EIN: 941049467
UEI: CNDLMAL8U8S5
Data as of August 21, 2026
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on June 13, 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 December 13, 2024 (617 days ago).
What is a management decision? →The Organization did not meet its financial reporting obligations under the grant during the year. The Organization was unable to complete the FYE 2023 audit timely and therefore were unable to file their Data Collection Form (SF-SAC) by the due date of March 31, 2024. Criteria: The Organization is required to file the Data Collection Form within 30 days after receipt of audit or 9 months after year end, whichever comes first. Cause: The Data Collection form was not filed within the required time period due to a delay in preparations for the audit. Questioned Costs: None Effect: The Organization was not in compliance with federal regulations. Recommendation: We recommend audit preparations are completed on a timely basis to ensure that the reporting deadline is met. View of Responsible Officials: Management acknowledges there were significant capacity issues caused by turnover within the organization which delayed the audit. Management will complete the Data Collection Form upon issuance of the audit.
Show full finding ▾Hide full finding ▴Finding 2023-001 Program Name: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Federal Assistance Listing Number: 93.498 Federal Agency: U.S. Department of Health and Human Services Questioned Costs: N/A Type of Finding: Significant Deficiency Compliance Requirement: Reporting Condition: The Organization did not meet its financial reporting obligations under the grant during the year. The Organization was unable to complete the FYE 2023 audit timely and therefore were unable to file their Data Collection Form (SF-SAC) by the due date of March 31, 2024. Criteria: The Organization is required to file the Data Collection Form within 30 days after receipt of audit or 9 months after year end, whichever comes first. Cause: The Data Collection form was not filed within the required time period due to a delay in preparations for the audit. Questioned Costs: None Effect: The Organization was not in compliance with federal regulations. Recommendation: We recommend audit preparations are completed on a timely basis to ensure that the reporting deadline is met. View of Responsible Officials: Management acknowledges there were significant capacity issues caused by turnover within the organization which delayed the audit. Management will complete the Data Collection Form upon issuance of the audit.
Management acknowledges the delay in completing the FYE 2023 audit and filing the Data Collection Form (SF-SAC) on time. We have since completed the audit and submitted the required documentation to the Federal Audit Clearinghouse. To prevent recurrence of this issue the following corrective actions will be implemented: -Establish a detailed timeline for the audit process, including key milestones and deadlines -Conduct regular progress review to ensure adherence to the timeline -Allocate additional resources to the finance departments as needed during critical periods to ensure timely completion of tasks -Improve communication between the audit team and mangement to promptly address any issues that may cause delays. Responsible Party: Ed Gonzalez, CFO, will be responsible for overseeing the implementation and execution of this corrective action plan. Estimated Completion Date: The corrective actions outlined above are expected to be fully implemented by May 31, 2024. We are committed to ensuring compliance with all financial reporting obligations and will take the necessary steps to prevent future occurrences of such delays.
FAC accepted this audit on April 4, 2022 — management decision was due October 4, 2022.
The Organization?s internal controls over compliance related to payroll were not effective. Criteria: The Provider Relief Funds were provided under the Coronavirus Aid, Relief, and Economic Security Act (Pub. L. No. 116-136, 134 Stat. 563) and are to be used to prevent, prepare for, and respond to coronavirus and that the funds shall reimburse the recipient only for health care related expenses or lost revenues that are attributable to coronavirus. Context: During the audit, it was determined that 9 of the 40 payroll disbursements tested were not recorded accurately under the Provider Relief Fund. Eight of the payroll expenditures selected were amounts less than the support showed but still fully allowed under the funds. One of the payroll expenditures tested was an amount greater than the support showed and that portion is unallowable. However, it was noted that the Organization had sufficient expenditures that covered the portion of the one expenditure that was unallowed. Cause: Management oversight. Effect: The Organization?s internal controls around compliance were not effective. Recommendation: We recommend that management review all expenditures for accuracy and allowability under the criterial provided by the Department of Health and Human Services. However, it was noted that the Hospital has enough excess lost revenue to cover the disbursements noted above and retain the grant funding. View of Responsible Management will review calculations and support for all payroll expenditures to ensure Officials: accuracy in future reporting.
