EIN: 611028725
UEI: E88ARR6RKGR8
Data as of August 25, 2026
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on September 30, 2025. 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 30, 2026 (148 days ago).
What is a management decision? →Norton Healthcare, Inc. and Affiliates (the Corporation) did not retain supporting documentation over its internal review and approval of expenses reported under Assistance Listing No. 97.036 COVID-19 Disaster Grants – Public Assistance (Presidentially Declared Disasters) (COVID-19 Disaster Grants), which is administered by the U.S. Department of Homeland Security. Furthermore, internal controls over management’s accumulation and review of such expenses for allowability were not suitably designed as it pertained to final approval of project submissions or certain labor costs incurred. Cause: While management designed and implemented internal controls that required expenditures to be reviewed by members of the respective departments in which they originated (e.g. payroll and accounts payable) as expenditures were incurred, internal controls were not designed or implemented around the accumulation of expenditures and review of such expenditures for allowability under the projects for which Norton was approved under the COVID-19 Disaster Grants. Furthermore, the Corporation does not have formalized policies or documentation around internal contract agency travel allowances, and the payroll department did not retain documentation to evidence the review of unapproved timesheets. Effect or potential effect: Lack of formalized policies and procedures and retention of documentation to support the review of expenditures reported under the COVID-19 Disaster Grants program could have resulted in unallowable expenses being charged to and reimbursed by the U.S. Department of Homeland Security. Questioned costs: None. Context: We reconciled the underlying expense detail to approved COVID-19 Disaster Grants project worksheets. Through discussion with management, it was determined that the expense populations were primarily derived from certain departments and transaction codes created specifically for COVID-19 expenses. Upon inspection of related documentation, it was determined that transactions coded to these departments and transaction codes were approved upon occurrence. However, there was no formal documentation retained around management’s subsequent accumulation of expenditures and review and approval or the allowability of such expenses under the COVID-19 Disaster Grants program. Furthermore, the payroll department did not retain documentation to evidence the review of unapproved timesheets, and the Corporation does not have formalized policies or documentation around contract agency travel allowances to support amounts were appropriate. We selected 40 transactions (totaling $865,532 in expenditures) for allowability testing with no compliance exceptions identified. Identification as a repeat finding, if applicable: Not applicable. Recommendation: Management should reassess the internal controls over the accumulation and approval of the allowability of expenditures submitted for reimbursement under the COVID-19 Disaster Grants program. Furthermore, documentation to substantiate the extent and execution of internal controls should be retained. The Corporation’s payroll department should implement an internal control to formalize the review of timecards that are not approved by direct supervisors. This internal control should be formalized with specific steps and evidence of execution retained. Additionally, policies should be formalized related to internal contract agency travel allowances. Views of responsible officials: Management agrees with this finding and will update policies and procedures to ensure that a comprehensive review, approval, and document retention process is applied consistently in the preparation of future projects approved under the COVID-19 Disaster Grant program. Additionally, the Corporation will challenge policies and procedures to formalize payroll department review of unapproved timesheets and internal contract agency travel allowances.
