EIN: 860181654
UEI: V37FF7QGCV99
Data as of August 26, 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 (150 days ago).
What is a management decision? →During our testing over the expenditures included in the project worksheets, we observed management did not have effective internal controls in place to ensure expenditures reported for reimbursement in the FEMA project worksheets were actual paid expenditures. This resulted in an overstatement of the amount reimbursed by FEMA. Management performed an analysis of all expenditures submitted to FEMA and determined there were 4 expenditures reported for reimbursement in the FEMA project worksheets that were not based on actual paid expenditures resulting in an overstatement of the amount reimbursed by FEMA in the amount of $1,406,446. Cause: Management did not have effective internal controls in place over the compliance requirements as stated in the criteria or specific requirement section above. Effect or potential effect: Management was reimbursed by FEMA for expenditures that were not based on actual paid expenditures which resulted in an overstatement of the amount reimbursed by FEMA. Without sufficient internal controls, other compliance matters could occur in the future. Questioned costs: $1,406,446 – Assistance Listing Number 97.036 – Federal award identification number – Project number 699651 – CV-727 2020 Q2 PPE and Screening Thermometers Questioned costs were computed by calculating the difference between the expenditures submitted for reimbursement in the FEMA project worksheets and the actual paid expenditures. Context: During our testing over the expenditures included in the project worksheets, we obtained a listing of expenditures submitted for reimbursement to FEMA and selected a sample of 67 for testing the compliance requirements. There was 1 out of 67 selections where the expenditure reported for reimbursement was not based on actual paid expenditure. The sampling was a statistically valid sample. Management performed an analysis of all expenditures submitted to FEMA and determined there were 4 expenditures reported for reimbursement in the FEMA project worksheets that were not based on actual paid expenditures resulting in an overstatement of the amount reimbursed by FEMA in the amount of $1,406,446. Management’s control regarding the review of the project worksheet expenditures did not identify this matter when submitting the project worksheet for reimbursement to FEMA. Identification as a repeat finding, if applicable: No. Recommendation: Management should develop and implement effective internal controls to ensure expenditures reported for reimbursement in the FEMA project worksheets are actual paid expenditures. Management should refund the questioned costs to FEMA and work with FEMA to determine the extent of additional courses of action. Views of responsible officials: Management concurs with the audit finding and has implemented a corrective action plan to address the identified issue. Management has notified Arizona DEMA of the identified expenditures and has begun the process of reimbursing the $1,406,446 to FEMA. For all future FEMA project applications, Management will conduct a comprehensive reconciliation process prior to submission. This process will include a detailed review of invoice documentation and verification of payment to ensure compliance with applicable federal requirements.
Show full finding ▾Hide full finding ▴Internal control deficiency and noncompliance over activities allowed or unallowed, allowable costs/cost principles, reporting, and special tests and provisions related to amounts reimbursed for the project worksheets. Identification of the federal program: Assistance Listing Number 97.036: • COVID-19 – Disaster Grants – Public Assistance (Presidentially Declared Disasters) • U.S. Department of Homeland Security • Federal award identification number: • Project number 699651 – CV-727 2020 Q2 PPE and Screening Thermometers • Federal award year – January 20, 2020 to May 11, 2023 • Pass-through entity – Arizona Department of Emergency and Military Affairs Criteria or specific requirement (including statutory, regulatory or other citation): Title 2, Subtitle A, Chapter II, Part 200, Subpart D, 200.303 Internal controls. The non-Federal entity must: (a) Establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States or the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). The Office of Management and Budget Compliance Supplement states the Federal Emergency Management Agency (FEMA) evaluates the eligibility of all costs claimed by the applicant. Not all costs incurred as a result of the incident are eligible. Costs must be: • Directly tied to the performance of eligible work; • Adequately documented; • Reduced by all applicable credits, such as insurance proceeds and salvage values; • Authorized and not prohibited under federal, state, territorial, tribal, or local government laws or regulations; • Consistent with applicant’s internal policies, regulations, and procedures that apply uniformly to both federal awards and other activities of the applicant; and • Necessary and reasonable to accomplish the work properly and efficiently The