EIN: 840586742
UEI: S6LTYZAM5GF1
Audited by: Sorren CPAs, P.C
Oversight agency: 10 [Department of Agriculture]
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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 June 17, 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 December 17, 2026 (104 days from today).
What is a management decision? →FAC accepted this audit on June 25, 2025 — management decision was due December 25, 2025.
FAC accepted this audit on June 20, 2024 — management decision was due December 20, 2024.
FAC accepted this audit on July 9, 2023 — management decision was due January 9, 2024.
Criteria or Specific Requirement ? The Hospital is required to submit filings with the Health Resource and Service Administration (HRSA) with respect to the Provider Relief Fund (PRF). Such filings include reporting of COVID-19 costs and lost revenues, as defined. Providers are not allowed to use PRF payments to reimburse expenses that have been reimbursed from other sources. Condition ? The Hospital?s Provider Relief Fund filing with HRSA for Reporting Period 4 did not consider COVID-19 costs that were potentially already reimbursed with a Paycheck Protection Program (PPP) loan. The PPP loan was subsequently forgiven. Context ? The Hospital engaged an independent firm to prepare its PRF filing for Reporting Period 4. Cause ? That firm did not consider the possibility that COVID-19 costs reported to the PRF could have been previously reimbursed by a PPP loan. The Hospital did not detect this oversight in its review of the Reporting Period 4 filing. Effect or Potential Effect ? The allowable COVID-19 costs incurred by the Hospital for Filing Period 4 exceeded the Filing Period 4 PRF payments received. Also, the costs included on the PPP loan forgiveness application exceeded the PPP loan. The Hospital performed an analysis which concluded that no COVID-19 costs included in the PRF Period 4 filing were previously reimbursed through the PPP loan forgiveness. Also, the Hospital incurred significant COVID-19 costs in 2022 that were not reported in the Period 4 Filing due to the aforementioned excess of costs during 2020 and 2021. However, the initial lack of consideration of the PPP loan forgiveness is an internal control deficiency. Questioned Costs ? There are no questioned costs. As noted above, the Hospital has concluded that the filing for Reporting Period 4 does not include costs that were previously reimbursed. Recommendation ? We recommend that the Hospital implement review procedures for any future filings with HRSA that ensure consideration of all relevant rules and regulations. Views of Responsible Officials and Planned Corrective Actions ? Management agrees with the finding and has taken steps to ensure any future filings consider all relevant rules and regulations.
Show full finding ▾Hide full finding ▴Criteria or Specific Requirement ? The Hospital is required to submit filings with the Health Resource and Service Administration (HRSA) with respect to the Provider Relief Fund (PRF). Such filings include reporting of COVID-19 costs and lost revenues, as defined. Providers are not allowed to use PRF payments to reimburse expenses that have been reimbursed from other sources. Condition ? The Hospital?s Provider Relief Fund filing with HRSA for Reporting Period 4 did not consider COVID-19 costs that were potentially already reimbursed with a Paycheck Protection Program (PPP) loan. The PPP loan was subsequently forgiven. Context ? The Hospital engaged an independent firm to prepare its PRF filing for Reporting Period 4. Cause ? That firm did not consider the possibility that COVID-19 costs reported to the PRF could have been previously reimbursed by a PPP loan. The Hospital did not detect this oversight in its review of the Reporting Period 4 filing. Effect or Potential Effect ? The allowable COVID-19 costs incurred by the Hospital for Filing Period 4 exceeded the Filing Period 4 PRF payments received. Also, the costs included on the PPP loan forgiveness application exceeded the PPP loan. The Hospital performed an analysis which concluded that no COVID-19 costs included in the PRF Period 4 filing were previously reimbursed through the PPP loan forgiveness. Also, the Hospital incurred significant COVID-19 costs in 2022 that were not reported in the Period 4 Filing due to the aforementioned excess of costs during 2020 and 2021. However, the initial lack of consideration of the PPP loan forgiveness is an internal control deficiency. Questioned Costs ? There are no questioned costs. As noted above, the Hospital has concluded that the filing for Reporting Period 4 does not include costs that were previously reimbursed. Recommendation ? We recommend that the Hospital implement review procedures for any future filings with HRSA that ensure consideration of all relevant rules and regulations. Views of Responsible Officials and Planned Corrective Actions ? Management agrees with the finding and has taken steps to ensure any future filings consider all relevant rules and regulations.
