Audit 36422

FINDING 2022-005 Federal program Federal Assistance Listing Number 93.498 U.S. Department of Health and Human Services COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Activities Allowed or Unallowed and Allowable Costs/Cost Principles and Reporting Material Weakness in Internal Control over Compliance and Material Noncompliance Criteria The terms and conditions of the CARES Act Provider Relief Fund (PRF) program state funds are not to be used to reimburse expenses or losses that have been reimbursed from other sources or that other sources are obligated to reimburse. Condition During the process of identifying expenses incurred to prevent, prepare for or respond to the coronavirus pandemic, management did not reduce certain costs by estimated cost-based reimbursement to be received from Medicare and included certain cost items reimbursed through the Covid-19 Testing and Mitigation for Rural Health Clinics program (Federal Assistance Listing Number 93.697). Cause Due to the amount of detailed information required to be compiled by management in order to enter data into the PRF reporting portal, management inadvertently did not reduce certain costs by the estimated Medicare cost-based reimbursement and included other cost amounts already reimbursed through the program 93.697. Effect Management included amounts in the PRF reporting portal which were not eligible based on the terms and conditions of the PRF program. Questioned costs Questioned costs amounted to a combined total of $225,556. The amount of $152,991 relates to management not reducing certain costs by its Medicare cost-based reimbursement and was calculated based off the underlying expense detail management used to complete the PRF reporting portal and the estimated Medicare cost-based reimbursement percentage. The remaining amount of $72,565 was noted as already reimbursed through program 93.697 and determined based off the underlying expense detail management used to complete the PRF reporting portal. Perspective/Context Management used an excel workbook to record and track potential eligible amounts to be reported in the PRF reporting portal. Management selected certain cost amounts to include in the reporting portal and inadvertently missed reducing some of these amounts by the estimated Medicare cost-based reimbursement percentage. Additionally, management used the same excel workbook to track cost for program 93.967 and inadvertently included some of these same costs in the PRF reporting portal. The workbook contained other cost amounts that appear to be eligible that were not input into the PRF reporting portal. Recommendation We recommend management contact HRSA to resolve the matter. The Hospital?s tracking workbook has various cost items listed that were not reported in the unreimbursed expenses section of the HRSA PRF reporting form. We suggest management work with HRSA to see if these additional amounts can be used to offset the questioned costs. Additionally, we recommend management review its current internal controls over federal award compliance and revise its processes to ensure that only eligible costs are included in amounts reported. Views of responsible officials and planned corrective actions Management agrees with the noted finding. Management will continue to refine processes to ensure only allowable costs are reported. Additionally, we have other costs in our cost tracking workbook we believe are allowable and sufficient to cover the $225,556 of questioned costs. We had intended to report these in the unreimbursed expenses section of the PRF reporting portal but inadvertently missed inputting them.

FINDING 2022-006 Federal program Federal Assistance Listing Number 93.498 U.S. Department of Health and Human Services COVID-19 Provider Relief Fund COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Activities Allowed or Unallowed and Allowable Costs/Cost Principles and Reporting Material Weakness in Internal Control over Compliance and Material Noncompliance Criteria The terms and conditions of the CARES Act PRF program require responses and or other informational data to be reported during the completion of the HRSA PRF reporting portal. Condition During the process of completing the HRSA PRF reporting form, various reporting errors were made. Cause Management was unaware of certain data required to be reported and misinterpreted other sections during the completion of the PRF reporting portal.Effect Management reported incorrect information in certain sections of the PRF reporting portal. Questioned costs None. Perspective/Context Management made the following reporting errors when reporting information in the PRF reporting portal: ? Management did not mark fiscal year 2022 as subject to Single Audit and that PRF payments would be included in the audit. ? The Hospital received two grants from the State of Kansas to be used towards COVID-19 expenses that were not reported in the Other Assistance section of the PRF reporting portal. A $103,000 grant should have been reported in quarter 2, 2022 and a $257,366 grant should have been reported in quarter 4, 2022. ? Total revenue/net charges from patient care were not reported for quarters 1 and 2 of fiscal year 2021. ? Management used an excel workbook to record and track various cost items that appear to be allowable under the program terms and conditions but did not report any amounts in the unreimbursed expenses section of the HRSA PRF reporting form. Recommendation We recommend management review its current internal controls over federal award compliance and revise its processes to ensure that all required information in reported correctly. Views of responsible officials and planned corrective actions Management agrees with the noted finding. We will review our current reporting processes and internal controls over PRF reporting to ensure all future reporting requirements are met.