Office of Management and Budget Compliance Supplement requires the entity to accurately complete the project application which is used to document the details of the applicant’s project and costs claimed. The Office of Management and Budget Compliance Supplement states the entity is required to certify that reported costs were incurred in performance of eligible work, that the approved work was completed, that the project is in compliance with the provisions of the FEMA-State Agreement, all grant conditions were met, and that payments for that project were made in accordance with the applicable payment provisions. Condition: During our testing over the expenditures included in the project worksheets, we observed management did not have effective internal controls in place to ensure expenditures reported for reimbursement in the FEMA project worksheets were actual paid expenditures. This resulted in an overstatement of the amount reimbursed by FEMA. Management performed an analysis of all expenditures submitted to FEMA and determined there were 4 expenditures reported for reimbursement in the FEMA project worksheets that were not based on actual paid expenditures resulting in an overstatement of the amount reimbursed by FEMA in the amount of $1,406,446. Cause: Management did not have effective internal controls in place over the compliance requirements as stated in the criteria or specific requirement section above. Effect or potential effect: Management was reimbursed by FEMA for expenditures that were not based on actual paid expenditures which resulted in an overstatement of the amount reimbursed by FEMA. Without sufficient internal controls, other compliance matters could occur in the future. Questioned costs: $1,406,446 – Assistance Listing Number 97.036 – Federal award identification number – Project number 699651 – CV-727 2020 Q2 PPE and Screening Thermometers Questioned costs were computed by calculating the difference between the expenditures submitted for reimbursement in the FEMA project worksheets and the actual paid expenditures. Context: During our testing over the expenditures included in the project worksheets, we obtained a listing of expenditures submitted for reimbursement to FEMA and selected a sample of 67 for testing the compliance requirements. There was 1 out of 67 selections where the expenditure reported for reimbursement was not based on actual paid expenditure. The sampling was a statistically valid sample. Management performed an analysis of all expenditures submitted to FEMA and determined there were 4 expenditures reported for reimbursement in the FEMA project worksheets that were not based on actual paid expenditures resulting in an overstatement of the amount reimbursed by FEMA in the amount of $1,406,446. Management’s control regarding the review of the project worksheet expenditures did not identify this matter when submitting the project worksheet for reimbursement to FEMA. Identification as a repeat finding, if applicable: No. Recommendation: Management should develop and implement effective internal controls to ensure expenditures reported for reimbursement in the FEMA project worksheets are actual paid expenditures. Management should refund the questioned costs to FEMA and work with FEMA to determine the extent of additional courses of action. Views of responsible officials: Management concurs with the audit finding and has implemented a corrective action plan to address the identified issue. Management has notified Arizona DEMA of the identified expenditures and has begun the process of reimbursing the $1,406,446 to FEMA. For all future FEMA project applications, Management will conduct a comprehensive reconciliation process prior to submission. This process will include a detailed review of invoice documentation and verification of payment to ensure compliance with applicable federal requirements.
Federal Award Findings and Questioned Costs – Year ending December 31, 2024 Finding 2024-001 – Internal control deficiency and noncompliance over activities allowed or unallowed, allowable costs/cost principles, reporting, and special tests and provisions related to amounts reimbursed for the project worksheets. Identification of the federal program: Assistance Listing Number 97.036: • COVID-19 – Disaster Grants – Public Assistance (Presidentially Declared Disasters) • U.S. Department of Homeland Security • Federal award identification number: o Project number 699651 – CV-727 2020 Q2 PPE and Screening Thermometers • Federal award year – January 20, 2020 to May 11, 2023 • Pass-through entity – Arizona Department of Emergency and Military Affairs (Arizona DEMA) Condition: During the testing over the expenditures included in the project worksheets, management did not have effective internal controls in place to ensure expenditures reported for reimbursement in the FEMA project worksheets were actual paid expenditures. This resulted in an overstatement of the amount reimbursed by FEMA. Management performed an analysis of all expenditures submitted to FEMA and determined there were 4 expenditures reported for reimbursement in the FEMA project worksheets that were not based on actual paid expenditures resulting in