Condition ? The Hospital?s Provider Relief Fund filing with HRSA for Reporting Period 4 did not consider COVID-19 costs that were potentially already reimbursed with a Paycheck Protection Program (PPP) loan. The PPP loan was subsequently forgiven. Recommendation ? We recommend that the Hospital implement review procedures for any future filings with HRSA that ensure consideration of all relevant rules and regulations. Views of Responsible Officials and Planned Corrective Actions ? Management agrees with the finding and has taken steps to ensure any future filings consider all relevant rules and regulations. Anticipated Date of Completion ? Completed June 21, 2023. Action Taken ? We have reviewed the recommendation and have taken steps to ensure any future filings consider all relevant rules and regulations. Person Responsible for Corrective Action Plan ? Calvin Carey, Chief Financial Officer
FAC accepted this audit on May 19, 2022 — management decision was due November 19, 2022.
FAC accepted this audit on November 28, 2021 — management decision was due May 28, 2022.
Criteria or Specific Requirement ? Management is responsible for preparing financial statements in accordance with generally accepted accounting principles. Condition ? An adjusting entry that is material to the financial statements was made to reduce other operating revenue by approximately $1.77 million related to the recognition of revenue for the provider relief funds received under the CARES Act. Context ? In connection with an analysis for the provider relief funds received under the CARES Act, it was determined that other operating revenues recognized were overstated. Cause ? The methodology used by the Hospital did not consider the impact of ongoing provider relief fund rule changes made by the U.S. Department of Health and Human Services and related accounting interpretations that have occurred throughout 2020 and 2021. Effect or Potential Effect ? The error resulted in a misstatement of the Hospital?s internal financial statements. Questioned Costs ? There are no questioned costs. Recommendation ? We recommend the Hospital ensure that their internal financial statements reflect the latest rule changes and related accounting interpretations. Views of Responsible Officials and Planned Corrective Actions ? Management agrees with the finding and will implement the recommendation.
Show full finding ▾Hide full finding ▴Criteria or Specific Requirement ? Management is responsible for preparing financial statements in accordance with generally accepted accounting principles. Condition ? An adjusting entry that is material to the financial statements was made to reduce other operating revenue by approximately $1.77 million related to the recognition of revenue for the provider relief funds received under the CARES Act. Context ? In connection with an analysis for the provider relief funds received under the CARES Act, it was determined that other operating revenues recognized were overstated. Cause ? The methodology used by the Hospital did not consider the impact of ongoing provider relief fund rule changes made by the U.S. Department of Health and Human Services and related accounting interpretations that have occurred throughout 2020 and 2021. Effect or Potential Effect ? The error resulted in a misstatement of the Hospital?s internal financial statements. Questioned Costs ? There are no questioned costs. Recommendation ? We recommend the Hospital ensure that their internal financial statements reflect the latest rule changes and related accounting interpretations. Views of Responsible Officials and Planned Corrective Actions ? Management agrees with the finding and will implement the recommendation.
Condition ? An adjusting entry that is material to the financial statements was made to reduce other operating revenue by approximately $1.77 million related to the recognition of revenue for the provider relief funds received under the CARES Act. Recommendation ? We recommend the Hospital ensure that their internal financial statements reflect the latest rule changes and related accounting interpretations. Views of Responsible Officials and Planned Corrective Actions ? Management agrees with the finding and will implement the recommendation. Date of Completion ? 06/15/21. Action Taken ? The adjustment was recorded and procedures to identify changes in CARES Act rules and related accounting interpretations were improved to ensure accurate internal financial statements. Person Responsible for Corrective Action Plan ? Chief Financial Officer.
