFR Section 200.303 of the Uniform Guidance states the following regarding internal control: “The Non-Federal entity must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States or the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). Condition: We noted the following matters during our testing of suspension and debarment control processes: (a) AdventHealth utilizes a third-party service provider to perform on-going monitoring and screening of its vendors and suppliers for suspension and debarment. AdventHealth relied on the results of the suspension and debarment checks performed by the third-party service provider without having a validation control to ensure the results provided by the third_x0002_party service provider were accurate. The third-party service provider does not have a SOC 1 (System and Organization Controls) Report. (b) AdventHealth does not receive a listing, from the third-party service provider, of all vendors and suppliers screened on a monthly basis. While AdventHealth does receive a listing of vendors and suppliers with a “match” or “potential match”, since the full listing of all vendors and suppliers screened was not available, it could not be determined whether all vendors and suppliers were appropriately screened by the third-party service provider. On an annual basis, AdventHealth did receive the full listing of all vendors and suppliers that were screened for suspension and debarment by the third-party service provider. However, a reconciliation between the vendor and supplier list provided by AdventHealth and the list that is received from the third-party service provider was not performed. Cause: AdventHealth did not add an additional validation control to ensure that the suspension and debarment checks performed by the third-party service provider aligned with the governmental suspension and debarment database when the search resulted in no match. In addition, AdventHealth did not have policies and procedures in place to require that documentation is retained to support the reconciliations performed between the vendor and supplier list sent to the third-party service provider and the results provided by the third-party service provider. Effect or Potential Effect: AdventHealth’s screening for suspension and debarment through the third-party service provider may not be accurate. By not performing a reconciliation between the vendor and supplier list in AdventHealth’s database and the results provided by the third-party service provider, there exists a risk that certain vendors and suppliers were not screened by the third-party service provider. Questioned costs: None Context: AdventHealth, as part of its internal control process, internally performs screening for all “new” vendors and suppliers prior to adding them in the database. We tested 40 new vendors that were added to the database in fiscal year 2023 and found no issues. As such, there exists a process to ensure that only valid and appropriately screened vendors and suppliers are contracted with. Since the issue relates to the on-going monitoring performed by the third-party service provider, for which appropriate controls were not put in place, this resulted in a deficiency in internal control process. The federal portion of expenditures subject to suspension and debarment was approximately $354,000, which represents approximately 5.5% of the total Research and Development Cluster federal expenditures. The total amount reported on the SEFA for R&D cluster is $6,392,558. Identification as a repeat finding, if applicable: Not a repeat finding Recommendation: Management should add controls to validate the accuracy of the suspension and debarment search results performed by the third-party service provider when the search results in no match. In addition, management should implement a process over the reconciliation of the vendor and supplier list to the third-party service provider list to ensure completeness of the suspension and debarment checks performed. Views of Responsible Officials: Management agrees with the finding. Management plans to add controls to validate the accuracy of the suspension and debarment search results performed by the third-party service provider when the search results in no match. In addition, management plans to implement a process over the reconciliation of the vendor and supplier list to the third-party service provider list to ensure completeness of the suspension and debarment checks performed.