Show full finding ▾Hide full finding ▴Finding 2021.002 Program Name/CFDA Title: Provider Relief Fund Federal Assistance Listing Number: 93.498 Federal Agency: U.S. Department of Health and Human Services Type of Finding: Significant Deficiency Compliance Requirement: Allowable Costs Condition: The Organization?s internal controls over compliance related to payroll were not effective. Criteria: The Provider Relief Funds were provided under the Coronavirus Aid, Relief, and Economic Security Act (Pub. L. No. 116-136, 134 Stat. 563) and are to be used to prevent, prepare for, and respond to coronavirus and that the funds shall reimburse the recipient only for health care related expenses or lost revenues that are attributable to coronavirus. Context: During the audit, it was determined that 9 of the 40 payroll disbursements tested were not recorded accurately under the Provider Relief Fund. Eight of the payroll expenditures selected were amounts less than the support showed but still fully allowed under the funds. One of the payroll expenditures tested was an amount greater than the support showed and that portion is unallowable. However, it was noted that the Organization had sufficient expenditures that covered the portion of the one expenditure that was unallowed. Cause: Management oversight. Effect: The Organization?s internal controls around compliance were not effective. Recommendation: We recommend that management review all expenditures for accuracy and allowability under the criterial provided by the Department of Health and Human Services. However, it was noted that the Hospital has enough excess lost revenue to cover the disbursements noted above and retain the grant funding. View of Responsible Management will review calculations and support for all payroll expenditures to ensure Officials: accuracy in future reporting.
Finding # 2021.002 Response - Orchard Hospital will review and update its process for calculation of payroll grant expenditures. Calculations of payroll expenditures that are allowable will be done by a member of the finance team and will be reviewed for accuracy and allowability by a member of the management team. Responsible Party - Tony Jimenez, Interim CFO Estimated Completion - 06/30/2022
The Organization did not meet its requirements to use the funds to prevent, prepare for, and respond to coronavirus and that the payment shall reimburse the recipient only for health care related expenses or lost revenues that are attributable to coronavirus. Criteria: The Provider Relief Funds were provided under the Coronavirus Aid, Relief, and Economic Security Act (Pub. L. No. 116-136, 134 Stat. 563) and are to be used to prevent, prepare for, and respond to coronavirus and that the funds shall reimburse the recipient only for health care related expenses or lost revenues that are attributable to coronavirus. Context: During the audit, it was determined that for 3 of 40 non-payroll expenditures were non-allowable or had a portion that was a non-allowable COVID expense under the Department of Health and Human Services guidelines for the use of Provider Relief Funds. The total amount of nonallowable costs was $18,135. Cause: Management oversight. Effect: The Organization is not in compliance with federal regulations and guidelines surrounding the use of the Provider Relief Funds. Recommendation: We recommend that management review all expenditures for accuracy and allowability under the criterial provided by the Department of Health and Human Services. However, it was noted that the Organization has enough excess lost revenue to cover the disbursements noted above and retain the grant funding. View of Responsible Management will review all expenditures to determine allowability under the specific Officials: grant?s rules and regulations.
Show full finding ▾Hide full finding ▴Finding 2021.003 Program Name/CFDA Title: Provider Relief Fund Federal Assistance Listing Number: 93.498 Federal Agency: U.S. Department of Health and Human Services Type of Finding: Significant Deficiency Compliance Requirement: Allowable Costs Condition: The Organization did not meet its requirements to use the funds to prevent, prepare for, and respond to coronavirus and that the payment shall reimburse the recipient only for health care related expenses or lost revenues that are attributable to coronavirus. Criteria: The Provider Relief Funds were provided under the Coronavirus Aid, Relief, and Economic Security Act (Pub. L. No. 116-136, 134 Stat. 563) and are to be used to prevent, prepare for, and respond to coronavirus and that the funds shall reimburse the recipient only for health care related expenses or lost revenues that are attributable to coronavirus. Context: During the audit, it was determined that for 3 of 40 non-payroll expenditures were non-allowable or had a portion that was a non-allowable COVID expense under the Department of Health and Human Services guidelines for the use of Provider Relief Funds. The total amount of nonallowable costs was $18,135. Cause: Management oversight. Effect: The Organization is not in compliance with federal regulations and guidelines surrounding the use of the Provider Relief Funds. Recommendation: We recommend that management review all expenditures for accuracy and allowability under the criterial provided by the Department of Health and Human Services. However, it was noted that the Organization has enough excess lost revenue to cover the disbursements noted above and retain the grant funding. View of Responsible Management will review all expenditures to determine allowability under the specific Officials: grant?s rules and regulations.
Finding # 2021.003 Response - Orchard Hospital will review and update its process for determining and record allowable grant expenditures. All invoices will be reviewed for allowability and the spreadsheet accumulating these expenditures will be reviewed for accuracy in amounts. The list of grant expenditures to be recognized will be prepared by a member of the finance team. The list and related invoices will be reviewed by a member of the management team. Responsible Party - Tony Jimenez, Interim CFO Estimated Completion - 06/30/2022
Data source: This information comes from the Federal Audit Clearinghouse, the official repository of Single Audit data. All data is public domain. Verify this organization's audit history at fac.gov.
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