Criteria or Specific Requirement ? Special Tests and Provisions for the major program sets out the following compliance requirement: Borrowers shall establish accounts into which borrower funds, Agency loan proceeds, the revenues of the facility financed, and any other income shall be deposited in accordance with the loan resolution(s) authorizing the incurrence of indebtedness related to the Agency loan proceeds. The accounts will be maintained in accordance with the loan resolution(s) as long as the authorized indebtedness to the Agency is outstanding. Accounts may include but are not limited to the following: (a) construction account, (b) general account, (c) debt service account, and (d) reserve account. Condition ? As required, the Hospital has established a separate deposit account for Medicare and Medicaid payments. However, payments received under the Medicare and Medicaid programs were not deposited into the separate deposit account in accordance with loan resolution until July 2020. Only a portion of the reimbursements and other payments received subsequent to July 2020 were deposited into the separate deposit account. Funds in the separate deposit fund were not swept and deposited into the Hospital?s main operating account daily, in accordance with the loan resolution. Context ? The loan resolution requires the Hospital to open and maintain a separate deposit account for the receipt of payments under the Medicare and Medicaid programs (the ?Medicare/Medicaid Payments Account?), which is separate and apart from Hospital?s general operating account. The Medicare/Medicaid Payments Account will be established with the same bank in which Hospital?s operating account is maintained for the Project. All payments received under the Medicare and Medicaid Programs shall be initially deposited into the Medicare/Medicaid Payments Account. At the end of each Business Day, all funds in the Medicare/Medicaid Payments Account shall be swept and deposited into Hospital?s main operating account. In addition to all other security for the Loans, Lender shall have a pledge of and perfected security interest in all deposit accounts of Hospital. Hospital shall cause deposit account control agreements to be executed by each bank or other financial institution in which Hospital has deposit or investment accounts (except that a control agreement shall not be required for the Medicare/Medicaid Payments Account), each in favor of Lender and with terms acceptable to Lender. Hospital shall instruct its depository bank to make the sweep and transfer of funds as set forth above, acceptable to Lender. Cause ? The Hospital does not have policies and procedures as internal controls to ensure accounts are maintained in compliance with loan resolutions. Effect or Potential Effect ?The potential effect is noncompliance with loan resolutions. Questioned Costs ? There are no questioned costs. Prior Year Finding ? In the prior audit period immediately preceding the current period, a similar finding, 2019-002, was noted. Recommendation ? We recommend procedures be put in place to ensure all reimbursements and other payments received under the federal Medicare and Medicaid programs are deposited into the separate deposit account and daily sweeps and transfers occur in accordance with the loan resolution. Views of Responsible Officials and Planned Corrective Actions ? Management agrees with the finding and will ensure processes regarding federal award compliance are updated and adhered to.
Show full finding ▾Hide full finding ▴Criteria or Specific Requirement ? Special Tests and Provisions for the major program sets out the following compliance requirement: Borrowers shall establish accounts into which borrower funds, Agency loan proceeds, the revenues of the facility financed, and any other income shall be deposited in accordance with the loan resolution(s) authorizing the incurrence of indebtedness related to the Agency loan proceeds. The accounts will be maintained in accordance with the loan resolution(s) as long as the authorized indebtedness to the Agency is outstanding. Accounts may include but are not limited to the following: (a) construction account, (b) general account, (c) debt service account, and (d) reserve account. Condition ? As required, the Hospital has established a separate deposit account for Medicare and Medicaid payments. However, payments received under the Medicare and Medicaid programs were not deposited into the separate deposit account in accordance with loan resolution until July 2020. Only a portion of the reimbursements and other payments received subsequent to July 2020 were deposited into the separate deposit account. Funds in the separate deposit fund were not swept and deposited into the Hospital?s main operating account daily, in accordance with the loan resolution. Context ? The loan resolution requires the Hospital to open and maintain a separate deposit account for the receipt of payments under the Medicare and Medicaid programs (the ?Medicare/Medicaid Payments Account?), which is separate and apart from Hospital?s general operating account. The Medicare/Medicaid Payments Account will be established with the same bank in which Hospital?s operating account is maintained for the Project. All payments received under the Medicare and Medicaid Programs shall be initially deposited into the Medicare/Medicaid Payments Account. At the end of each Business Day, all funds in the Medicare/Medicaid Payments Account shall be swept and deposited into Hospital?s main operating account. In addition to all other security for the Loans, Lender shall have a pledge of and perfected security interest in all deposit accounts of Hospital. Hospital shall cause deposit account control agreements to be executed by each bank or other financial institution in which Hospital has deposit or investment accounts (except that a control agreement shall not be required for the Medicare/Medicaid Payments Account), each in favor of Lender and with terms acceptable to Lender. Hospital shall instruct its depository bank to make the sweep and transfer of funds as set forth above, acceptable to Lender. Cause ? The Hospital does not have policies and procedures as internal controls to ensure accounts are maintained in compliance with loan resolutions. Effect or Potential Effect ?The potential effect is noncompliance with loan resolutions. Questioned Costs ? There are no questioned costs. Prior Year Finding ? In the prior audit period immediately preceding the current period, a similar finding, 2019-002, was noted. Recommendation ? We recommend procedures be put in place to ensure all reimbursements and other payments received under the federal Medicare and Medicaid programs are deposited into the separate deposit account and daily sweeps and transfers occur in accordance with the loan resolution. Views of Responsible Officials and Planned Corrective Actions ? Management agrees with the finding and will ensure processes regarding federal award compliance are updated and adhered to.