an overstatement of the amount reimbursed by FEMA in the amount of $1,406,446. Cause: Management did not have effective internal controls in place over the compliance requirements as stated in the criteria or specific requirement section of the report. Effect or potential effect: Management was reimbursed by FEMA for expenditures that were not based on actual paid expenditures which resulted in an overstatement of the amount reimbursed by FEMA. Without sufficient internal controls, other compliance matters could occur in the future. Questioned costs: $1,406,446 – Assistance Listing Number 97.036 – Federal award identification number – Project number 699651 – CV-727 2020 Q2 PPE and Screening Thermometers Questioned costs were computed by calculating the difference between the expenditures submitted for reimbursement in the FEMA project worksheets and the actual paid expenditures. Context: During the testing over the expenditures included in the project worksheets, the auditors obtained a listing of expenditures submitted for reimbursement to FEMA and selected a sample of 67 for testing the compliance requirements. There was 1 out of 67 selections where the expenditure reported for reimbursement was not based on actual paid expenditure. The sampling was a statistically valid sample. Management performed an analysis of all expenditures submitted to FEMA and determined there were 4 expenditures reported for reimbursement in the FEMA project worksheets that were not based on actual paid expenditures resulting in an overstatement of the amount reimbursed by FEMA in the amount of $1,406,446. Management’s control regarding the review of the project worksheet expenditures did not identify this matter when submitting the project worksheet for reimbursement to FEMA. Identification as a repeat finding, if applicable: No. Recommendation: Management should develop and implement effective internal controls to ensure expenditures reported for reimbursement in the FEMA project worksheets are actual paid expenditures. Management should refund the questioned costs to FEMA and work with FEMA to determine the extent of additional courses of action. Views of responsible officials: Management concurs with the audit finding and has implemented a corrective action plan to address the identified issue. Management has notified Arizona DEMA of the identified expenditures and has begun the process of reimbursing the $1,406,446 to FEMA. For all future FEMA project applications, Management will conduct a comprehensive reconciliation process prior to submission. This process will include a detailed review of invoice documentation and verification of payment to ensure compliance with applicable federal requirements. Responsible Parties: Heather Mahoney, Network Controller Anticipated Date of Completion: September 30, 2025
FAC accepted this audit on September 29, 2022 — management decision was due March 29, 2023.
Per discussion with management, HonorHealth has processes and internal controls in place to ensure claims submitted to HRSA for reimbursement are for allowable COVID 19 charges from eligible uninsured patients. In addition, management has indicated that the Company has processes and internal controls in place to not engage in balanced billing or cost sharing with the patient or third-party payor for those claims submitted to the HRSA uninsured program. These internal controls include validating the completeness and accuracy of the uninsured COVID 19 patient log report generated from HonorHealth?s patient accounting system, reviewing the billing of COVID 19 uninsured claims to HRSA and writing down the patient account balance to zero once the uninsured payments are received. However, management did not consistently retain documentation evidencing the performance of these controls. Cause: HonorHealth did not consistently retain documentation to evidence the performance of internal controls over the uninsured COVID 19 claims submitted for reimbursement. Effect or potential effect: There is no consistent documentation to support the performance of internal controls. Questioned costs: None. Context: Total federal expenditures for Assistance Listing 93.461 amounted to $4 million. Identification as a repeat finding, if applicable: The finding is a repeat finding ? finding 2020-001. Recommendation: HonorHealth should refine its process and retain documentation evidencing the performance of internal controls over the uninsured COVID 19 claims submitted for reimbursement. View of responsible officials: Although the uninsured program ended in 2022, HonorHealth agrees with the finding and the HonorHealth Revenue Cycle team implemented processes to retain documentation as to their review that the claim related to the reimbursement for COVID 19 testing and services provided to uninsured individuals, insurance verification for the patients uninsured claim, and that HonorHealth had not received reimbursement from another payor for the uninsured claim. In addition, the HonorHealth Revenue Cycle team is adding internal controls to validate the completeness and accuracy of the uninsured COVID 19 patient log, including timely review and approval of the uninsured COVID 19 patient log.