Finding 2022-001 Identification of the federal program: Federal Grantor: United States Department of Health and Human Services, Health Resources and Services Administration (HRSA) Assistance Listing No.: 93.461, COVID-19 Testing for the Uninsured Program Criteria or specific requirement (including statutory, regulatory or other citation): 2 CFR Section 200.303 of the Uniform Guidance states the following regarding internal control: ?The Non-Federal entity must: a) Establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). Condition: Management did not perform sufficient procedures to ensure that patients did not have health care coverage at the time the services were rendered. Refunds required to be made to the COVID-19 Testing for the Uninsured Program were not identified timely. Management represented that it inquired of the patients for insurance coverage, if any, prior to providing the services. However, documentation was not retained to support these inquiries. In addition, there were no procedures performed to support that a reasonable effort beyond inquiry was performed by management to verify the uninsured status of the patients. Further, Management did not maintain sufficient documentation to support the effectiveness of internal controls in place to ensure balance billing was not performed. Cause: Management did not have sufficient internal controls in place to retain documentation of inquiries and other procedures performed to verify that patients were uninsured at the time services were provided. Internal controls over balance billing were not suitably designed to maintain supporting documentation to test the operating effectiveness of the internal controls. Internal controls were not suitably designed to identify refunds in a timely manner. Effect or potential effect: A patient may not be uninsured, and, therefore, the related encounter may be ineligible for reimbursement under the COVID-19 Testing for the Uninsured Program. Credit balances may not be resolved timely, and refunds to the COVID-19 Testing for the Uninsured Program may not be identified or completed in a timely manner. Questioned costs: None Context: Management performed an analysis of payments received from HRSA related to services provided from FY 2020 through the end of the program in March 2022 and identified approximately $2.3 million of claims that should not have been billed to HRSA. The $2.3 million was refunded to HRSA in 2023. Total HRSA payments on patient claims for FY 2022 was $9,837,735. The amounts on the schedule of expenditures of federal awards is adjusted by $205,839 which represents the amounts reflected on the SEFA pertaining to the refunds made towards the COVID-19 Testing for the Uninsured Program Identification as a repeat finding, if applicable: 2021-002 Recommendation: The COVID-19 Testing for the Uninsured Program ended in the second quarter of 2022 and therefore development of internal controls is not required. However, if the program were to continue, we recommend Management should enhance its internal controls to ensure that reasonable procedures are performed to verify the uninsured status of the patients and that it documents the inquiries and retains support for other procedures performed. In addition, Management should enhance its internal controls to ensure that any refunds to HRSA, are timely remitted. Finally, Management should also ensure supporting documentation is retained to support the operating effectiveness of internal controls over balance billing. Views of responsible officials: Management agrees with the finding. Our standard procedure is to verify insurance coverage for all patients. We believe in instances where documentation was not maintained to evidence that additional insurance verification procedures were performed in addition to the standard patient inquiry, such instances were a documentation error and not a process issue. Since the federal program has ended, no further action will be taken. Management has noted that in certain instances, patients identify themselves as uninsured but following their date of service, AdventHealth identified that the patient either had insurance coverage or was eligible for Medicaid. AdventHealth was not aware that the patient had insurance coverage and requested reimbursement from HRSA, prior to AdventHealth identifying insurance coverage. AdventHealth has processed a refund to HRSA in instances where reimbursement was received from another payer or another payer was available to provide reimbursement. Documentation was established effective September 30, 2022, to evidence the operating effectiveness of internal controls in place over balance billing.

Identification of the federal program: Federal Agency: U.S. Department of Health and Human Services (HHS) Health Resources and Services Administration (HRSA) Assistance Listing: 93.498 COVID-19 Provider Relief Fund (PRF) and American Rescue Plan (ARP) Rural Distribution Award Year: 2020-2021 Criteria or specific requirement (including statutory, regulatory or other citation): 2 CFR Section 200.303 of the Uniform Guidance states the following regarding internal control: ?The non-Federal entity must: (a)Establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).? Condition: For its controlled affiliates, who filed two of the 103 PRF reports during Period 1 and Period 2, management did not retain sufficient documentation over its review of the HHS HRSA reports filed in the HHS HRSA portal. While management had a process to identify and calculate the lost revenue under the PRF program, documentation to support the review of the data entered in the HHS HRSA portal by appropriate personnel was not retained. Cause: Management does not have internal controls in place at its controlled affiliates to require supporting documentation be retained to evidence the review and approval of the data in the HHS HRSA portal submission. Effect or potential effect: A lack of internal controls over the review of data submitted in the HHS HRSA portal could result in a misstatement of the amounts reported in the HHS HRSA portal. Questioned costs: $0 Context: AdventHealth and its controlled affiliate organization submitted a total of 103 reports within the HRSA portal during period 1 and period 2. The total PRF payments received by AdventHealth and its controlled affiliate was $601,481,458 of which the amount for the controlled affiliate was $61,713,218. We tested 18 HHS HRSA submissions that had total payments from HHS HRSA amounting to $379,544,996 of which the controlled affiliate payments were $61,713,218. For the submissions related to the controlled affiliate, management did not retain documentation to support the review and approval of the data entered in the HHS HRSA portal. Identification as a repeat finding, if applicable: Not applicable Recommendation: Management should enhance its internal controls to ensure that sufficient documentation over the review and approval of the data entered in the HHS HRSA portal prior to submission is maintained. Views of responsible officials: Management agrees with the finding. The lack of documentation to evidence the review and approval of the data submitted within the HHS HRSA portal was isolated to a controlled affiliate who was responsible for submitting two of the 103 reports under the period of this review. A review and approval process did occur but was not documented in a manner sufficient for internal control testing. Management has enhanced the internal control to require documentation to be maintained to evidence the review and approval of data submitted within the HHS HRSA portal.

