EIN: 593051173
UEI: MVVFA4FW3CL4
Audited by: Draffin & Tucker, LLP
Oversight agency: 14 [Department of Housing and Urban Development]
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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 March 30, 2026. 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 September 30, 2026 (26 days from today).
What is a management decision? →FAC accepted this audit on November 12, 2024 — management decision was due May 12, 2025.
The Hospital did not have a separate USDA reserve bank account in place. Criteria: The Hospital is responsible for creating a separate USDA reserve bank account and required to submit an annual deposit equivalent to ten percent of the amount needed to pay the annual installment of principal and interest on the note. Cause: These deposits are required to be submitted, as specified in the applicable loan agreement, however, management did not make the annual deposits nor was there a process in place to ensure timely deposits. Context: The bank statement was never specifically requested throughout the year by the Hospital’s USDA representative, nor was the Hospital notified of its tardy submission at any point during the fiscal year. Effect and questioned costs: The Hospital did not create a loan reserve account of approximately $76,059 as laid out in the respective loan agreement for its reporting requirements. Recommendation: We recommend the Hospital should continue to improve its understanding of the reporting requirements as specified in the applicable loan document and create a process to ensure all USDA requirements are met. Views of Responsible Officials and Planned Corrective Actions: The Hospital agrees with this finding. See management’s corrective action plan.
Show full finding ▾Hide full finding ▴2023-003 – Material Weakness - Noncompliance Federal agency: U.S. Department of Agriculture (USDA): Rural Development Federal program title: Community Facilities Loans and Grants Assistance Listing No.: 10.766 Condition: The Hospital did not have a separate USDA reserve bank account in place. Criteria: The Hospital is responsible for creating a separate USDA reserve bank account and required to submit an annual deposit equivalent to ten percent of the amount needed to pay the annual installment of principal and interest on the note. Cause: These deposits are required to be submitted, as specified in the applicable loan agreement, however, management did not make the annual deposits nor was there a process in place to ensure timely deposits. Context: The bank statement was never specifically requested throughout the year by the Hospital’s USDA representative, nor was the Hospital notified of its tardy submission at any point during the fiscal year. Effect and questioned costs: The Hospital did not create a loan reserve account of approximately $76,059 as laid out in the respective loan agreement for its reporting requirements. Recommendation: We recommend the Hospital should continue to improve its understanding of the reporting requirements as specified in the applicable loan document and create a process to ensure all USDA requirements are met. Views of Responsible Officials and Planned Corrective Actions: The Hospital agrees with this finding. See management’s corrective action plan.
Calhoun-Liberty Hospital Association, Inc., D/B/A Calhoun-Liberty Hopsital, (Hospital), respectfully submits the following corrective action plan for the year ended December 31, 2023. The finding from the December 31, 2023, Schedule of Findings and Questioned Costs is discussed below. The finding is numbered consistently with the numbers assigned in the schedule. FEDERAL AWARD PROGRAMS AUDIT FINDING Significant Deficiency - Noncompliance (2023-003) Recommendation: The Hospital should continue to improve its understanding of the reporting requirements as specified in the applicable loan document and create a process to ensure all USDA requirements are met. Planned Corrective Action: As of September 30, 2024, the Hospital will open a bank account with the Hospital's current banking relationship. This account will be a restricted account dedicated to holding the required reserve as described in the existing USDA loan documents. The required reserve balance will be recorded on the Hospital's trial balance. The reconciliation for such balance will be provided upon request. Emily Brown Chief Executive Officer
FAC accepted this audit on November 18, 2023 — management decision was due May 18, 2024.
