EIN: 610518022
UEI: GSA_MIGRATION
Audited by: BLUE AND CO., LLC
Oversight agency: 93 [Department of Health and Human Services]
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Data as of September 7, 2026
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on February 8, 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 August 8, 2023 (1127 days ago).
What is a management decision? →2022-001: Supporting Documentation for Purchases Compliance Requirement(s): Allowable Costs/Cost Principles Criteria ? LHHS?s internal control processes and procedures should include retention of documentation to support payments made by the Hospital. Condition ? During our audit procedures, we noted that there were four instances where no purchase orders or receiving reports could be provided that supported invoices paid by LHHS. Cause ? The cause of this deficiency is due to the lack of internal control procedures within the cash disbursements process to ensure supporting documentation that substantiates payments made by LHHS are for allowable costs. Effect ? The effect could result in payments made for goods not received, or services not rendered, to LHHS. Recommendation ? We recommend that LHS implement internal control procedures to ensure retention of proper supporting documentation. Management?s Response ? We recognize the needs for proper internal control processes and procedures to properly retain supporting documentation. We are in the process of implementing these processes and procedures.
Show full finding ▾Hide full finding ▴2022-001: Supporting Documentation for Purchases Compliance Requirement(s): Allowable Costs/Cost Principles Criteria ? LHHS?s internal control processes and procedures should include retention of documentation to support payments made by the Hospital. Condition ? During our audit procedures, we noted that there were four instances where no purchase orders or receiving reports could be provided that supported invoices paid by LHHS. Cause ? The cause of this deficiency is due to the lack of internal control procedures within the cash disbursements process to ensure supporting documentation that substantiates payments made by LHHS are for allowable costs. Effect ? The effect could result in payments made for goods not received, or services not rendered, to LHHS. Recommendation ? We recommend that LHS implement internal control procedures to ensure retention of proper supporting documentation. Management?s Response ? We recognize the needs for proper internal control processes and procedures to properly retain supporting documentation. We are in the process of implementing these processes and procedures.
2021-001 Assistance Listing Number: 93.498 Title: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Condition: During testing of controls related to the federal program, LHHS was not able to provide purchase orders or receiving reports for four invoices that were paid during 2021. Action: The Hospital will implement internal control processes and procedures related to record retention prior to the March 31, 2023 reporting submission deadline for the Period 4 report to the HHS Provider Relief Fund portal.
2022-002: Reporting of Lost Revenues Compliance Requirement(s): Reporting Criteria ? LHHS should implement policies and procedures to ensure that amounts reported on the Health Resources and Services Administration (?HRSA?) Provider Relief Fund (?PRF?) reporting portal are supported by objective documentation within the financial system. Condition ? Based on the testing of amounts reported on the HRSA PRF portal for lost revenues applied towards PRF amounts received by LHHS, the amounts reported within the portal could not be corroborated to underlying objective supporting documentation. Cause ? The cause of this deficiency was a difference between the quarterly net revenues reported on the HRSA PRF reporting portal for each quarter, and the amounts of quarterly net revenues from the underlying information. Effect ? The effect was an incorrect calculation of lost revenues on the HRSA PRF reporting portal. However, this did not result in a misstatement of the schedule of expenditures of federal awards. Recommendation ? We recommend that LHHS review policies and procedures to ensure that lost revenues are reported correctly on the HRSA PRF reporting portal. Management?s Response ? We recognize the needs for proper internal control processes and procedures to ensure that amounts reported on the HRSA PRF reporting portal are accurate and supportable. We are in the process of implementing these processes and procedures.
Show full finding ▾Hide full finding ▴2022-002: Reporting of Lost Revenues Compliance Requirement(s): Reporting Criteria ? LHHS should implement policies and procedures to ensure that amounts reported on the Health Resources and Services Administration (?HRSA?) Provider Relief Fund (?PRF?) reporting portal are supported by objective documentation within the financial system. Condition ? Based on the testing of amounts reported on the HRSA PRF portal for lost revenues applied towards PRF amounts received by LHHS, the amounts reported within the portal could not be corroborated to underlying objective supporting documentation. Cause ? The cause of this deficiency was a difference between the quarterly net revenues reported on the HRSA PRF reporting portal for each quarter, and the amounts of quarterly net revenues from the underlying information. Effect ? The effect was an incorrect calculation of lost revenues on the HRSA PRF reporting portal. However, this did not result in a misstatement of the schedule of expenditures of federal awards. Recommendation ? We recommend that LHHS review policies and procedures to ensure that lost revenues are reported correctly on the HRSA PRF reporting portal. Management?s Response ? We recognize the needs for proper internal control processes and procedures to ensure that amounts reported on the HRSA PRF reporting portal are accurate and supportable. We are in the process of implementing these processes and procedures.
2021-002 Assistance Listing #: 93.498 Title: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Condition: The amounts reported for patient services revenues within the Phase I Provider Relief Fund reporting portal could not be supported by objective underlying documentation. Action: The Hospital will implement internal control processes and procedures prior to the March 31, 2023 reporting submission deadline for the Period 4 report to the HHS Provider Relief Fund portal to ensure that amounts reported within the reporting portal are supported by objective underlying documentation.
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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