Condition ? As required, the Hospital has established a separate deposit account for Medicare and Medicaid payments. However, payments received under the Medicare and Medicaid programs were not deposited into the separate deposit account in accordance with loan resolution until July 2020. Only a portion of the reimbursements and other payments received subsequent to July 2020 were deposited into the separate deposit account. Funds in the separate deposit fund were not swept and deposited into the Hospital?s main operating account daily, in accordance with the loan resolution. Recommendation ? We recommend procedures be put in place to ensure all reimbursements and other payments received under the federal Medicare and Medicaid programs are deposited into the separate deposit account and daily sweeps and transfers occur in accordance with the loan resolution. Views of Responsible Officials and Planned Corrective Actions ? Management agrees with the finding and will ensure processes regarding federal award compliance are updated and adhered to. Anticipated Date of Completion ? In progress. Action Taken ? We are working with government payers, i.e., Medicare and Medicaid to ensure the deposits are made to the MidFirst bank account. The appropriate forms have been filled out and submitted to the respective payers. We are working with MidFirst bank to ensure daily sweeps and transfers are occurring. Person Responsible for Corrective Action Plan ? Chief Financial Officer.
2019-002
FAC accepted this audit on May 31, 2020 — management decision was due December 1, 2020.
Criteria or Specific Requirement ? Management is responsible for preparing financial statements in accordance with generally accepted accounting principles. Condition ? An adjusting entry that is material to the financial statements was made as a result of the audit to reduce net patient accounts receivable by approximately $1.1 million. Context ? In connection with adoption of Accounting Standards Update 2014-09 and review of the Hospital?s historical collections, it was determined that net patient accounts receivable was overstated. Cause ? A subsequent payments analysis to assist with determination of the adequacy of its allowances for price concessions under ASU 2014-09 was not performed. Effect or Potential Effect ? The error resulted in a misstatement of the Hospital?s internal financial statements. Questioned Costs ? There are no questioned costs. Recommendation ? We recommend the Hospital ensure that net patient accounts receivable is recorded at its net realizable amount. This process should include periodic subsequent payment analyses of historical collection amounts by payer group and in total. Views of Responsible Officials and Planned Corrective Actions ?Management agrees with the finding and will implement the recommendation.
Show full finding ▾Hide full finding ▴Criteria or Specific Requirement ? Management is responsible for preparing financial statements in accordance with generally accepted accounting principles. Condition ? An adjusting entry that is material to the financial statements was made as a result of the audit to reduce net patient accounts receivable by approximately $1.1 million. Context ? In connection with adoption of Accounting Standards Update 2014-09 and review of the Hospital?s historical collections, it was determined that net patient accounts receivable was overstated. Cause ? A subsequent payments analysis to assist with determination of the adequacy of its allowances for price concessions under ASU 2014-09 was not performed. Effect or Potential Effect ? The error resulted in a misstatement of the Hospital?s internal financial statements. Questioned Costs ? There are no questioned costs. Recommendation ? We recommend the Hospital ensure that net patient accounts receivable is recorded at its net realizable amount. This process should include periodic subsequent payment analyses of historical collection amounts by payer group and in total. Views of Responsible Officials and Planned Corrective Actions ?Management agrees with the finding and will implement the recommendation.
Condition ? An adjusting entry that is material to the financial statements was made as a result of the audit to reduce net patient accounts receivable by approximately $1.1 million. Recommendation ? We recommend the Hospital ensure that net patient accounts receivable is recorded at its?s net realizable amount. This process should include periodic subsequent payment analyses of historical collection amounts by payer group and in total. Views of Responsible Officials and Planned Corrective Actions ? Management agrees with the finding and will implement the recommendation. Date of Completion ? 05/15/2020. Action Taken: Implemented prospective contractual allowance at time of billing on two primary payers; Medicare and Anthem (Blue Cross). Reports have been written to do the periodic analysis of self pay realization rates and ensure allowances are relevant to the realization rates. Person Responsible for Corrective Action Plan ? Chief Financial Officer.