Identification of the federal program: Federal Agency: U.S. Department of Health and Human Services (HHS) Health Resources and Services Administration (HRSA) Assistance Listing: COVID-19 HRSA COVID-19 Claims Reimbursement for the Uninsured Program and the COVID-19 Coverage Assistance Fund (Uninsured Program) Award Year: 2021 Criteria or specific requirement (including statutory, regulatory or other citation): 2 CFR Section 200.303 of the Uniform Guidance states the following regarding internal control: ?The non-Federal entity must: (a) Establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).? Health and Human Services (HHS) ? Health Resources and Services and Administrative (HRSA) issued Terms and Conditions for Participation in the HRSA COVID-19 Claims Reimbursement to Health Care Providers and Facilities for Testing, Treatment, and Vaccine Administration for the Uninsured Program (T&Cs) outlining requirements that recipients of funding from the HRSA COVID-19 Uninsured Program must comply with, including the following sections: Testing Services, Treatment Services and Vaccine Administration, and General Provisions in FY2020 Consolidated Appropriations. Per the HRSA T&Cs and further clarified in the HRSA FAQs for COVID-19 Claims Reimbursement to Health Care Providers and Facilities for Testing, Treatment and Vaccine Administration, the FAQ states the following: ?If a provider tests for COVID-19 as part of pre-operative or other medical treatment unrelated to COVID-19, is the test eligible for reimbursement? For the HRSA COVID-19 Uninsured Program, COVID-19 testing is eligible for reimbursement if one of the following diagnoses codes is included in any position on the claim: ? Z03.818 ? Encounter for observation for suspected exposure to other biological agents ruled out (possible exposure to COVID-19) ? Z11.59 ? Encounter for screening for other viral diseases (asymptomatic) ? Z20.828 ? Contact with and (suspected) exposure to other viral communicable (confirmed exposure to COVID-19) ? Z11.52 ? Encounter for screening for COVID-19 (asymptomatic) ? Z20.822 ? Contact with and (suspected) exposure to COVID-19 ? Z86.16 ? Personal history of COVID-19 Related treatment visits and services are not eligible for reimbursement given the primary reason for treatment is not COVID-19.? Per the HRSA T&Cs (for COVID-19 testing and testing-related items): ?FFCRA Uninsured Individuals means individuals who, as of the date of service for which Recipient seeks Payment, are not enrolled in? ? A Federal health care program (as defined under section 1128B(f) of the Social Security Act (42 U.S.C. 1320a-7b(f)), including an individual who is eligible for medical assistance only because of subsection (a)(10)(A)(ii)(XXIII) of Section 1902 of the Social Security Act; or ? A group health plan or health insurance coverage offered by a health insurance issuer in the group or individual market (as such terms are defined in section 2791 of the Public Health Service Act (42 U.S.C. 300gg-91)), or a health plan offered under chapter 89 of title 5, United States Code.? Per the HRSA T&Cs (for COVID-19 treatment): Uninsured individuals are ?individuals who do not have any health care coverage at the time the services were provided.? Condition: Based on our testing we noted Management did not perform sufficient procedures, at certain facilities, to ensure that patients did not have health care coverage at the time the services were rendered. Management represented that it inquired of the patients for insurance coverage, if any, prior to providing the services. However, documentation was not retained to support these inquiries. In addition, there were no procedures performed to support that a reasonable effort beyond inquiry was performed by management to verify the uninsured status of the patients. In addition, based on our testing, we noted the following: 1 For certain samples tested, adequate patient records were not available to support covered services were provided. 2 For certain samples where the Uninsured Program was billed and paid for the service, we noted the patient had either retroactive Medicaid coverage or other insurance available at the time services were provided. 