The Hospital elected to report Period 4 lost revenues utilizing Option 3, the alternative method of calculating lost revenues attributable to coronavirus. The Hospital’s alternative method did not consider the impact of Medicaid supplemental payments recognized to revenue for 2022 Quarter 1. Cause: The established internal controls did not consider the appropriate grouping of Medicaid supplemental payments when calculating Total Revenue/Net Charges from Patient Care. Effect: The lack of adequate policies governing report preparation and submission increases the risk that the report could be filed incorrectly. Questioned Costs: 2022 Quarter 1 Lost Revenue was overstated by $425,207. However, the Hospital’s Period 4 portal submission reflects $1,988,424 of remaining unused lost revenues that management believes could offset the identified questioned costs. Recommendation: We recommend the Hospital continue to design and implement controls, including levels of review, to ensure reporting is prepared using accurate financial information and in accordance with reporting requirements. Views of Responsible Officials of the Auditee: The Hospital agrees with this finding. See management’s corrective action plan.
Show full finding ▾Hide full finding ▴Criteria: Provider Relief Funds were provided under the Coronavirus Aid, Relief, and Economic Security Act and are to be used to prevent, prepare for, and respond to coronavirus. Recipients are required to establish and maintain effective internal control over the federal award and to report use of funds to HHS through the Health Resources and Services Administration (HRSA) Reporting Portal. The reporting is to be prepared using accurate financial information and be in accordance with reporting requirements. Condition: The Hospital elected to report Period 4 lost revenues utilizing Option 3, the alternative method of calculating lost revenues attributable to coronavirus. The Hospital’s alternative method did not consider the impact of Medicaid supplemental payments recognized to revenue for 2022 Quarter 1. Cause: The established internal controls did not consider the appropriate grouping of Medicaid supplemental payments when calculating Total Revenue/Net Charges from Patient Care. Effect: The lack of adequate policies governing report preparation and submission increases the risk that the report could be filed incorrectly. Questioned Costs: 2022 Quarter 1 Lost Revenue was overstated by $425,207. However, the Hospital’s Period 4 portal submission reflects $1,988,424 of remaining unused lost revenues that management believes could offset the identified questioned costs. Recommendation: We recommend the Hospital continue to design and implement controls, including levels of review, to ensure reporting is prepared using accurate financial information and in accordance with reporting requirements. Views of Responsible Officials of the Auditee: The Hospital agrees with this finding. See management’s corrective action plan.
FEDERAL AWARD PROGRAMS AUDIT FINDING Material Weakness in Internal Control over Compliance Finding (2022-003) Recommendation: We recommend the Association continue to design and implement controls, including levels of review, to ensure reporting is prepared using accurate financial information and in accordance with reporting requirements. Planned Corrective Action: The Association will ensure the appropriate grouping of Medicaid supplemental payments when calculating Total Revenue/Net Charges from patient care. One of the supplemental payments is related to the hospital's eligibility to receive the associated payment under the Medicaid Rural Disproportionate Share Hospital (ROSH) Program or the Rural Financial Assistance Program (RFAP). The RFAP is based upon a fixed sum of money. Therefore, the annual RFAP distribution received by a hospital represents an amount proportional to the hospital's contribution for providing indigent and Medicaid care as compared to all other RFAP eligible rural hospitals and is calculated in accordance with Florida statute. In addition, the Directed Payment Program (OPP}, as approved by the Florida legislature in 2021, provides funding for hospitals that provide inpatient and outpatient services to Medicaid managed care enrollees. This program is intended to address the shortfall to hospitals by collecting Intergovernmental Transfers (IGTs) and Local Provider assessments (LP) to draw down Federal Medicaid Matching dollars.
The Hospital elected to report Period 4 lost revenues utilizing Option 3, the alternative method of calculating lost revenues attributable to coronavirus. The Hospital’s alternative method did not consider the impact of Medicaid supplemental payments recognized to revenue for 2022 Quarter 1. Cause: The established internal controls did not consider the appropriate grouping of Medicaid supplemental payments when calculating Total Revenue/Net Charges from Patient Care. Effect: The lack of adequate policies governing report preparation and submission increases the risk that the report could be filed incorrectly. Questioned Costs: 2022 Quarter 1 Lost Revenue was overstated by $425,207. However, the Hospital’s Period 4 portal submission reflects $1,988,424 of remaining unused lost revenues that management believes could offset the identified questioned costs. Recommendation: We recommend the Hospital continue to design and implement controls, including levels of review, to ensure reporting is prepared using accurate financial information and in accordance with reporting requirements. Views of Responsible Officials of the Auditee: The Hospital agrees with this finding. See management’s corrective action plan.