Show full finding ▾Hide full finding ▴Finding 2024-001 – A. Activities Allowed or Unallowed, B. Allowable Costs/Cost Principles, H. Period of Performance Identification of the federal program: Federal Agency: U.S. Department of Homeland Security Assistance Listing No: 97.036 COVID-19 Disaster Grants – Public Assistance (Presidentially Declared Disasters) Award Period: January 1, 2024 through December 31, 2024 Criteria or specific requirement (including statutory, regulatory or other citation): Section 200.303 of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (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: Norton Healthcare, Inc. and Affiliates (the Corporation) did not retain supporting documentation over its internal review and approval of expenses reported under Assistance Listing No. 97.036 COVID-19 Disaster Grants – Public Assistance (Presidentially Declared Disasters) (COVID-19 Disaster Grants), which is administered by the U.S. Department of Homeland Security. Furthermore, internal controls over management’s accumulation and review of such expenses for allowability were not suitably designed as it pertained to final approval of project submissions or certain labor costs incurred. Cause: While management designed and implemented internal controls that required expenditures to be reviewed by members of the respective departments in which they originated (e.g. payroll and accounts payable) as expenditures were incurred, internal controls were not designed or implemented around the accumulation of expenditures and review of such expenditures for allowability under the projects for which Norton was approved under the COVID-19 Disaster Grants. Furthermore, the Corporation does not have formalized policies or documentation around internal contract agency travel allowances, and the payroll department did not retain documentation to evidence the review of unapproved timesheets. Effect or potential effect: Lack of formalized policies and procedures and retention of documentation to support the review of expenditures reported under the COVID-19 Disaster Grants program could have resulted in unallowable expenses being charged to and reimbursed by the U.S. Department of Homeland Security. Questioned costs: None. Context: We reconciled the underlying expense detail to approved COVID-19 Disaster Grants project worksheets. Through discussion with management, it was determined that the expense populations were primarily derived from certain departments and transaction codes created specifically for COVID-19 expenses. Upon inspection of related documentation, it was determined that transactions coded to these departments and transaction codes were approved upon occurrence. However, there was no formal documentation retained around management’s subsequent accumulation of expenditures and review and approval or the allowability of such expenses under the COVID-19 Disaster Grants program. Furthermore, the payroll department did not retain documentation to evidence the review of unapproved timesheets, and the Corporation does not have formalized policies or documentation around contract agency travel allowances to support amounts were appropriate. We selected 40 transactions (totaling $865,532 in expenditures) for allowability testing with no compliance exceptions identified. Identification as a repeat finding, if applicable: Not applicable. Recommendation: Management should reassess the internal controls over the accumulation and approval of the allowability of expenditures submitted for reimbursement under the COVID-19 Disaster Grants program. Furthermore, documentation to substantiate the extent and execution of internal controls should be retained. The Corporation’s payroll department should implement an internal control to formalize the review of timecards that are not approved by direct supervisors. This internal control should be formalized with specific steps and evidence of execution retained. Additionally, policies should be formalized related to internal contract agency travel allowances. Views of responsible officials: Management agrees with this finding and will update policies and procedures to ensure that a comprehensive review, approval, and document retention process is applied consistently in the preparation of future projects approved under the COVID-19 Disaster Grant program. Additionally, the Corporation will challenge policies and procedures to formalize payroll department review of unapproved timesheets and internal contract agency travel allowances.
Finding 2024-001 – A. Activities Allowed or Unallowed, B. Allowable Costs/Cost Principles, H. Period of Performance Identification of the federal program: Federal Agency: U.S. Department of Homeland Security Assistance Listing No: 97.036 COVID-19 Disaster Grants – Public Assistance (Presidentially Declared Disasters) Award Period: January 1, 2024 through December 31, 2024 Summary of finding: A material weakness in internal control over compliance was issued related to activities allowed or unallowed for the COVID-19 Disaster Grants – Public Assistance of Norton Healthcare, Inc. and Affiliates (the Corporation). While Management designed internal controls that required expenditures to be reviewed by members of the respective departments in which they originated (e.g. payroll and accounts payable) as expenditures were incurred, internal controls were not designed or implemented around the accumulation of expenditures and review of such expenditures for allowability under the projects for which Norton was approved under the COVID-19 Disaster Grants. Furthermore, the Company does not have formalized policies or documentation around internal contract agency travel allowances, and the payroll department did not retain documentation to evidence the function’s review of unapproved timesheets. Planned corrective action: Norton Healthcare is currently upgrading its timekeeping and attendance system. As part of this initiative, enhanced training and expanded functionality for timekeepers will help ensure that timecards are reviewed and approved prior to payment, in compliance with internal requirements. Relevant policies and procedures will be updated to support this process, including the retention of appropriate documentation. Additionally, the Norton Clinical Agency will establish a formal written policy outlining the stipend review and approval process, ensuring that all documentation is properly maintained. All other expenses submitted to FEMA will be reviewed and approved in writing, outside of the Grants Portal, with appropriate documentation. At this time, there are no pending or anticipated projects related to FEMA claims. Anticipated completion date: December 31, 2026 Responsible contact person: Adam Kempf
FAC accepted this audit on October 1, 2023 — management decision was due April 1, 2024.