FINDING 2022-007 Federal program Federal Assistance Listing 93.697 U.S. Department of Health and Human Services COVID-19 Testing and Mitigation for Rural Health Clinics Activities Allowed or Unallowed and Allowable Costs/Cost Principles and Reporting Material Weakness in Internal Control over Compliance and Material Noncompliance Criteria The terms and conditions of the COVID-19 Testing and Mitigation for Rural Health Clinics program state only expenses allowable under the terms and conditions of the program are to be reported. Condition During the process of identifying expenses eligible under the COVID-19 Testing and Mitigation for Rural Health Clinics program, management did not reduce certain costs by estimated cost-based reimbursement to be received from Medicare. Cause Due to the amount of detailed information required to be compiled by management in order to enter data into the PRF reporting portal, management inadvertently did not reduce certain costs by the estimated Medicare cost-based reimbursement. Effect Management included amounts in the PRF reporting portal which were not eligible based on the terms and conditions of the PRF program. Questioned costs Total questioned costs amounted to $42,155 and were calculated based off the underlying expense detail management used to complete the PRF reporting portal and the estimated Medicare cost-based reimbursement percentage. Perspective/Context During our testing related to program 93.498, we noted management used the same excel workbook to record and track potential eligible costs for program 93.697. In tracking the cost items reported for program 93.697 we also noted management inadvertently missed reducing some of the amounts by the estimated Medicare cost-based reimbursement percentage. Recommendation We recommend management contact HRSA to determine the steps necessary to resolve this matter. Additionally, we recommend management review its current internal controls over federal award compliance and revise its processes to ensure that only eligible costs are included in amounts reported. Views of responsible officials and planned corrective actions Management agrees with the noted finding. Management will continue to refine processes to ensure only allowable costs are reported.

FINDING 2022-008 INTERNAL CONTROLS OVER COMPLETION OF SCHEDULE OF FEDERAL EXPENDITURES - MATERIAL WEAKNESS Criteria Management should have a process in place to ensure the internal completion of the Schedule of Federal Expenditures (SEFA) including all required disclosures. Conditions Management required significant assistance from the external auditors to complete the SEFA. Cause The Hospital had limited personnel with the appropriate experience levels to complete the SEFA without assistance. Effect and recommendation Management required assistance from the auditors to accurately complete the SEFA. We recommend management review its current internal controls over completion of the SEFA to ensure it can be completed with limited assistance provided by its external auditors. Views of responsible officials and planned corrective actions Management agrees with the noted finding and although we have limited personnel, we will continue to monitor and enhance our internal controls over the completion of the SEFA.

FINDING 2022-005 Federal program Federal Assistance Listing Number 93.498 U.S. Department of Health and Human Services COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Activities Allowed or Unallowed and Allowable Costs/Cost Principles and Reporting Material Weakness in Internal Control over Compliance and Material Noncompliance Criteria The terms and conditions of the CARES Act Provider Relief Fund (PRF) program state funds are not to be used to reimburse expenses or losses that have been reimbursed from other sources or that other sources are obligated to reimburse. Condition During the process of identifying expenses incurred to prevent, prepare for or respond to the coronavirus pandemic, management did not reduce certain costs by estimated cost-based reimbursement to be received from Medicare and included certain cost items reimbursed through the Covid-19 Testing and Mitigation for Rural Health Clinics program (Federal Assistance Listing Number 93.697). Cause Due to the amount of detailed information required to be compiled by management in order to enter data into the PRF reporting portal, management inadvertently did not reduce certain costs by the estimated Medicare cost-based reimbursement and included other cost amounts already reimbursed through the program 93.697. Effect Management included amounts in the PRF reporting portal which were not eligible based on the terms and conditions of the PRF program. Questioned costs Questioned costs amounted to a combined total of $225,556. The amount of $152,991 relates to management not reducing certain costs by its Medicare cost-based reimbursement and was calculated based off the underlying expense detail management used to complete the PRF reporting portal and the estimated Medicare cost-based reimbursement percentage. The remaining amount of $72,565 was noted as already reimbursed through program 93.697 and determined based off the underlying expense detail management used to complete the PRF reporting portal. Perspective/Context Management used an excel workbook to record and track potential eligible amounts to be reported in the PRF reporting portal. Management selected certain cost amounts to include in the reporting portal and inadvertently missed reducing some of these amounts by the estimated Medicare cost-based reimbursement percentage. Additionally, management used the same excel workbook to track cost for program 93.967 and inadvertently included some of these same costs in the PRF reporting portal. The workbook contained other cost amounts that appear to be eligible that were not input into the PRF reporting portal. Recommendation We recommend management contact HRSA to resolve the matter. The Hospital?s tracking workbook has various cost items listed that were not reported in the unreimbursed expenses section of the HRSA PRF reporting form. We suggest management work with HRSA to see if these additional amounts can be used to offset the questioned costs. Additionally, we recommend management review its current internal controls over federal award compliance and revise its processes to ensure that only eligible costs are included in amounts reported. Views of responsible officials and planned corrective actions Management agrees with the noted finding. Management will continue to refine processes to ensure only allowable costs are reported. Additionally, we have other costs in our cost tracking workbook we believe are allowable and sufficient to cover the $225,556 of questioned costs. We had intended to report these in the unreimbursed expenses section of the PRF reporting portal but inadvertently missed inputting them.

