Finding No. 2022-004: Allowability of Costs Federal Program: Research and Development Cluster, ALN 93.361, Award Number R01NR018434 Federal Agency: U.S. Department of Health and Human Services Pass through entity: N/A Federal Award year: July 23, 2019 through July 31, 2023 Criteria or Requirement: Per 2 CFR 200.303, the nonfederal entity must establish and maintain effective internal control over the award that provides reasonable assurance that the nonfederal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. Condition Found, Including Perspective: During our testwork over payroll costs charged to the cluster, we identified one individual in a sample of 40 with certified effort less than the amount charged to the grant. While the individual and management agree that the amount charged was appropriate based on the actual effort performed, the records included a difference which had not been reconciled or explained. Cause and Possible Effect: While there is an effort certification process and review control in place to ensure all effort charged to federal grants is accurate and allowable, the control did not operate effectively to identify the difference reported on the effort certification. Questioned Costs: None. Statistical Validity: The sample was not intended to be, and was not, a statistically valid sample. Repeat Finding in the Prior Year: No Recommendation: We recommend that management reinforce the policies related to the effort certification process and the related reviews through training. Views of Responsible Officials: Atrium Health management agrees with the finding. To address the current year finding, Office of Sponsored Programs will review Huron Employee Compensation Compliance (ECC) system and enhance controls over changing effort percentages.
Finding No. 2022-003: Allowability of Costs Federal Program: Research and Development Cluster, ALN 93.396, 93.361, 93.395, Award Numbers R01CA172513, R01NR018434, R01CA215651 Federal Agency: U.S. Department of Health and Human Services Pass through entity: N/A Federal Award year: August 6, 2020 through February 28, 2023, July 23, 2019 through July 31, 2023, August 28, 2020 through July 31, 2023 Criteria or Requirement: Per 2 CFR 200.303, the nonfederal entity must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the nonfederal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. Uniform Guidance Part ?200.300(b), statutory and national policy requirements, establishes that the non Federal entity is responsible for complying with all requirements of the Federal award. Federal awards under the Consolidated Appropriations Act 2016 (H.R. 2029) granted by HHS National Institute of Health (NIH), have restrictions on the amount of direct salary charged to the awards limited to the Executive Level II of the Federal Executive pay scale (salary cap). Uniform Guidance Part ?200.408, limitation on allowance of costs, states that the Federal award may be subject to statutory requirements that limit the allowability of costs. When the maximum allowable under a limitation is less than the total amount of the award, the amount not recoverable under the Federal award may not be charged to the Federal award. Condition Found, Including Perspective: During our testwork over the NIH salary cap, we identified three individuals in a sample of 10 with a salary charged to an award in excess of the salary cap by $3,206. The sampled salary for NIH salary cap population was a charge to the grant of $187,586. Total salary charged to NIH was $2,128,430. Cause and Possible Effect: While there is a control in place to review all effort charged to NIH grants to ensure that charges, including any relevant cost transfers, do not exceed the defined salary cap, the control was not operating effectively in order to identify the overages. Questioned Costs: $3,206 Statistical Validity: The sample was not intended to be, and was not, a statistically valid sample. Repeat Finding in the Prior Year: No Recommendation: We recommend that management review its current policies and reinforce through training the elements necessary to fully comply with its policies and all requirements governing salary cap allowability. Views of Responsible Officials: Atrium Health management agrees with the finding. To address the current year finding, Office of Sponsored Programs has implemented internal control improvements to ensure all requirements that limit the salary cap allowability of costs are completed and documented appropriately.