Norton Healthcare, Inc. and Affiliates (the Company) did not retain supporting documentation over its internal review and approval of expenses reported to HRSA in the HHS portal. While management had a process to identify and record allowable expenses under the PRF and ARP Rural Distribution programs, internal controls over management's accumulation and review of such expenses for allowability under the PRF and ARP Rural Distribution programs were not suitably designed. Furthermore, evidence of the review and approval of the Period 4 report submitted in the HHS portal was not retained. Cause: While management designed and implemented internal controls that required expenditures to be reviewed by members of the payroll, human resources, and finance functions as expenditures occurred, internal controls were not designed or implemented around the accumulation of expenditures and review of such expenditures for allowability under the PRF and ARP Rural Distribution programs. Furthermore, documentation to support the review and approval of the Period 4 report submitted in the HHS portal was not retained. Effect or potential effect: Lack of formalized review and approval documentation pertaining to expenditures reported under the PRF and ARP Rural Distribution programs could have resulted in unallowable expenses being charged to the programs and incorrect information being submitted to the HHS portal. Questioned costs: None. Context: We inspected the reconciliation of the underlying expense detail to the Period 4 HHS portal submission, finding the expense balances reported to reconcile. Through discussion with management, it was determined that the expense populations were primarily derived from certain pay codes and general ledger accounts created specifically for COVID-19 expenses. Upon inspection of related documentation, it was determined that transactions coded to these pay codes and general ledger accounts were approved upon occurrence. However, there was no formal documentation retained around management?s subsequent accumulation of expenditures and review and approval of these expense totals or their allowability under the PRF or ARP Rural Distribution programs? guidelines. Furthermore, documentation of the review and approval of the Period 4 report submitted to the HHS portal was not retained. We selected 40 transactions (totaling $257,584 in expenditures) for compliance testing, with no compliance exceptions identified. The entire $4,401,728 balance of HRSA PRF program funds reported in Period 4 were supported through expenses, with no lost revenue utilized in the period. Identification as a repeat finding, if applicable: This is a repeat of the 2021-001 finding. Recommendation: Management should reassess its internal controls over the accumulation, review and approval of the allowability of expenditures and retain documentation supporting that review and approval, as well as the review and approval of reports submitted to the HHS portal Views of responsible officials: Management agrees with this finding and will update policies and procedures to ensure that a comprehensive review, approval, and document retention process is applied consistently in the preparation of future HHS portal submissions.
Show full finding ▾Hide full finding ▴Finding 2022-001 ? A. Activities Allowed or Unallowed, B. Allowable Costs/Cost Principles, L. Reporting Identification of the federal program: Federal Agency: U.S. Department of Health and Human Services (HHS), Health Resources and Services Administration (HRSA) Assistance Listing No: 93.498 Provider Relief Fund and American Rescue Plan (ARP) Rural Distributions (referred to as PRF and ARP Rural Distributions programs) Award Period: January 1, 2021 through December 31, 2022 Criteria or specific requirement (including statutory, regulatory or other citation): Section 200.303 of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (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: Norton Healthcare, Inc. and Affiliates (the Company) did not retain supporting documentation over its internal review and approval of expenses reported to HRSA in the HHS portal. While management had a process to identify and record allowable expenses under the PRF and ARP Rural Distribution programs, internal controls over management's accumulation and review of such expenses for allowability under the PRF and ARP Rural Distribution programs were not suitably designed. Furthermore, evidence of the review and approval of the Period 4 report submitted in the HHS portal was not retained. Cause: While management designed and implemented internal controls that required expenditures to be reviewed by members of the payroll, human resources, and finance functions as expenditures occurred, internal controls were not designed or implemented around the accumulation of expenditures and review of such expenditures for allowability under the PRF and ARP Rural Distribution programs. Furthermore, documentation to support the review and approval of the Period 4 report submitted in the HHS portal was not retained. Effect or potential effect: Lack of formalized review and approval documentation pertaining to expenditures reported under the PRF and ARP Rural Distribution programs could have resulted in unallowable expenses being charged to the programs and incorrect information being submitted to the HHS portal. Questioned costs: None. Context: We inspected the reconciliation of the underlying expense detail to the Period 4 HHS portal submission, finding the expense balances reported to reconcile. Through discussion with management, it was determined that the expense populations were primarily derived from certain pay codes and general ledger accounts created specifically for COVID-19 expenses. Upon inspection of related documentation, it was determined that transactions coded to these pay codes and general ledger accounts were approved upon occurrence. However, there was no formal documentation retained around management?s subsequent accumulation of expenditures and review and approval of these expense totals or their allowability under the PRF or ARP Rural Distribution programs? guidelines. Furthermore, documentation of the review and approval of the Period 4 report submitted to the HHS portal was not retained. We selected 40 transactions (totaling $257,584 in expenditures) for compliance testing, with no compliance exceptions identified. The entire $4,401,728 balance of HRSA PRF program funds reported in Period 4 were supported through expenses, with no lost revenue utilized in the period. Identification as a repeat finding, if applicable: This is a repeat of the 2021-001 finding. Recommendation: Management should reassess its internal controls over the accumulation, review and approval of the allowability of expenditures and retain documentation supporting that review and approval, as well as the review and approval of reports submitted to the HHS portal Views of responsible officials: Management agrees with this finding and will update policies and procedures to ensure that a comprehensive review, approval, and document retention process is applied consistently in the preparation of future HHS portal submissions.