Show full finding ▾Hide full finding ▴2022-003 - Material Weakness in Internal Control over Compliance Finding Federal agency: U.S. Department of Health and Human Services (HHS) Federal program title: COVID-19 Provider Relief Fund (PRF) - Period 4 Assistance Listing No.: 93.498 Criteria: Provider Relief Funds were provided under the Coronavirus Aid, Relief, and Economic Security Act and are to be used to prevent, prepare for, and respond to coronavirus. Recipients are required to establish and maintain effective internal control over the federal award and to report use of funds to HHS through the Health Resources and Services Administration (HRSA) Reporting Portal. The reporting is to be prepared using accurate financial information and be in accordance with reporting requirements. Condition: The Hospital elected to report Period 4 lost revenues utilizing Option 3, the alternative method of calculating lost revenues attributable to coronavirus. The Hospital’s alternative method did not consider the impact of Medicaid supplemental payments recognized to revenue for 2022 Quarter 1. Cause: The established internal controls did not consider the appropriate grouping of Medicaid supplemental payments when calculating Total Revenue/Net Charges from Patient Care. Effect: The lack of adequate policies governing report preparation and submission increases the risk that the report could be filed incorrectly. Questioned Costs: 2022 Quarter 1 Lost Revenue was overstated by $425,207. However, the Hospital’s Period 4 portal submission reflects $1,988,424 of remaining unused lost revenues that management believes could offset the identified questioned costs. Recommendation: We recommend the Hospital continue to design and implement controls, including levels of review, to ensure reporting is prepared using accurate financial information and in accordance with reporting requirements. Views of Responsible Officials of the Auditee: The Hospital agrees with this finding. See management’s corrective action plan.
FEDERAL AWARD PROGRAMS AUDIT FINDING Material Weakness in Internal Control over Compliance Finding (2022-003) Recommendation: We recommend the Association continue to design and implement controls, including levels of review, to ensure reporting is prepared using accurate financial information and in accordance with reporting requirements. Planned Corrective Action: The Association will ensure the appropriate grouping of Medicaid supplemental payments when calculating Total Revenue/Net Charges from patient care. One of the supplemental payments is related to the hospital's eligibility to receive the associated payment under the Medicaid Rural Disproportionate Share Hospital (ROSH) Program or the Rural Financial Assistance Program (RFAP). The RFAP is based upon a fixed sum of money. Therefore, the annual RFAP distribution received by a hospital represents an amount proportional to the hospital's contribution for providing indigent and Medicaid care as compared to all other RFAP eligible rural hospitals and is calculated in accordance with Florida statute. In addition, the Directed Payment Program (OPP}, as approved by the Florida legislature in 2021, provides funding for hospitals that provide inpatient and outpatient services to Medicaid managed care enrollees. This program is intended to address the shortfall to hospitals by collecting Intergovernmental Transfers (IGTs) and Local Provider assessments (LP) to draw down Federal Medicaid Matching dollars.
FAC accepted this audit on February 22, 2024 — management decision was due August 22, 2024.
The Hospital elected to report Period 4 lost revenues utilizing Option 3, the alternative method of calculating lost revenues attributable to coronavirus. The Hospital’s alternative method did not consider the impact of Medicaid supplemental payments recognized to revenue for 2022 Quarter 1. Cause: The established internal controls did not consider the appropriate grouping of Medicaid supplemental payments when calculating Total Revenue/Net Charges from Patient Care. Effect: The lack of adequate policies governing report preparation and submission increases the risk that the report could be filed incorrectly. Questioned Costs: 2022 Quarter 1 Lost Revenue was overstated by $425,207. However, the Hospital’s Period 4 portal submission reflects $1,988,424 of remaining unused lost revenues that management believes could offset the identified questioned costs. Recommendation: We recommend the Hospital continue to design and implement controls, including levels of review, to ensure reporting is prepared using accurate financial information and in accordance with reporting requirements. Views of Responsible Officials of the Auditee: The Hospital agrees with this finding. See management’s corrective action plan.