3 We noted that AdventHealth did not maintain sufficient documentation to support the effectiveness of internal controls in place to ensure balance billing was not performed. Cause: Management did not have sufficient internal controls in place to retain documentation of inquiries and other procedures performed to verify that patients were uninsured at the time services were provided. Management did not have sufficient internal controls for certain patients over documenting and retaining support for the services provided to the patients in the patient files. Internal controls over balance billing were not suitably designed to maintain supporting documentation to test the operating effectiveness of the internal controls. Effect or potential effect: Lack of adequate internal controls could potentially result in claims submitted to HRSA for ineligible patients and balance billing being performed. Questioned costs: Total questioned costs related to the Uninsured Program total $1,212 and are comprised of the following: $91 ? Refund to HRSA not made when costs were reimbursed by other insurance. $735 ? Billing to HRSA when Medicaid or other insurance was available. $285 ? Patient timelines and documentation supporting the COVID related services were unavailable during testing. Context: We tested a total of 120 patient claims from three different billing systems used by AdventHealth. We noted the following exceptions and/or internal control matters: a. For 40 out of 40 patients processed at AdventHealth?s urgent care and testing locations, documentation supporting the procedures performed to ensure the uninsured status of the patient was not available. However, AdventHealth received a HRSA temporary I.D. for the patients. The total claim amount for these 40 samples totaled $2,389. b. For 7 out of the 40 samples tested from AdventHealth?s hospital locations, documentation supporting the procedures performed to ensure the uninsured status of the patient was not available. However, AdventHealth received a HRSA temporary I.D. for the patients. The total claim amount for these 7 samples totaled $633. Total claims tested totaled $5,978. c. For 3 out of the 40 samples tested from AdventHealth?s Physician practice locations, documentation supporting the procedures performed to ensure the uninsured status of the patient was not available. However, AdventHealth received a HRSA temporary I.D. for the patients. The total claim amount for these 3 samples totaled $72. Total claims tested totaled $4,226. d. For 2 out of the 40 samples tested from AdventHealth?s urgent care and testing locations, documentation supporting the account status to verify no other payments were received from other payors was not provided and as such we could not verify if balance billing occurred. The total claim amount for these 2 samples totaled $101. Total claims tested were $2,389. e. For 1 out of the 40 samples tested from AdventHealth?s urgent care and testing locations, evidence showing the refund to HRSA, when payments from other insurance was received, was not provided. The total claim amount for this 1 sample was $91.Total claims tested were $2,389. f. For 4 out of the 40 samples tested from the AdventHealth?s Physician practice locations, AdventHealth received reimbursement from HRSA when coverage from other insurance/Medicaid was available. The total claim amount for these 4 samples totaled $735. Total claims tested were $4,226. g. For 4 out of the 40 samples tested from AdventHealth?s Physician practice locations, documentation supporting that the services provided to the patients related to COVID/COVID related services were not provided. The total claim amount for these 4 samples totaled $285. Total claims tested were $4,226. The total HRSA payments on patient claims for FY 2021 was $66,551,091. Identification as a repeat finding, if applicable: Not applicable Recommendation: The Uninsured Program ended in the second quarter of 2022. If the program were to continue, Management should address the following recommendations. Management should enhance its internal controls to ensure that reasonable procedures are performed to verify the uninsured status of the patients and that it documents the inquiries and retains support for other procedures performed. In addition, Management should enhance its internal controls to ensure that any refunds to HRSA, are timely remitted. Finally, Management should also ensure supporting documentation is retained to support the operating effectiveness of internal controls over balance billing. Views of responsible officials: Management agrees with the finding. As it relates to this program, no further action will be taken regarding prospective documentation of patient uninsured status as the program has since ended. AdventHealth will continue to follow our standard practice for verifying patient insurance. Management will confirm that any refunds due to HRSA are remitted. Management will also retain supporting documentation to evidence the operating effectiveness of internal controls over balance billing.

