Audit 399700

Federal Program Information: Program: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Funding Agency: U.S. Department of Health and Human Services (HHS), Health Resources and Services Administration (HRSA) Assistance Listing Number: 93.498 Criteria or Specific Requirement: HRSA PRF Reporting Requirements and Terms and Conditions require recipients subject to PRF reporting to submit reports through the PRF Reporting Portal by HRSA-established deadlines and in accordance with the instructions posted on HRSA’s website. Condition/Context: The Hospital was unable to produce copies of PRF reports submitted via the HRSA PRF Reporting Portal or other evidence (e.g., confirmation emails, portal receipts) that the reports were filed for the applicable reporting period(s). As a result, we were unable to verify whether required PRF reporting was completed timely and accurately, or to reconcile the Hospital’s Schedule of Expenditures of Federal Awards (SEFA) amounts for PRF to the HRSA PRF report(s), as contemplated by the compliance requirements. Cause: The Hospital did not maintain documentation evidencing submission of the PRF report(s) (e.g., copies of submitted reports, portal confirmation receipts, or other verifiable proof). Effect: • Potential noncompliance with PRF reporting requirements and Uniform Guidance record retention requirements. • Increased risk that PRF amounts reported on the SEFA may be inaccurate or incomplete if not supported by the PRF report(s), which could affect the Single Audit and related reporting. • Potential HRSA enforcement actions for failure to meet PRF reporting requirements, including possible repayment or other sanctions if reports were not filed timely or as required. Questioned Costs: None. Auditor’s Recommendation: Verify PRF reporting status within the HRSA PRF Reporting Portal and retrieve official evidence of submission (e.g., confirmation emails, portal receipts, or report PDFs). If unavailable, contact HRSA Provider Support to obtain formal confirmation of filing or guidance on remediation. Views of Responsible Officials: The hospital staff member – reimbursement analyst- who no longer works for the hospital - submitted PRF reports in the portal within timelines, but he did not save copies of the reports. We were only able to get the blank templates from his company folder. I confirmed with the then chief compliance officer for Sheridan Community Hospital that she signed the reports in the portal before they were submitted. During the audit, we were unable to produce these reports, however, we are in the process of retrieving these reports from the HRSA portal to keep with our records as proof that it was completed per the auditor’s recommendation above.

Federal Program Information: Program: All Funding Agency: All Assistance Listing Number: All Criteria or Specific Requirement: The Uniform Guidance 2 CFR 200.512(a) requires the audit package and data collection form be submitted 30 days after receipt of the auditor’s report or 9 months after the end of the fiscal year, whichever comes first. Condition/Context: The Hospital’s fiscal year 2022 single audit reporting package was not submitted within nine months after the end of the audit period. Cause: The Hospital did not have appropriate internal control policies and procedures in place to ensure accounting records and financial statements were reconciled timely and the audit conducted to meet compliance requirements. Effect: The single audit reporting package was submitted after the required reporting time period. Questioned Costs: None. Auditor’s Recommendation: To ensure compliance with the Uniform Guidance, the Hospital should prepare accurate, complete and timely financial statements and ensure an audit is performed to ensure the timely submission of the single audit reporting package. Views of Responsible Officials: In FY 2020 through FY 2022, the hospital was going through a transition due to financial constraints, hence several internal operations were affected. Even though we have internal policy to schedule Annual Financial audits 90 days after close of every Fiscal year, we fell behind and for a period of two years were unable to schedule annual financial audits timely. At the time when the FY 2022 single Audit was due, we had not even completed our FY2020 Audit hence the delay. Currently, the hospital is working toward getting caught up with the annual financial audits to get back on track with our policy. We just completed FY 2023 and are working on FY 2024. We hope to be done with FY 2025 and FY 2026 in the Fall of calendar year 2026.