Finding 2022-001 ? A. Activities Allowed or Unallowed, B. Allowable Costs/Cost Principles, L. Reporting Federal program information: Federal Program: 93.498 COVID-19 Provider Relief Fund (PRF) Federal Agency: U.S. Department of Health and Human Services (HHS), Health Resources and Services Administration (HRSA) Norton Healthcare, Inc. and Affiliates Locations: Various Award Numbers: Various Award Period: January 1, 2022 through December 31, 2022 Summary of finding: A material weakness in internal control over compliance was issued related to activities allowed or unallowed for the COVID-19 Provider Relief Fund program of Norton Healthcare, Inc. and Affiliates (the Corporation). While Management designed internal controls that required PRF expenditures to be reviewed by finance, the internal control was not implemented consistently and supporting documentation of the review process was not retained. Planned corrective action: Management will ensure that a comprehensive review, approval, and document retention process is implemented and applied consistently across all affected entities for any future PRF disbursements. Finance is responsible for this corrective action plan. It should be noted this repeat finding is a direct result of a newly acquired entity effective January 1, 2022. During the transition period, management has sought for consistent treatment for all affiliates. Anticipated completion date: December 31, 2023 Responsible contact person: Adam Kempf
2021-001
FAC accepted this audit on September 27, 2022 — management decision was due March 27, 2023.
Norton Healthcare, Inc. and Affiliates (the Corporation) did not retain supporting documentation over its internal review and approval of expenses reported to HRSA in the HHS portal. While management had a process to identify and review expenses for allowability under the PRF program, internal controls over management's review of reported personnel costs were not suitably designed, specifically related to document retention, and, in certain instances, were not operating effectively. Insufficient review of underlying expense detail resulted in inclusion of labor hours incurred within the expense balance reported in the HRSA PRF submission for Period 1. Cause: While management designed internal controls that required PRF expenditures to be reviewed by members of the payroll, human resources, and finance functions, the internal controls were not implemented consistently across the Corporation. Furthermore, supporting documentation of these reviews were not retained. Effect or potential effect: Lack of formalized review and approval documentation pertaining to expenses reported under the Provider Relief Fund resulted in unallowable expenses being charged to the PRF program. Questioned costs: $785,206 of expenses attributable to the Period 1 Norton Healthcare, Inc. HRSA Provider Relief Fund HHS portal submission. Context: We inspected the reconciliation of the underlying expense detail to the Period 1 HRSA PRF submission, determining that the expense total reported inappropriately included 785,206 of labor hours worked as a dollar cost incurred. We selected 80 transactions (totaling $43,763 in expenditures) reported under the HRSA PRF program and determined that in numerous instances documentation was not maintained to evidence management?s review of the related personnel cost prior to reporting under the program. Total expenses reported in the Corporation?s Period 1 HHS portal filings were $38,321,819, while total lost revenues reported were $156,048,761. Total PRF lost revenue and expenditures reported on the SEFA are $112,285,811 for the year ended December 31, 2021. Identification as a repeat finding, if applicable: The finding is not a repeat finding. Recommendation: Management should reassess its internal controls over the review and approval of allowability of expenditures and retain documentation supporting that review and approval. Views of responsible officials: Management agrees with this finding and will update policies and procedures to ensure that a comprehensive review, approval, and document retention process is applied consistently in the preparation of future HHS portal submissions.