Show full finding ▾Hide full finding ▴Finding 2021-001: Internal Control Deficiency over Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Eligibility and Special Tests and Provisions Identification of the federal program: Assistance Listing Number 93.461: ? COVID 19 ? HRSA COVID 19 Claims Reimbursement for the Uninsured Program and the COVID 19 Coverage Assistance Fund ? U.S. Department of Health and Human Services ? Federal award identification number ? Not Applicable ? Federal award year ? February 4, 2020 and after Criteria or specific requirement (including statutory, regulatory or other citation): Title 2, Subtitle A Chapter II Part 200 Subpart D 200.303 Internal controls states the following regarding internal control: ?The non-Federal entity must: (a) Establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework,? issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). The HRSA terms and conditions of the federal award requires the recipient to submit claims for reimbursement for COVID 19 testing and services provided to uninsured individuals and to certify that the patients identified on the claim form were uninsured individuals at the time the services were provided. The recipient health care entity should not engage in balance billing or cost sharing for any COVID 19 related testing or treatment for which a claim has been submitted under the uninsured program. Condition: Per discussion with management, HonorHealth has processes and internal controls in place to ensure claims submitted to HRSA for reimbursement are for allowable COVID 19 charges from eligible uninsured patients. In addition, management has indicated that the Company has processes and internal controls in place to not engage in balanced billing or cost sharing with the patient or third-party payor for those claims submitted to the HRSA uninsured program. These internal controls include validating the completeness and accuracy of the uninsured COVID 19 patient log report generated from HonorHealth?s patient accounting system, reviewing the billing of COVID 19 uninsured claims to HRSA and writing down the patient account balance to zero once the uninsured payments are received. However, management did not consistently retain documentation evidencing the performance of these controls. Cause: HonorHealth did not consistently retain documentation to evidence the performance of internal controls over the uninsured COVID 19 claims submitted for reimbursement. Effect or potential effect: There is no consistent documentation to support the performance of internal controls. Questioned costs: None. Context: Total federal expenditures for Assistance Listing 93.461 amounted to $4 million. Identification as a repeat finding, if applicable: The finding is a repeat finding ? finding 2020-001. Recommendation: HonorHealth should refine its process and retain documentation evidencing the performance of internal controls over the uninsured COVID 19 claims submitted for reimbursement. View of responsible officials: Although the uninsured program ended in 2022, HonorHealth agrees with the finding and the HonorHealth Revenue Cycle team implemented processes to retain documentation as to their review that the claim related to the reimbursement for COVID 19 testing and services provided to uninsured individuals, insurance verification for the patients uninsured claim, and that HonorHealth had not received reimbursement from another payor for the uninsured claim. In addition, the HonorHealth Revenue Cycle team is adding internal controls to validate the completeness and accuracy of the uninsured COVID 19 patient log, including timely review and approval of the uninsured COVID 19 patient log.
Finding 2021-001: Internal Control Deficiency over Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Eligibility and Special Tests and Provisions Identification of the federal program: Assistance Listing Number 93.461: ? COVID-19 ? HRSA COVID-19 Claims Reimbursement for the Uninsured Program and the COVID-19 Coverage Assistance Fund ? U.S. Department of Health and Human Services ? Federal award identification number ? Not Applicable ? Federal award year ? February 4, 2020 and after Condition: Per discussion with management, HonorHealth has processes and internal controls in place to ensure claims submitted to HRSA for reimbursement are for allowable COVID 19 charges from eligible uninsured patients. In addition, management has indicated that the Company has processes and internal controls in place to not engage in balanced billing or cost sharing with the patient or third-party payor for those claims submitted to the HRSA uninsured program. These internal controls include validating the completeness and accuracy of the uninsured COVID 19 patient log report generated from HonorHealth?s patient accounting system, reviewing the billing of COVID 19 uninsured claims to HRSA and writing down the patient account balance to zero once the uninsured payments are received. However, management did not consistently retain documentation evidencing the performance of these controls. Cause: HonorHealth did not consistently retain documentation to evidence the performance of internal controls over the uninsured COVID 19 claims submitted for reimbursement. Effect or potential effect: There is no consistent documentation to support the performance of internal controls. Questioned costs: None. Context: Total federal expenditures for Assistance Listing 93.461 amounted to $4 million. Identification as a repeat finding, if applicable: The finding is a repeat finding ? finding 2020-001. Recommendation: HonorHealth should refine its process and retain documentation evidencing the performance of internal controls over the uninsured COVID-19 claims submitted for reimbursement. View of responsible officials: Although the uninsured program ended in 2022, HonorHealth agrees with the finding and the HonorHealth Revenue Cycle team implemented processes to retain documentation as to their review that the claim related to the reimbursement for COVID-19 testing and services provided to uninsured individuals, insurance verification for the patients uninsured claim, and that HonorHealth had not received reimbursement from another payor for the uninsured claim. In addition, the HonorHealth Revenue Cycle team is adding internal controls to validate the completeness and accuracy of the uninsured COVID 19 patient log, including timely review and approval of the uninsured COVID 19 patient log. Responsible Parties: Heather Mahoney, Network Controller Anticipated Date of Completion: September 30, 2022