Criteria or Specific Requirement ? Special Tests and Provisions for the major program sets out the following compliance requirement: Borrowers shall establish accounts into which borrower funds, Agency loan proceeds, the revenues of the facility financed, and any other income shall be deposited in accordance with the loan resolution(s) authorizing the incurrence of indebtedness related to the Agency loan proceeds. The accounts will be maintained in accordance with the loan resolution(s) as long as the authorized indebtedness to the Agency is outstanding. Accounts may include but are not limited to the following: (a) construction account, (b) general account, (c) debt service account, and (d) reserve account. Condition ? As required, the Hospital has established a separate deposit account for Medicare and Medicaid payments. However, no payments received under the Medicare and Medicaid programs were deposited into the separate deposit account in accordance with loan resolution. Context ? The loan resolution requires the Hospital to open and maintain a separate deposit account for the receipt of payments under the Medicare and Medicaid programs (the ?Medicare/Medicaid Payments Account?), which is separate and apart from Hospital?s general operating account. The Medicare/Medicaid Payments account will be established with the same bank in which Hospital?s operating account is maintained for the Project. All payments received under the Medicare and Medicaid Programs shall be initially deposited into the Medicare/Medicaid Payments Account. At the end of each Business Day, all funds in the Medicare/Medicaid Payments Account shall be swept and deposited into Hospital?s main operating account. In addition to all other security for the Loans, Lender shall have a pledge of and perfected security interest in all deposit accounts of Hospital. Hospital shall cause deposit account control agreements to be executed by each bank or other financial institution in which Hospital has deposit or investment accounts (except that a control agreement shall not be required for the Medicare/Medicaid Payments Account), each in favor of Lender and with terms acceptable to Lender. Hospital shall instruct its depository bank to make the sweep and transfer of funds as set forth above, acceptable to Lender. Cause ? The Hospital does not have policies and procedures as internal controls to ensure accounts are maintained in compliance with loan resolutions. Effect or Potential Effect ?The potential effect is noncompliance with loan resolution. Questioned Costs ? There are no questioned costs. Recommendation ? We recommend procedures be put in place to ensure all payments received under the Medicare and Medicaid programs are deposited into the separate deposit account as required. Views of Responsible Officials and Planned Corrective Actions ? Management agrees with the finding and will ensure processes regarding federal award compliance are updated and adhered to.
Show full finding ▾Hide full finding ▴Criteria or Specific Requirement ? Special Tests and Provisions for the major program sets out the following compliance requirement: Borrowers shall establish accounts into which borrower funds, Agency loan proceeds, the revenues of the facility financed, and any other income shall be deposited in accordance with the loan resolution(s) authorizing the incurrence of indebtedness related to the Agency loan proceeds. The accounts will be maintained in accordance with the loan resolution(s) as long as the authorized indebtedness to the Agency is outstanding. Accounts may include but are not limited to the following: (a) construction account, (b) general account, (c) debt service account, and (d) reserve account. Condition ? As required, the Hospital has established a separate deposit account for Medicare and Medicaid payments. However, no payments received under the Medicare and Medicaid programs were deposited into the separate deposit account in accordance with loan resolution. Context ? The loan resolution requires the Hospital to open and maintain a separate deposit account for the receipt of payments under the Medicare and Medicaid programs (the ?Medicare/Medicaid Payments Account?), which is separate and apart from Hospital?s general operating account. The Medicare/Medicaid Payments account will be established with the same bank in which Hospital?s operating account is maintained for the Project. All payments received under the Medicare and Medicaid Programs shall be initially deposited into the Medicare/Medicaid Payments Account. At the end of each Business Day, all funds in the Medicare/Medicaid Payments Account shall be swept and deposited into Hospital?s main operating account. In addition to all other security for the Loans, Lender shall have a pledge of and perfected security interest in all deposit accounts of Hospital. Hospital shall cause deposit account control agreements to be executed by each bank or other financial institution in which Hospital has deposit or investment accounts (except that a control agreement shall not be required for the Medicare/Medicaid Payments Account), each in favor of Lender and with terms acceptable to Lender. Hospital shall instruct its depository bank to make the sweep and transfer of funds as set forth above, acceptable to Lender. Cause ? The Hospital does not have policies and procedures as internal controls to ensure accounts are maintained in compliance with loan resolutions. Effect or Potential Effect ?The potential effect is noncompliance with loan resolution. Questioned Costs ? There are no questioned costs. Recommendation ? We recommend procedures be put in place to ensure all payments received under the Medicare and Medicaid programs are deposited into the separate deposit account as required. Views of Responsible Officials and Planned Corrective Actions ? Management agrees with the finding and will ensure processes regarding federal award compliance are updated and adhered to.
Condition ? As required, the Hospital has established a separate deposit account for Medicare and Medicaid payments. However, no payments received under the Medicare and Medicaid programs were deposited into the separate deposit account in accordance with loan resolution. Recommendation ? We recommend procedures be put in place to ensure all payments received under the Medicare and Medicaid programs are deposited into the separate deposit account as required. Views of Responsible Officials and Planned Corrective Actions ? Management agrees with the finding and will ensure processes regarding federal award compliance are updated and adhered to. Anticipated Date of Completion ? In Progress. Action taken: Working with government payers, i.e., Medicare and Medicaid to ensure the deposits are made to the MidFirst bank account. The appropriate forms have been filled out and submitted to the respective payer. Person Responsible for Corrective Action Plan ? Chief Financial Officer.
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