Show full finding ▾Hide full finding ▴Criteria: Provider Relief Funds were provided under the Coronavirus Aid, Relief, and Economic Security Act and are to be used to prevent, prepare for, and respond to coronavirus. Recipients are required to establish and maintain effective internal control over the federal award and to report use of funds to HHS through the Health Resources and Services Administration (HRSA) Reporting Portal. The reporting is to be prepared using accurate financial information and be in accordance with reporting requirements. Condition: The Hospital elected to report Period 4 lost revenues utilizing Option 3, the alternative method of calculating lost revenues attributable to coronavirus. The Hospital’s alternative method did not consider the impact of Medicaid supplemental payments recognized to revenue for 2022 Quarter 1. Cause: The established internal controls did not consider the appropriate grouping of Medicaid supplemental payments when calculating Total Revenue/Net Charges from Patient Care. Effect: The lack of adequate policies governing report preparation and submission increases the risk that the report could be filed incorrectly. Questioned Costs: 2022 Quarter 1 Lost Revenue was overstated by $425,207. However, the Hospital’s Period 4 portal submission reflects $1,988,424 of remaining unused lost revenues that management believes could offset the identified questioned costs. Recommendation: We recommend the Hospital continue to design and implement controls, including levels of review, to ensure reporting is prepared using accurate financial information and in accordance with reporting requirements. Views of Responsible Officials of the Auditee: The Hospital agrees with this finding. See management’s corrective action plan.
FEDERAL AWARD PROGRAMS AUDIT FINDING Material Weakness in Internal Control over Compliance Finding (2022-003) Recommendation: We recommend the Association continue to design and implement controls, including levels of review, to ensure reporting is prepared using accurate financial information and in accordance with reporting requirements. Planned Corrective Action: The Association will ensure the appropriate grouping of Medicaid supplemental payments when calculating Total Revenue/Net Charges from patient care. One of the supplemental payments is related to the hospital's eligibility to receive the associated payment under the Medicaid Rural Disproportionate Share Hospital (ROSH) Program or the Rural Financial Assistance Program (RFAP). The RFAP is based upon a fixed sum of money. Therefore, the annual RFAP distribution received by a hospital represents an amount proportional to the hospital's contribution for providing indigent and Medicaid care as compared to all other RFAP eligible rural hospitals and is calculated in accordance with Florida statute. In addition, the Directed Payment Program (OPP}, as approved by the Florida legislature in 2021, provides funding for hospitals that provide inpatient and outpatient services to Medicaid managed care enrollees. This program is intended to address the shortfall to hospitals by collecting Intergovernmental Transfers (IGTs) and Local Provider assessments (LP) to draw down Federal Medicaid Matching dollars.
The Hospital elected to report Period 4 lost revenues utilizing Option 3, the alternative method of calculating lost revenues attributable to coronavirus. The Hospital’s alternative method did not consider the impact of Medicaid supplemental payments recognized to revenue for 2022 Quarter 1. Cause: The established internal controls did not consider the appropriate grouping of Medicaid supplemental payments when calculating Total Revenue/Net Charges from Patient Care. Effect: The lack of adequate policies governing report preparation and submission increases the risk that the report could be filed incorrectly. Questioned Costs: 2022 Quarter 1 Lost Revenue was overstated by $425,207. However, the Hospital’s Period 4 portal submission reflects $1,988,424 of remaining unused lost revenues that management believes could offset the identified questioned costs. Recommendation: We recommend the Hospital continue to design and implement controls, including levels of review, to ensure reporting is prepared using accurate financial information and in accordance with reporting requirements. Views of Responsible Officials of the Auditee: The Hospital agrees with this finding. See management’s corrective action plan.