2020-001
During our testing, we noted that HonorHealth included labor costs in their period one provider relief fund report submission to HRSA. Total labor costs included in the provider relief fund report amounted to $1,508,000, which included a $200,000 labor accrual. Management was able to subsequently identify $269,000 of additional labor costs incurred to treat COVID 19 patients. The $200,000 payroll accrual included in the HRSA report submission was not supported by actual personnel labor costs, but rather an estimate of the labor cost. Cause: Certain labor costs included in the provider relief fund report submitted to HRSA included an estimate of labor costs incurred, as opposed to actual documentation of the labor costs incurred to treat COVID 19 patients. Effect or potential effect: HonorHealth included unsupported labor costs to treat COVID 19 patients in the provider relief fund report submitted to HRSA. Questioned costs: The estimated labor accrual of $200,000, however, management was able to subsequently support $269,000 of actual labor costs incurred to treat COVID 19 patients. Context: HonorHealth included $1,508,000 of labor costs in their period one provider relief fund report submitted to HRSA. At the time of the provider relief fund report submission, management identified $1,308,000 of actual labor costs incurred for treating COVID 19 patients and included an estimated labor accrual amounting to $200,000. Subsequently, management identified an additional $269,000 of actual labor costs related to the treatment of COVID 19 patients. The inclusion of the estimated labor costs of $200,000 did not have an impact as to HonorHealth?s ability to demonstrate that sufficient COVID 19 expenses and lost revenues were incurred in excess of the provider relief funds received as reflected in the provider relief fund report submitted to HRSA. Identification as a repeat finding, if applicable: The finding is not a repeat finding. Recommendation: HonorHealth should refine its processes to ensure all costs included in the provider relief fund reports submitted to HRSA represent actual supported costs to treat COVID 19 patients. View of responsible officials: Management will refine the process for future provider relief fund reports to only include costs incurred during the quarterly period and exclude accruals from that period.
Show full finding ▾Hide full finding ▴Finding 2021-002: Noncompliance Over Provider Relief Fund Labor Costs Identification of the federal program: Assistance Listing Number 93.498: ? COVID 19 ? Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution ? U.S. Department of Health and Human Services ? Federal award identification number ? Not Applicable ? Federal award year: ? Period 1 ? January 1, 2020 to June 30, 2021 ? Period 2 ? January 1, 2020 to December 31, 2021 Criteria or specific requirement (including statutory, regulatory or other citation): 2 CFR Part 200 Section 200.84 states a questioned cost as a cost that either (a) resulted from a violation or possible violation of a statue, regulation, or the terms and conditions of a Federal award, including for funds used to match Federal awards (b) where the costs, at the time of the audit, are not supported by adequate documentation, or (c) where the cost incurred appear unreasonable and do not reflect the actions a prudent person would take in the circumstances. The terms and conditions of the award states the recipient certifies that the payment will only be used to prevent, prepare for, and respond to coronavirus, and that the payment shall reimburse the recipient only for health care related expenses and lost revenues that are attributable to coronavirus. Condition: During our testing, we noted that HonorHealth included labor costs in their period one provider relief fund report submission to HRSA. Total labor costs included in the provider relief fund report amounted to $1,508,000, which included a $200,000 labor accrual. Management was able to subsequently identify $269,000 of additional labor costs incurred to treat COVID 19 patients. The $200,000 payroll accrual included in the HRSA report submission was not supported by actual personnel labor costs, but rather an estimate of the labor cost. Cause: Certain labor costs included in the provider relief fund report submitted to HRSA included an estimate of labor costs incurred, as opposed to actual documentation of the labor costs incurred to treat COVID 19 patients. Effect or potential effect: HonorHealth included unsupported labor costs to treat COVID 19 patients in the provider relief fund report submitted to HRSA. Questioned costs: The estimated labor accrual of $200,000, however, management was able to subsequently support $269,000 of actual labor costs incurred to treat COVID 19 patients. Context: HonorHealth included $1,508,000 of labor costs in their period one provider relief fund report submitted to HRSA. At the time of the provider relief fund report submission, management identified $1,308,000 of actual labor costs incurred for treating COVID 19 patients and included an estimated labor accrual amounting to $200,000. Subsequently, management identified an additional $269,000 of actual labor costs related to the treatment of COVID 19 patients. The inclusion of the estimated labor costs of $200,000 did not have an impact as to HonorHealth?s ability to demonstrate that sufficient COVID 19 expenses and lost revenues were incurred in excess of the provider relief funds received as reflected in the provider relief fund report submitted to HRSA. Identification as a repeat finding, if applicable: The finding is not a repeat finding. Recommendation: HonorHealth should refine its processes to ensure all costs included in the provider relief fund reports submitted to HRSA represent actual supported costs to treat COVID 19 patients. View of responsible officials: Management will refine the process for future provider relief fund reports to only include costs incurred during the quarterly period and exclude accruals from that period.