Show full finding ▾Hide full finding ▴Finding 2021-001 - Activities Allowed or Unallowed, B. Allowable Costs/Cost Principles, L. Reporting 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 Provider Relief Fund (PRF) and American Rescue Plan (ARP) Rural Distributions Award Period: January 1, 2020 through December 31, 2021 Criteria or specific requirement (including statutory, regulatory or other citation): Section 200.303 of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (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: Norton Healthcare, Inc. and Affiliates (the Corporation) did not retain supporting documentation over its internal review and approval of expenses reported to HRSA in the HHS portal. While management had a process to identify and review expenses for allowability under the PRF program, internal controls over management's review of reported personnel costs were not suitably designed, specifically related to document retention, and, in certain instances, were not operating effectively. Insufficient review of underlying expense detail resulted in inclusion of labor hours incurred within the expense balance reported in the HRSA PRF submission for Period 1. Cause: While management designed internal controls that required PRF expenditures to be reviewed by members of the payroll, human resources, and finance functions, the internal controls were not implemented consistently across the Corporation. Furthermore, supporting documentation of these reviews were not retained. Effect or potential effect: Lack of formalized review and approval documentation pertaining to expenses reported under the Provider Relief Fund resulted in unallowable expenses being charged to the PRF program. Questioned costs: $785,206 of expenses attributable to the Period 1 Norton Healthcare, Inc. HRSA Provider Relief Fund HHS portal submission. Context: We inspected the reconciliation of the underlying expense detail to the Period 1 HRSA PRF submission, determining that the expense total reported inappropriately included 785,206 of labor hours worked as a dollar cost incurred. We selected 80 transactions (totaling $43,763 in expenditures) reported under the HRSA PRF program and determined that in numerous instances documentation was not maintained to evidence management?s review of the related personnel cost prior to reporting under the program. Total expenses reported in the Corporation?s Period 1 HHS portal filings were $38,321,819, while total lost revenues reported were $156,048,761. Total PRF lost revenue and expenditures reported on the SEFA are $112,285,811 for the year ended December 31, 2021. Identification as a repeat finding, if applicable: The finding is not a repeat finding. Recommendation: Management should reassess its internal controls over the review and approval of allowability of expenditures and retain documentation supporting that review and approval. Views of responsible officials: Management agrees with this finding and will update policies and procedures to ensure that a comprehensive review, approval, and document retention process is applied consistently in the preparation of future HHS portal submissions.
Finding 2021-001 ? A. Activities Allowed or Unallowed, B. Allowable Costs/Cost Principles, L. Reporting Federal program information: Federal Program: 93.498 COVID-19 Provider Relief Fund (PRF) Federal Agency: U.S. Department of Health and Human Services (HHS), Health Resources and Services Administration (HRSA) Norton Healthcare, Inc. and Affiliates Locations: Various Award Numbers: Various Award Period: January 1, 2020 through December 31, 2021 Summary of finding: A material weakness in internal control over compliance was issued related to activities allowed or unallowed for the COVID-19 Provider Relief Fund program of Norton Healthcare, Inc. and Affiliates (the Corporation). While Management designed internal controls that required PRF expenditures to be reviewed by finance, the internal control was not implemented consistently and supporting documentation of the review process was not retained. Planned corrective action: Management will ensure that a comprehensive review, approval, and document retention process is implemented and applied consistently across all affected entities for any future PRF disbursements. Finance is responsible for this corrective action plan. Anticipated completion date: December 31, 2022 Responsible contact person: Adam Kempf
FAC accepted this audit on March 30, 2022 — management decision was due September 30, 2022.