Show full finding ▾Hide full finding ▴2022-003 - Material Weakness in Internal Control over Compliance Finding Federal agency: U.S. Department of Health and Human Services (HHS) Federal program title: COVID-19 Provider Relief Fund (PRF) - Period 4 Assistance Listing No.: 93.498 Criteria: Provider Relief Funds were provided under the Coronavirus Aid, Relief, and Economic Security Act and are to be used to prevent, prepare for, and respond to coronavirus. Recipients are required to establish and maintain effective internal control over the federal award and to report use of funds to HHS through the Health Resources and Services Administration (HRSA) Reporting Portal. The reporting is to be prepared using accurate financial information and be in accordance with reporting requirements. Condition: The Hospital elected to report Period 4 lost revenues utilizing Option 3, the alternative method of calculating lost revenues attributable to coronavirus. The Hospital’s alternative method did not consider the impact of Medicaid supplemental payments recognized to revenue for 2022 Quarter 1. Cause: The established internal controls did not consider the appropriate grouping of Medicaid supplemental payments when calculating Total Revenue/Net Charges from Patient Care. Effect: The lack of adequate policies governing report preparation and submission increases the risk that the report could be filed incorrectly. Questioned Costs: 2022 Quarter 1 Lost Revenue was overstated by $425,207. However, the Hospital’s Period 4 portal submission reflects $1,988,424 of remaining unused lost revenues that management believes could offset the identified questioned costs. Recommendation: We recommend the Hospital continue to design and implement controls, including levels of review, to ensure reporting is prepared using accurate financial information and in accordance with reporting requirements. Views of Responsible Officials of the Auditee: The Hospital agrees with this finding. See management’s corrective action plan.
FEDERAL AWARD PROGRAMS AUDIT FINDING Material Weakness in Internal Control over Compliance Finding (2022-003) Recommendation: We recommend the Association continue to design and implement controls, including levels of review, to ensure reporting is prepared using accurate financial information and in accordance with reporting requirements. Planned Corrective Action: The Association will ensure the appropriate grouping of Medicaid supplemental payments when calculating Total Revenue/Net Charges from patient care. One of the supplemental payments is related to the hospital's eligibility to receive the associated payment under the Medicaid Rural Disproportionate Share Hospital (ROSH) Program or the Rural Financial Assistance Program (RFAP). The RFAP is based upon a fixed sum of money. Therefore, the annual RFAP distribution received by a hospital represents an amount proportional to the hospital's contribution for providing indigent and Medicaid care as compared to all other RFAP eligible rural hospitals and is calculated in accordance with Florida statute. In addition, the Directed Payment Program (OPP}, as approved by the Florida legislature in 2021, provides funding for hospitals that provide inpatient and outpatient services to Medicaid managed care enrollees. This program is intended to address the shortfall to hospitals by collecting Intergovernmental Transfers (IGTs) and Local Provider assessments (LP) to draw down Federal Medicaid Matching dollars.
FAC accepted this audit on February 22, 2024 — management decision was due August 22, 2024.
The Hospital reported expenses within the HHS Health Resources and Services Administration (HRSA) Reporting Portal that were reimbursed by other sources. Cause: Although the Hospital has a process in place to identify and report allowable expenses, the Hospital did not take into consideration HHS guidance as it relates to cost-based reimbursement. Effect and questioned costs: The Hospital reported expenses that were reimbursed by other sources of approximately $284,000, however there are additional coronavirus related expenses and lost revenues that were reported in the Period 1 portal submission to cover the identified issue. Recommendation: We recommend the Hospital design and implement controls, including levels of review, to ensure reports are submitted in accordance with the HHS guidelines with supporting documentation retained. Views of responsible officials and planned corrective actions: See management?s corrective action plan.