Finding 2021-002: Noncompliance over provider relief fund labor costs Identification of the federal program: Assistance Listing Number 93.498: ? COVID-19 ? Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution ? U.S. Department of Health and Human Services ? Federal award identification number ? Not Applicable ? Federal award year: o Period 1 ? January 1, 2020 to June 30, 2021 o Period 2 ? January 1, 2020 to December 31, 2021 Condition: During our testing, we noted that HonorHealth included labor costs in their period one provider relief fund report submission to HRSA. Total labor costs included in the provider relief fund report amounted to $1,508,000, which included a $200,000 labor accrual. Management was able to subsequently identify $269,000 of additional labor costs incurred to treat COVID 19 patients. The $200,000 payroll accrual included in the HRSA report submission was not supported by actual personnel labor costs, but rather an estimate of the labor cost. Cause: Certain labor costs included in the provider relief fund report submitted to HRSA included an estimate of labor costs incurred, as opposed to actual documentation of the labor costs incurred to treat COVID 19 patients. Effect or potential effect: HonorHealth included unsupported labor costs to treat COVID 19 patients in the provider relief fund report submitted to HRSA. Questioned costs: The estimated labor accrual of $200,000 was subsequently supported by $269,000 of actual labor costs incurred to treat COVID 19 patients. Context: HonorHealth included $1,508,000 of labor costs in their period one provider relief fund report submitted to HRSA. At the time of the provider relief fund report submission, management identified $1,308,000 of actual labor costs incurred for treating COVID 19 patients and included an estimated labor accrual amounting to $200,000. Subsequently, management identified an additional $269,000 of actual labor costs related to the treatment of COVID 19 patients. The inclusion of the estimated labor costs of $200,000 did not have an impact as to HonorHealth?s ability to demonstrate that sufficient COVID-19 expenses and lost revenues were incurred in excess of the provider relief funds received as reflected in the provider relief fund report submitted to HRSA. Identification as a repeat finding, if applicable: The finding is not a repeat finding. Recommendation: HonorHealth should refine its processes to ensure all costs included in the provider relief fund reports submitted to HRSA represent actual supported costs to treat COVID 19 patients. View of responsible officials: Management will refine the process for future provider relief fund reports to only include costs incurred during the quarterly period and exclude accruals from that period. Responsible Parties: Heather Mahoney, Network Controller Anticipated Date of Completion: September 30, 2022
FAC accepted this audit on March 30, 2022 — management decision was due September 30, 2022.
Per discussion with management, the Company has processes and internal controls in place to ensure claims submitted to HRSA for reimbursement are for allowable COVID-19 charges from eligible uninsured patients. These internal controls include validating the completeness and accuracy of the uninsured COVID-19 patient log report generated from HonorHealth?s patient accounting system and reviewing the billing of COVID-19 uninsured claims to HRSA. However, management did not consistently retain documentation evidencing the performance of these controls. Cause: HonorHealth did not consistently retain documentation to evidence the performance of internal controls over the uninsured COVID-19 claims submitted for reimbursement. Effect or potential effect: There is no consistent documentation to support the performance of internal controls. Questioned Costs: None. Context: Total federal expenditures for Assistance Listing 93.461 amounted to $3 million. Identification as a repeat finding, if applicable: The finding is not a repeat finding. Recommendation: HonorHealth should refine its process and retain documentation evidencing that management verified the patient?s coverage or eligibility prior to submitting claims to HRSA. View of Responsible Officials: HonorHealth agrees with the finding and has developed a plan to correct the finding. The HonorHealth Revenue Cycle team is implementing workflows to develop a documentation retention process related to patient insurance verification for uninsured claims. In addition, the HonorHealth Revenue Cycle team is adding internal controls to validate the completeness and accuracy of the uninsured COVID-19 patient log which will include timely review and approval of the uninsured COVID-19 patient log.