Finding No. 2022-003: Allowability of Costs Federal Program: Research and Development Cluster, ALN 93.396, 93.361, 93.395, Award Numbers R01CA172513, R01NR018434, R01CA215651 Federal Agency: U.S. Department of Health and Human Services Pass through entity: N/A Federal Award year: August 6, 2020 through February 28, 2023, July 23, 2019 through July 31, 2023, August 28, 2020 through July 31, 2023 Criteria or Requirement: Per 2 CFR 200.303, the nonfederal entity must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the nonfederal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. Uniform Guidance Part ?200.300(b), statutory and national policy requirements, establishes that the non Federal entity is responsible for complying with all requirements of the Federal award. Federal awards under the Consolidated Appropriations Act 2016 (H.R. 2029) granted by HHS National Institute of Health (NIH), have restrictions on the amount of direct salary charged to the awards limited to the Executive Level II of the Federal Executive pay scale (salary cap). Uniform Guidance Part ?200.408, limitation on allowance of costs, states that the Federal award may be subject to statutory requirements that limit the allowability of costs. When the maximum allowable under a limitation is less than the total amount of the award, the amount not recoverable under the Federal award may not be charged to the Federal award. Condition Found, Including Perspective: During our testwork over the NIH salary cap, we identified three individuals in a sample of 10 with a salary charged to an award in excess of the salary cap by $3,206. The sampled salary for NIH salary cap population was a charge to the grant of $187,586. Total salary charged to NIH was $2,128,430. Cause and Possible Effect: While there is a control in place to review all effort charged to NIH grants to ensure that charges, including any relevant cost transfers, do not exceed the defined salary cap, the control was not operating effectively in order to identify the overages. Questioned Costs: $3,206 Statistical Validity: The sample was not intended to be, and was not, a statistically valid sample. Repeat Finding in the Prior Year: No Recommendation: We recommend that management review its current policies and reinforce through training the elements necessary to fully comply with its policies and all requirements governing salary cap allowability. Views of Responsible Officials: Atrium Health management agrees with the finding. To address the current year finding, Office of Sponsored Programs has implemented internal control improvements to ensure all requirements that limit the salary cap allowability of costs are completed and documented appropriately.
Finding No. 2022-003: Allowability of Costs Federal Program: Research and Development Cluster, ALN 93.396, 93.361, 93.395, Award Numbers R01CA172513, R01NR018434, R01CA215651 Federal Agency: U.S. Department of Health and Human Services Pass through entity: N/A Federal Award year: August 6, 2020 through February 28, 2023, July 23, 2019 through July 31, 2023, August 28, 2020 through July 31, 2023 Criteria or Requirement: Per 2 CFR 200.303, the nonfederal entity must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the nonfederal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. Uniform Guidance Part ?200.300(b), statutory and national policy requirements, establishes that the non Federal entity is responsible for complying with all requirements of the Federal award. Federal awards under the Consolidated Appropriations Act 2016 (H.R. 2029) granted by HHS National Institute of Health (NIH), have restrictions on the amount of direct salary charged to the awards limited to the Executive Level II of the Federal Executive pay scale (salary cap). Uniform Guidance Part ?200.408, limitation on allowance of costs, states that the Federal award may be subject to statutory requirements that limit the allowability of costs. When the maximum allowable under a limitation is less than the total amount of the award, the amount not recoverable under the Federal award may not be charged to the Federal award. Condition Found, Including Perspective: During our testwork over the NIH salary cap, we identified three individuals in a sample of 10 with a salary charged to an award in excess of the salary cap by $3,206. The sampled salary for NIH salary cap population was a charge to the grant of $187,586. Total salary charged to NIH was $2,128,430. Cause and Possible Effect: While there is a control in place to review all effort charged to NIH grants to ensure that charges, including any relevant cost transfers, do not exceed the defined salary cap, the control was not operating effectively in order to identify the overages. Questioned Costs: $3,206 Statistical Validity: The sample was not intended to be, and was not, a statistically valid sample. Repeat Finding in the Prior Year: No Recommendation: We recommend that management review its current policies and reinforce through training the elements necessary to fully comply with its policies and all requirements governing salary cap allowability. Views of Responsible Officials: Atrium Health management agrees with the finding. To address the current year finding, Office of Sponsored Programs has implemented internal control improvements to ensure all requirements that limit the salary cap allowability of costs are completed and documented appropriately.