Show full finding ▾Hide full finding ▴Federal agency: U.S. Department of Health and Human Services (HHS) Federal program title: COVID-19 Provider Relief Fund (PRF) ? Period 1 Assistance Listing No.: 93.498 Criteria: Provider Relief Funds were provided under the Coronavirus Aid, Relief, and Economic Security Act and are to be used to prevent, prepare for, and respond to coronavirus. The funds shall reimburse the recipient only for expenses or lost revenues that are attributable to coronavirus and that have not been reimbursed from other sources or that other sources are obligated to reimburse. Condition: The Hospital reported expenses within the HHS Health Resources and Services Administration (HRSA) Reporting Portal that were reimbursed by other sources. Cause: Although the Hospital has a process in place to identify and report allowable expenses, the Hospital did not take into consideration HHS guidance as it relates to cost-based reimbursement. Effect and questioned costs: The Hospital reported expenses that were reimbursed by other sources of approximately $284,000, however there are additional coronavirus related expenses and lost revenues that were reported in the Period 1 portal submission to cover the identified issue. Recommendation: We recommend the Hospital design and implement controls, including levels of review, to ensure reports are submitted in accordance with the HHS guidelines with supporting documentation retained. Views of responsible officials and planned corrective actions: See management?s corrective action plan.
Management agrees with the finding as stated and the additional actions that will be taken by the Hospital will endeavor to utilize all grant funds prudently, comply with federal statues, and regulations. The hospital will implement internal controls and account management requirements.
The Hospital reported expenses within the HHS Health Resources and Services Administration (HRSA) Reporting Portal that were reimbursed by other sources. Cause: Although the Hospital has a process in place to identify and report allowable expenses, the Hospital did not take into consideration HHS guidance as it relates to cost-based reimbursement. Effect and questioned costs: The Hospital reported expenses that were reimbursed by other sources of approximately $284,000, however there are additional coronavirus related expenses and lost revenues that were reported in the Period 1 portal submission to cover the identified issue. Recommendation: We recommend the Hospital design and implement controls, including levels of review, to ensure reports are submitted in accordance with the HHS guidelines with supporting documentation retained. Views of responsible officials and planned corrective actions: See management’s corrective action plan.
Show full finding ▾Hide full finding ▴Federal agency: U.S. Department of Health and Human Services (HHS) Federal program title: COVID-19 Provider Relief Fund (PRF) – Period 1 Assistance Listing No.: 93.498 Criteria: Provider Relief Funds were provided under the Coronavirus Aid, Relief, and Economic Security Act and are to be used to prevent, prepare for, and respond to coronavirus. The funds shall reimburse the recipient only for expenses or lost revenues that are attributable to coronavirus and that have not been reimbursed from other sources or that other sources are obligated to reimburse. Condition: The Hospital reported expenses within the HHS Health Resources and Services Administration (HRSA) Reporting Portal that were reimbursed by other sources. Cause: Although the Hospital has a process in place to identify and report allowable expenses, the Hospital did not take into consideration HHS guidance as it relates to cost-based reimbursement. Effect and questioned costs: The Hospital reported expenses that were reimbursed by other sources of approximately $284,000, however there are additional coronavirus related expenses and lost revenues that were reported in the Period 1 portal submission to cover the identified issue. Recommendation: We recommend the Hospital design and implement controls, including levels of review, to ensure reports are submitted in accordance with the HHS guidelines with supporting documentation retained. Views of responsible officials and planned corrective actions: See management’s corrective action plan.
Material Weakness 2021-004 Actions by Management: Management agrees with the finding as stated and the additional actions that will be taken by the Hospital will endeavor to utilize all grant funds prudently, comply with federal statues, and regulations. The Hospital will implement internal controls and account management requirements.
FAC accepted this audit on September 29, 2022 — management decision was due March 29, 2023.
The Hospital reported expenses within the HHS Health Resources and Services Administration (HRSA) Reporting Portal that were reimbursed by other sources. Cause: Although the Hospital has a process in place to identify and report allowable expenses, the Hospital did not take into consideration HHS guidance as it relates to cost-based reimbursement. Effect and questioned costs: The Hospital reported expenses that were reimbursed by other sources of approximately $284,000, however there are additional coronavirus related expenses and lost revenues that were reported in the Period 1 portal submission to cover the identified issue. Recommendation: We recommend the Hospital design and implement controls, including levels of review, to ensure reports are submitted in accordance with the HHS guidelines with supporting documentation retained. Views of responsible officials and planned corrective actions: See management?s corrective action plan.