Show full finding ▾Hide full finding ▴Finding 2020-001 ? Internal Control Deficiency over Activities Allowed or Unallowed and Eligibility Identification of the federal program: Federal Grantor: United States Department of Health and Human Services, Health Resources and Services Administration (HRSA) Assistance Listing No.: 93.461, COVID-19 Claims Reimbursement to Health Care Providers and Facilities for Testing, Treatment, and Vaccine Administration for the Uninsured Award Period of Performance: February 4, 2020 to December 31, 2020. Criteria or Specific Requirement (including statutory, regulatory or other citation): Section 200.303 of the Uniform Guidance states the following regarding internal control: ?The non-Federal entity must: (a) Establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). The Health Resources and Services Administration (HRSA) terms and conditions of the federal award requires the recipient certify that the patients identified on the claim form were uninsured individuals at the time the services were provided. Condition: Per discussion with management, the Company has processes and internal controls in place to ensure claims submitted to HRSA for reimbursement are for allowable COVID-19 charges from eligible uninsured patients. These internal controls include validating the completeness and accuracy of the uninsured COVID-19 patient log report generated from HonorHealth?s patient accounting system and reviewing the billing of COVID-19 uninsured claims to HRSA. However, management did not consistently retain documentation evidencing the performance of these controls. Cause: HonorHealth did not consistently retain documentation to evidence the performance of internal controls over the uninsured COVID-19 claims submitted for reimbursement. Effect or potential effect: There is no consistent documentation to support the performance of internal controls. Questioned Costs: None. Context: Total federal expenditures for Assistance Listing 93.461 amounted to $3 million. Identification as a repeat finding, if applicable: The finding is not a repeat finding. Recommendation: HonorHealth should refine its process and retain documentation evidencing that management verified the patient?s coverage or eligibility prior to submitting claims to HRSA. View of Responsible Officials: HonorHealth agrees with the finding and has developed a plan to correct the finding. The HonorHealth Revenue Cycle team is implementing workflows to develop a documentation retention process related to patient insurance verification for uninsured claims. In addition, the HonorHealth Revenue Cycle team is adding internal controls to validate the completeness and accuracy of the uninsured COVID-19 patient log which will include timely review and approval of the uninsured COVID-19 patient log.
Finding 2020-001 ? Internal Control Deficiency over Activities Allowed or Unallowed and Eligibility Information on the federal program: Federal Grantor: United States Department of Health and Human Services, Health Resources and Services Administration (HRSA) Assistance Listing No.: 93.461, COVID-19 Claims Reimbursement to Health Care Providers and Facilities for Testing, Treatment, and Vaccine Administration for the Uninsured Community: Various Pass-Through Award Number: Various Pass-Through Award Period of Performance: 02/04/2020-12/31/2020 Condition: HonorHealth has processes and internal controls in place to ensure claims submitted to HRSA for reimbursement are for allowable COVID-19 charges from eligible uninsured patients. These internal controls include validating the completeness and accuracy of the uninsured COVID-19 patient log report generated from HonorHealth?s patient accounting system and reviewing the billing of COVID-19 uninsured claims to HRSA. However, management did not consistently retain documentation evidencing the performance of these controls. Cause: HonorHealth did not consistently retain documentation to evidence the performance of internal controls over the uninsured COVID-19 claims submitted for reimbursement. View of Responsible Officials and Planned Corrective Actions: HonorHealth agrees with the finding and has developed a plan to correct the finding. The HonorHealth Revenue Cycle team is documenting controls and workflows related to the patient accounting system insurance verification for uninsured claims. In addition, the HonorHealth Revenue Cycle team is adding internal controls to validate the completeness and accuracy of the uninsured COVID-19 patient log which will include timely review and approval of the uninsured COVID-19 patient log. Responsible Parties: Derek Hampshire, Network-Controller Anticipated Date of Completion: March 31, 2022
During our testing, we noted that the Company included labor costs in support of this grant. Those costs included labor costs incurred in February 2020 being charged to the award. Per the criteria section above, the allowable period of performance for this award is March 1, 2020 through December 31, 2020. Cause: Certain labor costs in support of this grant included labor costs incurred in February 2020; the Company did not exclude these related labor costs, which was prior to the period of performance. The Company?s internal control was designed to prevent a material misstatement to within a desired threshold, but not to ensure all costs were incurred within the period of performance. Effect or potential effect: The Company expended funds that fell outside the period of performance. Questioned Costs: $100,318 for assistance listing 21.019. HonorHealth reported to the Arizona Department of Health Services COVID-19 expenditures amounting to $5,432,525, which was $1,741,189 in excess of the $3,691,336 granted to HonorHealth. Context: Through our testing, we identified 2 ($200) transactions that were for labor costs incurred during February 2020. After we identified the 2 exceptions, management quantified all labor costs incurred in February 2020 ($100,318). HonorHealth reported to the Arizona Department of Health Services COVID-19 expenditures amounting to $5,432,525, which was $1,741,189 in excess of the $3,691,336 granted to HonorHealth. The inclusion of February 2020 labor costs did not have an impact on the amount of funding received. Identification as a repeat finding, if applicable: The finding is not a repeat finding. Recommendation: We recommend the Company refine its internal control to ensure all costs incurred to support the grant are within the period of performance. View of Responsible Officials: Management agrees with the recommendation and has taken steps to refine the internal control to ensure all costs incurred are within the period of performance. Further, management believes that sufficient other eligible expenditures were incurred during the period of performance which exceeded the questioned costs identified and that support the full amount of the expended grant.