Identification of the federal program: Federal Grantor: United States Department of the Treasury Assistance Listing No.: 21.019, COVID-19 Coronavirus Relief Fund (CRF) Pass-Through Award Numbers: Various Pass-Through Award Period of Performance: 03/01/2020?12/30/2020 Criteria or specific requirement (including statutory, regulatory or other citation): Section 200.303 of the Uniform Guidance states the following regarding internal control: ?The non-Federal entity must: (a) Establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).? Section 200.430 Compensation ? personal services of the Uniform Guidance states the following: ?(a) General. Compensation for personal services includes all remuneration, paid currently or accrued, for services of employees rendered during the period of performance under the Federal award, including but not necessarily limited to wages and salaries. Compensation for personal services may also include fringe benefits which are addressed in ? 200.431. Costs of compensation are allowable to the extent that they satisfy the specific requirements of this part, and that the total compensation for individual employees: (1) Is reasonable for the services rendered and conforms to the established written policy of the non-Federal entity consistently applied to both Federal and non-Federal activities; (2) Follows an appointment made in accordance with a non-Federal entity's laws and/or rules or written policies and meets the requirements of Federal statute, where applicable; and (3) Is determined and supported as provided in paragraph (i) of this section, when applicable.? Condition: As part of our testing of the operating effectiveness of internal controls over the activities allowed and allowable costs compliance requirement, we noted there was no evidence of review and approval of an employee?s time sheet if the manager did not certify the hours as the payroll still ran. Cause: AdventHealth did not follow its policies and procedures or internal controls in place that require the review and approval of the payroll charged to the federal program during the fiscal year. Effect or potential effect: AdventHealth could be reimbursed for unallowable costs; however, the results of our compliance testing did not result in any unallowable costs. Questioned costs: Not applicable. Context: Care Center Overland Park ? We selected 57 payroll transactions from a population of 240,497. We noted from our sample, there were 7 instances where approval was not evidenced. Hendersonville ? We selected 60 payroll transactions from a population of 2,137. We noted from our sample, there were 9 instances where approval was not evidenced. Identification as a repeat finding, if applicable: The finding is not a repeat finding. Recommendation: AdventHealth should reinforce the importance of adherence to policies and procedures and internal controls over payroll. Evidence of review and approval, including elements of the review process validated by the reviewer, and related underlying support for the calculation should be maintained. Views of responsible officials: AdventHealth agrees with the finding and has developed a plan to correct the finding.

Identification of the federal program: Federal Grantor: United States Department of the Treasury Assistance Listing No.: 21.019, COVID-19 Coronavirus Relief Fund (CRF) Pass-Through Award Numbers: Various Pass-Through Award Period of Performance: 03/01/2020?12/30/2020 Criteria or specific requirement (including statutory, regulatory or other citation): Section 200.303 of the Uniform Guidance states the following regarding internal control: ?The non-Federal entity must: (a) Establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).? Section 200.403 of the Uniform Guidance states, ?Factors affecting allowability of costs. Except where otherwise authorized by statute, costs must meet the following general criteria in order to be allowable under Federal awards: (g) Be adequately documented.? Condition: We noted there was a lack of evidence of approvals over purchases less than $2,500 Cause: Management did not retain sufficient supporting documentation to provide evidence that review over purchases less than $2,500 for this major program were designed effectively and placed in operation during the period under audit. Effect or potential effect: AdventHealth could be reimbursed for unallowable costs; however, the results of our compliance testing did not result in any unallowable costs. Questioned costs: Not applicable. Context: We selected 61 purchases from a total of 204. From our sample, there were 19 instances where approval was not evidenced. Identification as a repeat finding, if applicable: The finding is not a repeat finding. Recommendation: AdventHealth should formalize the review and approval process over purchases less than $2,500 that relate to federal expenditures. Evidence of review and approval, including elements of the review process validated by the reviewer, and adequate supporting documents should be maintained. Views of responsible officials: AdventHealth agrees with the finding and has developed a plan to correct the finding.

Identification of the federal program: Federal Grantor: United States Department of the Treasury Assistance Listing No.: 21.019, COVID-19 Coronavirus Relief Fund (CRF) Pass-Through Award Numbers: Various Pass-Through Award Period of Performance: 03/01/2020?12/30/2020 Criteria or specific requirement (including statutory, regulatory or other citation): Section 200.303 of the Uniform Guidance states the following regarding internal control: ?The non-Federal entity must: (a) Establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).? The Coronavirus Relief Fund agreement states the following ?The HOSPITAL separately represents and warrants that it will not claim reimbursement under this Agreement for expenditures 1) for which the HOSPITAL previously received reimbursement from another source of funds including, but not limited to, other federal programs; or 2) for which the HOSPITAL has a reimbursement request pending before another source of funds including, but not limited to, other federal programs. In the event the HOSPITAL determines either of the conditions above apply to a reimbursement request that is pending or has been paid under this Agreement, it shall immediately provide notice to the COUNTY and withdraw its request or repay such funds provided hereunder, as applicable.? Condition: AdventHealth did not reduce expenditures claimed for reimbursement by income received from other sources. Cause: As this was a new program, management was not aware of the need to reduce expenditures claimed for reimbursement by certain sources of income. Effect or potential effect: AdventHealth could be reimbursed for more than the amount that they are entitled to. Questioned costs: Lake Wales ? We noted there were 6 instances where certain income sources were not reduced from the amounts claimed for reimbursement which totaled $130,335. Heart of Florida ? We noted there were 5 instances where certain income sources were not reduced from the amounts claimed for reimbursement which totaled $112,199. Context: Lake Wales ? We selected 19 purchases for a total of $429,847 from a total population of 40 items and $528,831. Heart of Florida ? We selected 29 purchases for a total of $238,010 from a total population of 74 items and $335,095. Identification as a repeat finding, if applicable: The finding is not a repeat finding. Recommendation: AdventHealth should reduce expenditures claimed for reimbursement by income received from other sources. Views of responsible officials: AdventHealth agrees with the finding and has developed a plan to correct the finding.