Finding No. 2022-001: Allowability Federal Program: COVID-19 ? HRSA COVID-19 Claims Reimbursement for the Uninsured Program and the COVID-19 Coverage Assistance Fund (ALN 93.461) Federal Award Year: January 1, 2022 through December 31, 2022 Federal Award Agency: U.S. Department of Health and Human Services Criteria or Requirement: Per 2 CFR 200.303, the nonfederal entity must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the nonfederal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. Condition Found, Including Perspective: While no insurance was identified for any of the patients sampled, for 4 out of 40 patients sampled, there was no documentation available to demonstrate that an insurance check was performed prior to Health Resources and Services Administration (HRSA) claim submission. Possible Cause and Asserted Effect: The control to ensure appropriate documentation supporting the performance of the insurance check for each patient prior to the claim submission was not operating effectively. Questioned Costs: None. Statistical Validity: The sample was not intended to be, and was not, a statistically valid sample. Repeat Finding in the Prior Year: Yes, Finding 2021-001 Recommendation: We recommend Atrium Health Enterprise improve its existing insurance verification process to ensure documentation evidencing that all patients identified on the claim form were uninsured individuals at the time the services were provided is retained. Views of Responsible Officials: Atrium Health CMHA currently has an insurance verification process for potentially uninsured patients meeting the criteria prescribed by HRSA whereby identified accounts are sent nightly to Experian, a multinational consumer credit reporting company, who searches for insurance coverage. Negative confirmation documentation is inserted into the patient record. Management is aware of the importance of this process and has continued education efforts with applicable teammates to ensure this process is followed and documented with each patient. Additionally, the HRSA COVID-19 Uninsured Program ended in April of 2022.
Finding No. 2022-002: Reporting and Allowable Costs Federal Program: COVID-19 ? Provider Relief Fund and American Rescue Plan Rural Distribution (ALN 93.498) Federal Award Year: January 1, 2022 through December 31, 2022 Federal Award Agency: U.S. Department of Health and Human Services Criteria or Requirement: Per 2 CFR 200.303, the nonfederal entity must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the nonfederal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. Per the terms and conditions of the award, recipients are required to submit a report in the Provider Relief Fund reporting portal for reach reporting period. Condition Found, Including Perspective: Certain costs reported for Wilkes Regional Medical Center totaling $2,063,873 were reported in Period 4 as Other Healthcare Expenses while the expenses to support the draw should have been allocated to the Personnel, Fringe Benefits, Equipment, and Supplies sections of the report. Further, for certain costs of Wilkes Regional Medical Center totaling $29,454 the materials were not received and should not have been charged. Possible Cause and Asserted Effect: The control to ensure that all costs claimed were allowable per the grant and reported appropriately was not operating effectively to ensure that the appropriate costs categories were claimed for Wilkes Regional Medical Center. Questioned Costs: $29,454 Statistical Validity: The sample was not intended to be, and was not, a statistically valid sample Repeat Finding in the Prior Year: No Recommendation: We recommend Wilkes Regional Medical Center enhance its controls over review of expenditures claimed to ensure that the appropriate costs are claimed within the appropriate categories for the Provider Relief Fund reporting. Views of Responsible Officials: Atrium Health management believes that, while the Provider Relief Funds reporting was completed on a periodic basis throughout the pandemic, the intent from HRSA was to document the use of those funds for COVID-19 expenses and for lost revenues over the course of the entire pandemic. Because the PRF portal did not allow for previous periods to be restated in response to new information or corrections identified from previous reported periods, the only recourse available for health systems to restate COVID-19 expenses or lost revenues is through future PRF reporting or through the HRSA audit process. Management agrees that the control process in place during the initial reporting process for Wilkes Regional Medical Center did not yield the ultimate cost categorization that was corrected in the PRF reporting noted above; however, management?s interaction with HRSA throughout 2022 and the resulting clarification of COVID-19 expenses, is now incorporated into the overall PRF reporting control process. With respect to the identified questioned costs, management agrees that these costs should not have been included as COVID-19 related expenses for that period. However, management also recognizes that Wilkes Regional Medical Center has unused lost revenues more than this amount and as such, the questioned costs would not be subject to a return of the PRF proceeds. This position is supported by a similar finding in the 2021 Atrium Health Enterprise audit that was resolved with this conclusion and is documented in the Management Decision Letter issued by HRSA dated June 26, 2023