Show full finding ▾Hide full finding ▴Finding 2020-002 ? Noncompliance over the period of performance compliance requirement. Identification of the federal program: Federal Grantor: Department of the Treasury passed through Arizona Department of Health Services Assistance Listing No.: 21.019, COVID-19 ? Coronavirus Relief Fund Award Period of Performance: March 1, 2020 to December 31, 2020. Criteria or Specific Requirement: The CARES Act Sec. 5001, SEC. 601. CORONAVIRUS RELIEF FUND states the following: ?(d) USE OF FUNDS: A State, Tribal government, and unit of local government shall use the funds provided under a payment made under this section to cover only those costs of the State, Tribal government, or unit of local government that: (3) were incurred during the period that begins on March 1, 2020, and ends on December 31, 2021.? Condition: During our testing, we noted that the Company included labor costs in support of this grant. Those costs included labor costs incurred in February 2020 being charged to the award. Per the criteria section above, the allowable period of performance for this award is March 1, 2020 through December 31, 2020. Cause: Certain labor costs in support of this grant included labor costs incurred in February 2020; the Company did not exclude these related labor costs, which was prior to the period of performance. The Company?s internal control was designed to prevent a material misstatement to within a desired threshold, but not to ensure all costs were incurred within the period of performance. Effect or potential effect: The Company expended funds that fell outside the period of performance. Questioned Costs: $100,318 for assistance listing 21.019. HonorHealth reported to the Arizona Department of Health Services COVID-19 expenditures amounting to $5,432,525, which was $1,741,189 in excess of the $3,691,336 granted to HonorHealth. Context: Through our testing, we identified 2 ($200) transactions that were for labor costs incurred during February 2020. After we identified the 2 exceptions, management quantified all labor costs incurred in February 2020 ($100,318). HonorHealth reported to the Arizona Department of Health Services COVID-19 expenditures amounting to $5,432,525, which was $1,741,189 in excess of the $3,691,336 granted to HonorHealth. The inclusion of February 2020 labor costs did not have an impact on the amount of funding received. Identification as a repeat finding, if applicable: The finding is not a repeat finding. Recommendation: We recommend the Company refine its internal control to ensure all costs incurred to support the grant are within the period of performance. View of Responsible Officials: Management agrees with the recommendation and has taken steps to refine the internal control to ensure all costs incurred are within the period of performance. Further, management believes that sufficient other eligible expenditures were incurred during the period of performance which exceeded the questioned costs identified and that support the full amount of the expended grant.
Finding 2020-002 ? Noncompliance over the period of performance compliance requirement. Information on the federal program: Federal Grantor: Department of the Treasury passed through Arizona Department of Health Services Assistance Listing No.: 21.019, COVID-19 ? Coronavirus Relief Fund Pass-Through Award Number: RFGA2021-003-02 Pass-Through Award Period of Performance: 01/01/2020-12/31/2020 Condition: During EY?s testing, it was noted that the Company included labor costs in support of this grant. Those costs included labor costs incurred in February 2020 being charged to the award. Per the criteria, the allowable period of performance for this award is March 1, 2020 through December 31, 2020. Cause: Certain labor costs in support of this grant included labor costs incurred in February 2020; the Company did not exclude these related costs, which was prior to the period of performance. The Company?s internal control was designed to prevent a material misstatement to within a desired threshold, but not to ensure all costs were incurred within the period of performance. View of Responsible Officials and Planned Corrective Actions: Management has taken steps to refine the internal control to ensure all costs incurred are within the period of performance. Since the program has ended, a remediation date is not applicable however future, similar, programs will be subject to enhanced review by accounting personnel to ensure costs reported were incurred within the period of performance. Responsible Parties: Derek Hampshire, Network-Controller Anticipated Date of Completion: March 31, 2022
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