FINDING 2022-006 Federal program Federal Assistance Listing Number 93.498 U.S. Department of Health and Human Services COVID-19 Provider Relief Fund COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Activities Allowed or Unallowed and Allowable Costs/Cost Principles and Reporting Material Weakness in Internal Control over Compliance and Material Noncompliance Criteria The terms and conditions of the CARES Act PRF program require responses and or other informational data to be reported during the completion of the HRSA PRF reporting portal. Condition During the process of completing the HRSA PRF reporting form, various reporting errors were made. Cause Management was unaware of certain data required to be reported and misinterpreted other sections during the completion of the PRF reporting portal.Effect Management reported incorrect information in certain sections of the PRF reporting portal. Questioned costs None. Perspective/Context Management made the following reporting errors when reporting information in the PRF reporting portal: ? Management did not mark fiscal year 2022 as subject to Single Audit and that PRF payments would be included in the audit. ? The Hospital received two grants from the State of Kansas to be used towards COVID-19 expenses that were not reported in the Other Assistance section of the PRF reporting portal. A $103,000 grant should have been reported in quarter 2, 2022 and a $257,366 grant should have been reported in quarter 4, 2022. ? Total revenue/net charges from patient care were not reported for quarters 1 and 2 of fiscal year 2021. ? Management used an excel workbook to record and track various cost items that appear to be allowable under the program terms and conditions but did not report any amounts in the unreimbursed expenses section of the HRSA PRF reporting form. Recommendation We recommend management review its current internal controls over federal award compliance and revise its processes to ensure that all required information in reported correctly. Views of responsible officials and planned corrective actions Management agrees with the noted finding. We will review our current reporting processes and internal controls over PRF reporting to ensure all future reporting requirements are met.

FINDING 2022-007 Federal program Federal Assistance Listing 93.697 U.S. Department of Health and Human Services COVID-19 Testing and Mitigation for Rural Health Clinics Activities Allowed or Unallowed and Allowable Costs/Cost Principles and Reporting Material Weakness in Internal Control over Compliance and Material Noncompliance Criteria The terms and conditions of the COVID-19 Testing and Mitigation for Rural Health Clinics program state only expenses allowable under the terms and conditions of the program are to be reported. Condition During the process of identifying expenses eligible under the COVID-19 Testing and Mitigation for Rural Health Clinics program, management did not reduce certain costs by estimated cost-based reimbursement to be received from Medicare. Cause Due to the amount of detailed information required to be compiled by management in order to enter data into the PRF reporting portal, management inadvertently did not reduce certain costs by the estimated Medicare cost-based reimbursement. Effect Management included amounts in the PRF reporting portal which were not eligible based on the terms and conditions of the PRF program. Questioned costs Total questioned costs amounted to $42,155 and were calculated based off the underlying expense detail management used to complete the PRF reporting portal and the estimated Medicare cost-based reimbursement percentage. Perspective/Context During our testing related to program 93.498, we noted management used the same excel workbook to record and track potential eligible costs for program 93.697. In tracking the cost items reported for program 93.697 we also noted management inadvertently missed reducing some of the amounts by the estimated Medicare cost-based reimbursement percentage. Recommendation We recommend management contact HRSA to determine the steps necessary to resolve this matter. Additionally, we recommend management review its current internal controls over federal award compliance and revise its processes to ensure that only eligible costs are included in amounts reported. Views of responsible officials and planned corrective actions Management agrees with the noted finding. Management will continue to refine processes to ensure only allowable costs are reported.

FINDING 2022-008 INTERNAL CONTROLS OVER COMPLETION OF SCHEDULE OF FEDERAL EXPENDITURES - MATERIAL WEAKNESS Criteria Management should have a process in place to ensure the internal completion of the Schedule of Federal Expenditures (SEFA) including all required disclosures. Conditions Management required significant assistance from the external auditors to complete the SEFA. Cause The Hospital had limited personnel with the appropriate experience levels to complete the SEFA without assistance. Effect and recommendation Management required assistance from the auditors to accurately complete the SEFA. We recommend management review its current internal controls over completion of the SEFA to ensure it can be completed with limited assistance provided by its external auditors. Views of responsible officials and planned corrective actions Management agrees with the noted finding and although we have limited personnel, we will continue to monitor and enhance our internal controls over the completion of the SEFA.