Finding No. 2022-004: Allowability of Costs Federal Program: Research and Development Cluster, ALN 93.361, Award Number R01NR018434 Federal Agency: U.S. Department of Health and Human Services Pass through entity: N/A Federal Award year: July 23, 2019 through July 31, 2023 Criteria or Requirement: Per 2 CFR 200.303, the nonfederal entity must establish and maintain effective internal control over the award that provides reasonable assurance that the nonfederal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. Condition Found, Including Perspective: During our testwork over payroll costs charged to the cluster, we identified one individual in a sample of 40 with certified effort less than the amount charged to the grant. While the individual and management agree that the amount charged was appropriate based on the actual effort performed, the records included a difference which had not been reconciled or explained. Cause and Possible Effect: While there is an effort certification process and review control in place to ensure all effort charged to federal grants is accurate and allowable, the control did not operate effectively to identify the difference reported on the effort certification. Questioned Costs: None. Statistical Validity: The sample was not intended to be, and was not, a statistically valid sample. Repeat Finding in the Prior Year: No Recommendation: We recommend that management reinforce the policies related to the effort certification process and the related reviews through training. Views of Responsible Officials: Atrium Health management agrees with the finding. To address the current year finding, Office of Sponsored Programs will review Huron Employee Compensation Compliance (ECC) system and enhance controls over changing effort percentages.
Finding No. 2022-003: Allowability of Costs Federal Program: Research and Development Cluster, ALN 93.396, 93.361, 93.395, Award Numbers R01CA172513, R01NR018434, R01CA215651 Federal Agency: U.S. Department of Health and Human Services Pass through entity: N/A Federal Award year: August 6, 2020 through February 28, 2023, July 23, 2019 through July 31, 2023, August 28, 2020 through July 31, 2023 Criteria or Requirement: Per 2 CFR 200.303, the nonfederal entity must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the nonfederal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. Uniform Guidance Part ?200.300(b), statutory and national policy requirements, establishes that the non Federal entity is responsible for complying with all requirements of the Federal award. Federal awards under the Consolidated Appropriations Act 2016 (H.R. 2029) granted by HHS National Institute of Health (NIH), have restrictions on the amount of direct salary charged to the awards limited to the Executive Level II of the Federal Executive pay scale (salary cap). Uniform Guidance Part ?200.408, limitation on allowance of costs, states that the Federal award may be subject to statutory requirements that limit the allowability of costs. When the maximum allowable under a limitation is less than the total amount of the award, the amount not recoverable under the Federal award may not be charged to the Federal award. Condition Found, Including Perspective: During our testwork over the NIH salary cap, we identified three individuals in a sample of 10 with a salary charged to an award in excess of the salary cap by $3,206. The sampled salary for NIH salary cap population was a charge to the grant of $187,586. Total salary charged to NIH was $2,128,430. Cause and Possible Effect: While there is a control in place to review all effort charged to NIH grants to ensure that charges, including any relevant cost transfers, do not exceed the defined salary cap, the control was not operating effectively in order to identify the overages. Questioned Costs: $3,206 Statistical Validity: The sample was not intended to be, and was not, a statistically valid sample. Repeat Finding in the Prior Year: No Recommendation: We recommend that management review its current policies and reinforce through training the elements necessary to fully comply with its policies and all requirements governing salary cap allowability. Views of Responsible Officials: Atrium Health management agrees with the finding. To address the current year finding, Office of Sponsored Programs has implemented internal control improvements to ensure all requirements that limit the salary cap allowability of costs are completed and documented appropriately.
