EIN: 870788731
UEI: GSA_MIGRATION
Data as of August 19, 2026
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on November 15, 2022. 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 May 15, 2023, which was (1193 days ago).
What is a management decision? →Criteria or specific requirement: According to ?200.303 Internal Controls of 2 CFR Part 200, the non-Federal entity must 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. Condition: As part of our testing we noted that the District had a number of issues related to how it estimated and reported costs in the Phase 1 Provider Relief Fund (PRF) report which resulted in questions costs. We have outlined the questioned costs below: ? Noted that contract labor costs were overstated by $184,107 in the 3rd quarter of 2020. ? The District reduced costs charged to PRF by the amount reimbursed through the Medicare cost report. The percentage used by the District was estimated at 32%, but the actual percentage was 25% resulting in an understatement of costs of $99,288. ? The District estimated benefits as a percent of salaries at 30% when the actual percent was 37%. This resulted in an understatement of costs of $28,062. ? The District double counted two pieces of equipment charged to PRF which resulted in overstatement of costs of $16,165. ? The District charged construction in progress to PRF in the amount of $262,017. These projects were not completed by the June 30, 2021 deadline thus resulting in an overstatement of $262,017. Questioned costs: $334,939 Context: The costs were identified during general disbursement testing. Cause: Management oversight and turnover within the finance team. Effect: The auditor noted instances of noncompliance. Noncompliance results in possible over charges to the grant. Repeat finding: N/A Recommendation: We recommend the District review the Provider Relief Fund Terms and Conditions and the Frequently Asked Questions to ensure the funds are being used in compliance with the requirements. Views of responsible officials: There is no disagreement with the audit finding. Management?s response: During the reporting period three different CFO?s, two different Controllers, two different HR Directors and multiple other accounting staff and other HR staff turned over. This along with a weak Accounting Controls created multi-numeral problems with Internal Controls in general. During the onset of the COVID-19 pandemic and the distribution of the PRF dollars, there were many unknowns and many elements changed including criteria and timelines. The District will continue to review the PRF Terms and Conditions and understand these to the best of our knowledge. Based on the updated lost revenue numbers the District?s lost revenue would have increased from what was reported in the Phase 1 PRF report. We would look to HRSA to see how you would like us to correct the Phase 1 report.
Provider Relief Fund ? Assistance Listing No. 93.498 Recommendation: We recommend the District review the Provider Relief Fund Terms and Conditions and the Frequently Asked Questions to ensure the funds are being used in compliance with the requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: During the reporting period three different CFO?s, two different Controllers, two different HR Directors and multiple other accounting staff and other HR staff turned over. This along with a weak Accounting Controls created multi-numeral problems with Internal Controls in general. During the onset of the COVID-19 pandemic and the distribution of the PRF dollars, there were many unknowns and many elements changed including criteria and timelines. The District will continue to review the PRF Terms and Conditions and understand these to the best of our knowledge. Based on the updated lost revenue numbers the District?s lost revenue would have increased from what was reported in the Phase 1 PRF report. We would look to HRSA to see how you would like us to correct the Phase 1 report. Name(s) of the contact person(s) responsible for corrective action: Lionel Montoya, CFO Planned completion date for corrective action plan: Upon working with HRSA on how to correct the report.
Criteria or specific requirement: According to ?200.303 Internal Controls of 2 CFR Part 200, the nonfederal entity?s financial management systems, including records documenting compliance with Federal Statutes, regulations, and the terms and conditions of the federal award, must be sufficient to permit the preparation of reports required by general and program-specific terms and conditions. Further, the financial management system of each non-federal entity must provide accurate, current, and complete disclosure of the financial results of each federal award or program, in accordance with the reporting requirements. Condition: During our testing we noted the Hospital did not accurately complete the Phase 1 Provider Relief Fund reporting. It was noted that the lost revenue numbers were not accurately input into the report. Questioned costs: None noted. Context: The incorrect reporting was identified in our reporting testing. Cause: Management oversight and turnover within the finance team. Effect: The auditor noted instances of noncompliance. Noncompliance resulted in the lost revenues reported within the Phase 1 report being understated. Repeat Finding: N/A Recommendation: We recommend that the Hospital create a review process to ensure the Provider Relief Fund reports are accurately completed. Views of responsible officials: There is no disagreement with the audit finding. Management?s response: During the reporting period three different CFO?s, two different Controllers, two different HR Directors and multiple other accounting staff and other HR staff turned over. This along with a weak Accounting Controls created multi-numeral problems with Internal Controls in general. The staff has stabilized, new policies have been written, and the District is converting its Accounting platform building updated controls from ground zero. This will establish needed controls over the District?s Accounting Systems. Based on the updated lost revenue numbers the District?s lost revenue would have increased from what was reported in the Phase 1 PRF report. We would look to HRSA to see how you would like us to correct the Phase 1 report.
Recommendation: We recommend that the Hospital create a review process to ensure the Provider Relief Fund reports are accurately completed. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: During the reporting period three different CFO?s, two different Controllers, two different HR Directors and multiple other accounting staff and other HR staff turned over. This along with a weak Accounting Controls created multi-numeral problems with Internal Controls in general. The staff has stabilized, new policies have been written, and the District is converting its Accounting platform building updated controls from ground zero. This will establish needed controls over the District?s Accounting Systems. Based on the updated lost revenue numbers the District?s lost revenue would have increased from what was reported in the Phase 1 PRF report. We would look to HRSA to see how you would like us to correct the Phase 1 report. Name(s) of the contact person(s) responsible for corrective action: Lionel Montoya, CFO Planned completion date for corrective action plan: Upon working with HRSA on how to correct the report.
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