Show full finding ▾Hide full finding ▴Federal agency: U.S. Department of Health and Human Services (HHS) Federal program title: COVID-19 Provider Relief Fund (PRF) ? Period 1 Assistance Listing No.: 93.498 Criteria: Provider Relief Funds were provided under the Coronavirus Aid, Relief, and Economic Security Act and are to be used to prevent, prepare for, and respond to coronavirus. The funds shall reimburse the recipient only for expenses or lost revenues that are attributable to coronavirus and that have not been reimbursed from other sources or that other sources are obligated to reimburse. Condition: The Hospital reported expenses within the HHS Health Resources and Services Administration (HRSA) Reporting Portal that were reimbursed by other sources. Cause: Although the Hospital has a process in place to identify and report allowable expenses, the Hospital did not take into consideration HHS guidance as it relates to cost-based reimbursement. Effect and questioned costs: The Hospital reported expenses that were reimbursed by other sources of approximately $284,000, however there are additional coronavirus related expenses and lost revenues that were reported in the Period 1 portal submission to cover the identified issue. Recommendation: We recommend the Hospital design and implement controls, including levels of review, to ensure reports are submitted in accordance with the HHS guidelines with supporting documentation retained. Views of responsible officials and planned corrective actions: See management?s corrective action plan.
Management agrees with the finding as stated and the additional actions that will be taken by the Hospital will endeavor to utilize all grant funds prudently, comply with federal statues, and regulations. The hospital will implement internal controls and account management requirements.
The Hospital reported expenses within the HHS Health Resources and Services Administration (HRSA) Reporting Portal that were reimbursed by other sources. Cause: Although the Hospital has a process in place to identify and report allowable expenses, the Hospital did not take into consideration HHS guidance as it relates to cost-based reimbursement. Effect and questioned costs: The Hospital reported expenses that were reimbursed by other sources of approximately $284,000, however there are additional coronavirus related expenses and lost revenues that were reported in the Period 1 portal submission to cover the identified issue. Recommendation: We recommend the Hospital design and implement controls, including levels of review, to ensure reports are submitted in accordance with the HHS guidelines with supporting documentation retained. Views of responsible officials and planned corrective actions: See management’s corrective action plan.
Show full finding ▾Hide full finding ▴Federal agency: U.S. Department of Health and Human Services (HHS) Federal program title: COVID-19 Provider Relief Fund (PRF) – Period 1 Assistance Listing No.: 93.498 Criteria: Provider Relief Funds were provided under the Coronavirus Aid, Relief, and Economic Security Act and are to be used to prevent, prepare for, and respond to coronavirus. The funds shall reimburse the recipient only for expenses or lost revenues that are attributable to coronavirus and that have not been reimbursed from other sources or that other sources are obligated to reimburse. Condition: The Hospital reported expenses within the HHS Health Resources and Services Administration (HRSA) Reporting Portal that were reimbursed by other sources. Cause: Although the Hospital has a process in place to identify and report allowable expenses, the Hospital did not take into consideration HHS guidance as it relates to cost-based reimbursement. Effect and questioned costs: The Hospital reported expenses that were reimbursed by other sources of approximately $284,000, however there are additional coronavirus related expenses and lost revenues that were reported in the Period 1 portal submission to cover the identified issue. Recommendation: We recommend the Hospital design and implement controls, including levels of review, to ensure reports are submitted in accordance with the HHS guidelines with supporting documentation retained. Views of responsible officials and planned corrective actions: See management’s corrective action plan.
Material Weakness 2021-004 Actions by Management: Management agrees with the finding as stated and the additional actions that will be taken by the Hospital will endeavor to utilize all grant funds prudently, comply with federal statues, and regulations. The Hospital will implement internal controls and account management requirements.
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