Finding No. 2022-003: Allowability of Costs Federal Program: Research and Development Cluster, ALN 93.396, 93.361, 93.395, Award Numbers R01CA172513, R01NR018434, R01CA215651 Federal Agency: U.S. Department of Health and Human Services Pass through entity: N/A Federal Award year: August 6, 2020 through February 28, 2023, July 23, 2019 through July 31, 2023, August 28, 2020 through July 31, 2023 Criteria or Requirement: Per 2 CFR 200.303, the nonfederal entity must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the nonfederal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. Uniform Guidance Part ?200.300(b), statutory and national policy requirements, establishes that the non Federal entity is responsible for complying with all requirements of the Federal award. Federal awards under the Consolidated Appropriations Act 2016 (H.R. 2029) granted by HHS National Institute of Health (NIH), have restrictions on the amount of direct salary charged to the awards limited to the Executive Level II of the Federal Executive pay scale (salary cap). Uniform Guidance Part ?200.408, limitation on allowance of costs, states that the Federal award may be subject to statutory requirements that limit the allowability of costs. When the maximum allowable under a limitation is less than the total amount of the award, the amount not recoverable under the Federal award may not be charged to the Federal award. Condition Found, Including Perspective: During our testwork over the NIH salary cap, we identified three individuals in a sample of 10 with a salary charged to an award in excess of the salary cap by $3,206. The sampled salary for NIH salary cap population was a charge to the grant of $187,586. Total salary charged to NIH was $2,128,430. Cause and Possible Effect: While there is a control in place to review all effort charged to NIH grants to ensure that charges, including any relevant cost transfers, do not exceed the defined salary cap, the control was not operating effectively in order to identify the overages. Questioned Costs: $3,206 Statistical Validity: The sample was not intended to be, and was not, a statistically valid sample. Repeat Finding in the Prior Year: No Recommendation: We recommend that management review its current policies and reinforce through training the elements necessary to fully comply with its policies and all requirements governing salary cap allowability. Views of Responsible Officials: Atrium Health management agrees with the finding. To address the current year finding, Office of Sponsored Programs has implemented internal control improvements to ensure all requirements that limit the salary cap allowability of costs are completed and documented appropriately.
Finding No. 2022-003: Allowability of Costs Federal Program: Research and Development Cluster, ALN 93.396, 93.361, 93.395, Award Numbers R01CA172513, R01NR018434, R01CA215651 Federal Agency: U.S. Department of Health and Human Services Pass through entity: N/A Federal Award year: August 6, 2020 through February 28, 2023, July 23, 2019 through July 31, 2023, August 28, 2020 through July 31, 2023 Criteria or Requirement: Per 2 CFR 200.303, the nonfederal entity must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the nonfederal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. Uniform Guidance Part ?200.300(b), statutory and national policy requirements, establishes that the non Federal entity is responsible for complying with all requirements of the Federal award. Federal awards under the Consolidated Appropriations Act 2016 (H.R. 2029) granted by HHS National Institute of Health (NIH), have restrictions on the amount of direct salary charged to the awards limited to the Executive Level II of the Federal Executive pay scale (salary cap). Uniform Guidance Part ?200.408, limitation on allowance of costs, states that the Federal award may be subject to statutory requirements that limit the allowability of costs. When the maximum allowable under a limitation is less than the total amount of the award, the amount not recoverable under the Federal award may not be charged to the Federal award. Condition Found, Including Perspective: During our testwork over the NIH salary cap, we identified three individuals in a sample of 10 with a salary charged to an award in excess of the salary cap by $3,206. The sampled salary for NIH salary cap population was a charge to the grant of $187,586. Total salary charged to NIH was $2,128,430. Cause and Possible Effect: While there is a control in place to review all effort charged to NIH grants to ensure that charges, including any relevant cost transfers, do not exceed the defined salary cap, the control was not operating effectively in order to identify the overages. Questioned Costs: $3,206 Statistical Validity: The sample was not intended to be, and was not, a statistically valid sample. Repeat Finding in the Prior Year: No Recommendation: We recommend that management review its current policies and reinforce through training the elements necessary to fully comply with its policies and all requirements governing salary cap allowability. Views of Responsible Officials: Atrium Health management agrees with the finding. To address the current year finding, Office of Sponsored Programs has implemented internal control improvements to ensure all requirements that limit the salary cap allowability of costs are completed and documented appropriately.