Norton Healthcare, Inc. and Affiliates (the Corporation) did not document its compliance with the HRSA COVID-19 Uninsured Program T&Cs. Internal controls over the determination of a patient?s uninsured/self-pay status and management's review of credit balances were not suitably designed, specifically related to document retention, and, in certain instances, were not operating effectively. Cause: The Corporation did not design or have internal controls in place to monitor the T&Cs and underlying HRSA COVID-19 Uninsured Program regulations during the COVID-19 pandemic. The Corporation did not have internal controls in place to formally document its compliance with the HRSA COVID-19 Uninsured Program T&Cs. Additionally, the Corporation did not have internal controls in place to formally document its compliance with the HRSA COVID-19 Uninsured Program?s allowability requirements. Standard policies, procedures, and internal controls over the review for patient insurance coverage and review of credit balances used in the federal program were not suitability designed to address the unique aspects of the HRSA COVID-19 Uninsured Program. Documentation was not maintained to evidence insurance coverage discovery was completed prior to billing to HRSA. Effect or potential effect: The Corporation could be in noncompliance with the HRSA COVID-19 Uninsured Program T&Cs. A patient may not be uninsured and therefore the related encounter may be ineligible for reimbursement under the HRSA COVID-19 Uninsured Program. Credit balances may not be resolved timely and refunds to the HRSA COVID-19 Uninsured Program may not be identified or completed in a timely manner. Questioned costs: None. Context: We sampled 60 claims (totaling $9,296 in federal expenditures) for services occurring during the award period that were billed to the HRSA COVID-19 Uninsured Program and noted internal controls over the determination of uninsured/self-pay status were not effectively designed or were not operating effectively. For these patient encounters, documentation was not maintained to evidence insurance coverage discovery was completed prior to billing to HRSA. Documentation was not maintained to evidence credit balance review of accounts billed to HRSA. Total federal expenditures for Assistance Listing 93.461 totaled $1,013,991 for the year ended December 31, 2020. Identification as a repeat finding, if applicable: The finding is not a repeat finding. Recommendation: The Corporation should design and implement internal controls to document its review and compliance with the HRSA COVID-19 Uninsured Program T&C?s. The Corporation should design and implement sufficiently precise internal controls to review changes to the HRSA COVID-19 Uninsured Program to ensure it is administering the program in compliance with the HRSA COVID-19 Uninsured Program regulations. In addition, internal controls should be designed and implemented to ensure claims submitted to the HRSA COVID-19 Uninsured Program meet the allowability criteria established by the HRSA COVID-19 Uninsured Program regulations before claims are submitted to HRSA for reimbursement. Standard policies, procedures, and internal controls over the review for patient insurance coverage and review of credit balances should be updated to address the unique aspects of the HRSA COVID-19 Uninsured Program. Evidence of insurance discovery to verify third-party insurance searches are completed with no other insurance identified should be maintained. Evidence of credit balance reviews to timely identify refunds to HRSA should be maintained. Views of responsible officials: We agree with this finding and will update policies and work procedures to ensure compliance with HRSA COVID-19 Uninsured Program regulations. We will also implement additional internal controls over the submission of claims to HRSA and review of T&C?s of the federal program.
