EIN: 880201578
UEI: EYGECW74VXX7
Data as of August 20, 2026
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on April 1, 2024. 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 October 1, 2024, which was (689 days ago).
What is a management decision? →United States Department of Agriculture Federal Assistance Listing #10.766 Community Facilities Loans and Grants Cluster Department of Health and Human Services Federal Assistance Listing #93.498 COVID‐19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Preparation of Schedule of Expenditures of Federal Awards Material Weakness in Internal Control Over Compliance – Other Criteria: Proper controls over financial reporting include the ability to prepare the schedule of expenditures of federal awards (Schedule) and accompanying notes to the Schedule. Condition: The Hospital does not have an internal control system designed to provide for a complete and accurate schedule of expenditures of federal awards being audited. We were requested to draft the Schedule. Cause: Auditor assistance with preparation of the schedule is not unusual, as the Schedule has unique and specialized requirements and preparation is only required when the Hospital meets a specified threshold of federal expenditures. Effect: There is a reasonable possibility that the Hospital would not be able to draft a Schedule that is correct without assistance of the auditors. Questioned Costs: None reported. Context: Sampling was not used. Repeat Finding from Prior Years: No. Recommendation: While we recognize that this condition is not unusual for an organization with limited staffing, we recommend management be aware of the financial reporting requirements relating to the Hospital’s schedule of expenditures of federal awards and internal controls that impact financial reporting. Views of Responsible Officials Management agrees with the finding.
United States Department of Agriculture Federal Assistance Listing #10.766 Community Facilities Loans and Grants Cluster Department of Health and Human Services Federal Assistance Listing #93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Preparation of Schedule of Expenditures of Federal Awards Material Weakness in Internal Control Over Compliance – Other Finding Summary: The Hospital does not have an internal control system designed to provide for a complete and accurate schedule of expenditures of federal awards being audited. We were requested to draft the Schedule. Responsible Individuals: Lynn Broyles, CFO Corrective Action Plan: Having auditors assist with preparing the SEFA is not unusual. Due to the delays in obtained the guidance to conduct the compliance audit for the Provider Relief Funds, this finding would generally be included as part of the financial statement audit under Government Auditing Standards (Yellowbook). As the financial statement audit had been issued prior to the compliance audit being completed, this finding needed to be identified separately. Anticipated Completion Date: Ongoing
Department of Health and Human Services Federal Assistance Listing #93.498 COVID‐19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Reporting Material Weakness in Internal Control Over Compliance and Material Noncompliance Criteria: 2 CFR 200.303(a) establishes that the auditee must establish and maintain effective internal control over the federal award that provides assurance that the entity is managing the federal award in compliance with federal statutes, regulations, and conditions of the federal award. The Hospital claimed lost revenues based on a method other than the method reported. Condition: The Hospital selected the Actual Revenue Option (i.e., Option 1) in the HHS Special Report. Option 1 is based on actual quarterly net revenues by payor which are included in the HHS Special Report ‐Period 4 for years 2019 through 2022. However, management calculated the net revenues using various allocations due to reporting limitations within the accounting and billing system and did not use the actual quarterly financial statements to complete the HHS Special Report. The calculation used by management would be considered an Alternative Reasonable Methodology (i.e., Option 3). The selection of Option 1 was improperly reported within the HHS Special Report – Period 4 which caused the report to be inaccurate. In addition, for Quarter 3 and Quarter 4 of 2021, the amounts reported on the HHS Special Report do not agree to the related client support by $168,838 and $157,009, respectively. In both cases, the support indicated a higher amount of revenue. It should be noted that no lost revenue was reported for Quarter 3 and Quarter 4 in 2021, so there was no impact to the lost revenue calculation. In addition, lost revenue was not used to support the provider relief fund amounts claimed by the Hospital in the HHS Special Report – Period 4 as the Hospital had eligible expenditures to support the amount of provider relief funds claimed. Cause: The Hospital did not have an adequate internal control policy in place to the ensure the appropriate method of reporting lost revenue on the HHS Special Report under the federal programs was selected. In addition, there was not an adequate internal control policy in place to ensure the amount reported on the HHS Special Report – Period 4 agreed to the supporting documentation. Effect: The lack of adequate policies governing lost revenue calculations and HHS Special Report preparation and submission increases the risk that employees participating in the federal award administration may not be able to detect and correct noncompliance in a timely manner. The Hospital selected the incorrect method of reporting lost revenues based on the calculation used. In addition, the support for two quarters does not agree to the amounts reported. The total difference is $325,847. Questioned Costs: None reported. Context: The lost revenue calculation for all applicable quarters was tested. All key line items were tested on the HHS Special Report submitted to the Department of Health and Human Services for Period 4. Repeat Finding from Prior Years: No. Recommendation: We recommend that the Hospital review the lost revenue calculation methodology utilized to ensure that the methodology utilized matches the methods reported. In this case, the reporting to HHS should be under the Alternative Reasonable Methodology (i.e., Option 3) which also requires management to document why this method is appropriate. Views of Responsible Officials: Management agrees with the finding.
Department of Health and Human Services Federal Assistance Listing #93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Reporting Material Weakness in Internal Control Over Compliance and Material Noncompliance Finding Summary: The Hospital selection the Actual Revenue Option (i.e., Option 1) in the HHS Special Report. Option 1 is based on actual quarterly net revenues by payor which are included in the HHS Special Report -Period 4 for years 2019 through 2022. However, management calculated the net revenues using various allocations due to reporting limitations within the accounting and billing system and did not use the actual quarterly financial statements to complete the HHS Special Report. The calculation used by management would be considered an Alternative Reasonable Methodology (i.e., Option 3). The selection of Option 1 was improperly reported within the HHS Special Report – Period 4 which caused the report to be inaccurate. In addition, for Quarter 3 and Quarter 4 of 2021, the amounts reported on the HHS Special Report do not agree to the related client support by $168,838 and $157,009, respectively. In both cases, the support indicated a higher amount of revenue. It should be noted that no lost revenue was reported for Quarter 3 and Quarter 4 in 2021, so there was no impact to the lost revenue calculation. In addition, lost revenue was not used to support the provider relief fund amounts claimed by the Hospital in the HHS Special Report – Period 4 as the Hospital had eligible expenditures to support the amount of provider relief funds claimed. Responsible Individuals: Lynn Broyles, CFO Corrective Action Plan: The Hospital will update the selection for lost revenue on the Report to option 3 and will include a lost revenue calculation narrative on the next Special Report that is required to be filed for Provider Relief Funds. Anticipated Completion Date: June 30, 2024
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