Finding No. 2022-001: Allowability Federal Program: COVID-19 ? HRSA COVID-19 Claims Reimbursement for the Uninsured Program and the COVID-19 Coverage Assistance Fund (ALN 93.461) Federal Award Year: January 1, 2022 through December 31, 2022 Federal Award Agency: U.S. Department of Health and Human Services Criteria or Requirement: Per 2 CFR 200.303, the nonfederal entity must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the nonfederal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. Condition Found, Including Perspective: While no insurance was identified for any of the patients sampled, for 4 out of 40 patients sampled, there was no documentation available to demonstrate that an insurance check was performed prior to Health Resources and Services Administration (HRSA) claim submission. Possible Cause and Asserted Effect: The control to ensure appropriate documentation supporting the performance of the insurance check for each patient prior to the claim submission was not operating effectively. Questioned Costs: None. Statistical Validity: The sample was not intended to be, and was not, a statistically valid sample. Repeat Finding in the Prior Year: Yes, Finding 2021-001 Recommendation: We recommend Atrium Health Enterprise improve its existing insurance verification process to ensure documentation evidencing that all patients identified on the claim form were uninsured individuals at the time the services were provided is retained. Views of Responsible Officials: Atrium Health CMHA currently has an insurance verification process for potentially uninsured patients meeting the criteria prescribed by HRSA whereby identified accounts are sent nightly to Experian, a multinational consumer credit reporting company, who searches for insurance coverage. Negative confirmation documentation is inserted into the patient record. Management is aware of the importance of this process and has continued education efforts with applicable teammates to ensure this process is followed and documented with each patient. Additionally, the HRSA COVID-19 Uninsured Program ended in April of 2022.
Finding No. 2022-002: Reporting and Allowable Costs Federal Program: COVID-19 ? Provider Relief Fund and American Rescue Plan Rural Distribution (ALN 93.498) Federal Award Year: January 1, 2022 through December 31, 2022 Federal Award Agency: U.S. Department of Health and Human Services Criteria or Requirement: Per 2 CFR 200.303, the nonfederal entity must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the nonfederal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. Per the terms and conditions of the award, recipients are required to submit a report in the Provider Relief Fund reporting portal for reach reporting period. Condition Found, Including Perspective: Certain costs reported for Wilkes Regional Medical Center totaling $2,063,873 were reported in Period 4 as Other Healthcare Expenses while the expenses to support the draw should have been allocated to the Personnel, Fringe Benefits, Equipment, and Supplies sections of the report. Further, for certain costs of Wilkes Regional Medical Center totaling $29,454 the materials were not received and should not have been charged. Possible Cause and Asserted Effect: The control to ensure that all costs claimed were allowable per the grant and reported appropriately was not operating effectively to ensure that the appropriate costs categories were claimed for Wilkes Regional Medical Center. Questioned Costs: $29,454 Statistical Validity: The sample was not intended to be, and was not, a statistically valid sample Repeat Finding in the Prior Year: No Recommendation: We recommend Wilkes Regional Medical Center enhance its controls over review of expenditures claimed to ensure that the appropriate costs are claimed within the appropriate categories for the Provider Relief Fund reporting. Views of Responsible Officials: Atrium Health management believes that, while the Provider Relief Funds reporting was completed on a periodic basis throughout the pandemic, the intent from HRSA was to document the use of those funds for COVID-19 expenses and for lost revenues over the course of the entire pandemic. Because the PRF portal did not allow for previous periods to be restated in response to new information or corrections identified from previous reported periods, the only recourse available for health systems to restate COVID-19 expenses or lost revenues is through future PRF reporting or through the HRSA audit process. Management agrees that the control process in place during the initial reporting process for Wilkes Regional Medical Center did not yield the ultimate cost categorization that was corrected in the PRF reporting noted above; however, management?s interaction with HRSA throughout 2022 and the resulting clarification of COVID-19 expenses, is now incorporated into the overall PRF reporting control process. With respect to the identified questioned costs, management agrees that these costs should not have been included as COVID-19 related expenses for that period. However, management also recognizes that Wilkes Regional Medical Center has unused lost revenues more than this amount and as such, the questioned costs would not be subject to a return of the PRF proceeds. This position is supported by a similar finding in the 2021 Atrium Health Enterprise audit that was resolved with this conclusion and is documented in the Management Decision Letter issued by HRSA dated June 26, 2023