Show full finding ▾Hide full finding ▴Finding 2020-001 ? A. Activities Allowed or Unallowed and E. Eligibility Identification of the federal program: Federal Program: COVID-19 Claims Reimbursement to Health Care Providers and Facilities for Testing, Treatment, and Vaccine Administration for the Uninsured, Assistance Listing No. 93.461 (Assistance Listing No. 93.461) (COVID-19 Uninsured Program) Federal Agency: U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA) Norton Healthcare, Inc. and Affiliates Location: Various Award Numbers: Various Award Period: February 4, 2020 through December 31, 2020 Criteria or specific requirement (including statutory, regulatory or other citation): Section 200.303 of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (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. Condition: Norton Healthcare, Inc. and Affiliates (the Corporation) did not document its compliance with the HRSA COVID-19 Uninsured Program T&Cs. Internal controls over the determination of a patient?s uninsured/self-pay status and management's review of credit balances were not suitably designed, specifically related to document retention, and, in certain instances, were not operating effectively. Cause: The Corporation did not design or have internal controls in place to monitor the T&Cs and underlying HRSA COVID-19 Uninsured Program regulations during the COVID-19 pandemic. The Corporation did not have internal controls in place to formally document its compliance with the HRSA COVID-19 Uninsured Program T&Cs. Additionally, the Corporation did not have internal controls in place to formally document its compliance with the HRSA COVID-19 Uninsured Program?s allowability requirements. Standard policies, procedures, and internal controls over the review for patient insurance coverage and review of credit balances used in the federal program were not suitability designed to address the unique aspects of the HRSA COVID-19 Uninsured Program. Documentation was not maintained to evidence insurance coverage discovery was completed prior to billing to HRSA. Effect or potential effect: The Corporation could be in noncompliance with the HRSA COVID-19 Uninsured Program T&Cs. A patient may not be uninsured and therefore the related encounter may be ineligible for reimbursement under the HRSA COVID-19 Uninsured Program. Credit balances may not be resolved timely and refunds to the HRSA COVID-19 Uninsured Program may not be identified or completed in a timely manner. Questioned costs: None. Context: We sampled 60 claims (totaling $9,296 in federal expenditures) for services occurring during the award period that were billed to the HRSA COVID-19 Uninsured Program and noted internal controls over the determination of uninsured/self-pay status were not effectively designed or were not operating effectively. For these patient encounters, documentation was not maintained to evidence insurance coverage discovery was completed prior to billing to HRSA. Documentation was not maintained to evidence credit balance review of accounts billed to HRSA. Total federal expenditures for Assistance Listing 93.461 totaled $1,013,991 for the year ended December 31, 2020. Identification as a repeat finding, if applicable: The finding is not a repeat finding. Recommendation: The Corporation should design and implement internal controls to document its review and compliance with the HRSA COVID-19 Uninsured Program T&C?s. The Corporation should design and implement sufficiently precise internal controls to review changes to the HRSA COVID-19 Uninsured Program to ensure it is administering the program in compliance with the HRSA COVID-19 Uninsured Program regulations. In addition, internal controls should be designed and implemented to ensure claims submitted to the HRSA COVID-19 Uninsured Program meet the allowability criteria established by the HRSA COVID-19 Uninsured Program regulations before claims are submitted to HRSA for reimbursement. Standard policies, procedures, and internal controls over the review for patient insurance coverage and review of credit balances should be updated to address the unique aspects of the HRSA COVID-19 Uninsured Program. Evidence of insurance discovery to verify third-party insurance searches are completed with no other insurance identified should be maintained. Evidence of credit balance reviews to timely identify refunds to HRSA should be maintained. Views of responsible officials: We agree with this finding and will update policies and work procedures to ensure compliance with HRSA COVID-19 Uninsured Program regulations. We will also implement additional internal controls over the submission of claims to HRSA and review of T&C?s of the federal program.
Corrective Action Plan Federal Award Findings and Questioned Costs ? For the Year Ended December 31, 2020 Finding 2020-001 ? A. Activities Allowed or Unallowed and E. Eligibility Federal program information: Federal Program: COVID-19 Claims Reimbursement to Health Care Providers and Facilities for Testing, Treatment, and Vaccine Administration for the Uninsured, Assistance Listing No. 93.461 (Assistance Listing No. 93.461) (COVID-19 Uninsured Program) Federal Agency: U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA) Norton Healthcare, Inc. and Affiliates Locations: Various Award Numbers: Various Award Period: February 4, 2020 through December 31, 2020 Summary of finding: Norton Healthcare, Inc. and Affiliates (the Corporation) did not document its compliance with the HRSA COVID-19 Uninsured Program Terms & Conditions. Internal controls over the determination of a patient?s uninsured/self-pay status were not suitably designed, specifically related to document retention, and in certain instances were not operating effectively. Planned corrective action: Management will review claims submitted to the HRSA COVID-19 Testing for the Uninsured Program for potential payments for ineligible services and will timely resubmit any claims that require reprocessing due to overpayment. Management will review credit balances to identify refunds to be made to HRSA. In March 2022, HRSA announced the discontinuance of the HRSA COVID-19 Testing for the Uninsured program and, therefore, remediation of internal controls in no longer applicable. Anticipated completion date: April 5, 2022 Responsible contact person: Adam Kempf, Senior Vice President and Chief Financial Officer
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