Identification of the federal program: Federal Grantor: United States Department of Health and Human Services, Health Resources and Services Administration (HRSA) Assistance Listing No.: 93.461, COVID-19 Testing for the Uninsured Pass-Through Award Numbers: Not applicable Pass-Through Award Period of Performance: 02/04/2020?12/31/2020 Criteria or specific requirement (including statutory, regulatory or other citation): Section 200.303 of the Uniform Guidance states the following regarding internal control: ?The non-Federal entity must: (a) Establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).? Section 200.502 of the Uniform Guidance states the following regarding the financial statements: ?(b) Schedule of expenditures of Federal awards. The auditee must also prepare a schedule of expenditures of Federal awards for the period covered by the auditee's financial statements which must include the total Federal awards expended as determined in accordance with 200.502.? Condition: AdventHealth was unable to determine the complete program expenditures to include on the schedule of expenditures of Federal awards. Cause: The AdventHealth billing department did not consistently code the payments related to the program to the appropriate payor class. Effect or potential effect: AdventHealth was unable to determine the the complete program expenditures to include on the schedule of expenditures of Federal awards. Questioned costs: The potential questioned costs are the difference between the amounts reported on the schedule of Federal awards of $20,390,175 up to the total of payments provided by AdventHealth of $23,454,775. Context: We selected 40 expenditures for a total of $29,414 from the total payments of $23,454,775. We determined that there were 10 selections for a total of $911 that were inappropriately excluded from the schedule of Federal awards for the program Identification as a repeat finding, if applicable: The finding is not a repeat finding. Recommendation: AdventHealth should ensure billing department personnel are appropriately coding the payments related to the program to the proper payor class, including sufficient review. Views of responsible officials: AdventHealth agrees with the finding and has developed a plan to correct the finding.

Identification of the federal program: Federal Grantor: United States Department of Health and Human Services Assistance Listing No.: 93.889, COVID-19 National Bioterrorism Hospital Preparedness Program Pass-Through Award Numbers: Not applicable Pass-Through Award Period of Performance: 04/10/2020?04/09/2025 Criteria or specific requirement (including statutory, regulatory or other citation): Section 200.303 of the Uniform Guidance states the following regarding internal control: ?The non-Federal entity must: (a) Establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).? Section 200.320 Methods of procurement to be followed states the following: ?The non-Federal entity must have and use documented procurement procedures, consistent with the standards of this section and ?? 200.317, 200.318, and 200.319" regarding the methods of procurement used for the acquisition of property or services required under a Federal award or sub-award. Condition: As part of our testing of the operating effectiveness of internal controls over the Procurement and Suspension and Debarment, we noted AdventHealth did not have entity-wide procurement policies that conform to the Uniform Guidance for purchases made with Federal funds. Cause: AdventHealth did not update its procurement policies to include those provisions required by the Uniform Guidance upon receiving such federal awards. Effect or potential effect: Purchases could be made with federal funds that are not in accordance with the Uniform Guidance. However, the results of our compliance testing did not result in any purchases that were not in accordance with Uniform Guidance purchasing provisions. Questioned costs: Not applicable. Context: We selected 49 purchases from a total of 142 purchases and noted no exceptions to the Uniform Guidance purchasing provisions. Identification as a repeat finding, if applicable: The finding is not a repeat finding. Recommendation: AdventHealth should update its procurement policies to include those provisions required by the Uniform Guidance when making purchases with federal funds. Views of responsible officials: AdventHealth agrees with the finding and has developed a plan to correct the finding.

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