Finding 1155271 (2022-003)

Material Weakness Repeat Finding
Requirement
ABHL
Questioned Costs
$1
Year
2022
Accepted
2025-09-25
Audit: 367503
Organization: Comanche County Medical Center (TX)

AI Summary

  • Core Issue: The Hospital reported COVID-19 expenses under FEMA that were already reimbursed by other sources, leading to questioned costs of $173,180.
  • Impacted Requirements: Reporting guidelines and allowable costs under federal regulations were not properly followed, resulting in a repeat finding from 2021.
  • Recommended Follow-Up: Revise policies and procedures for federal grant reporting to ensure expenses claimed are not covered by other reimbursements.

Finding Text

Federal Programs: Disaster Grants – Public Assistance (Presidentially Declared Disasters) Assistance Listing Numbers 97.036 Federal Agencies: U.S. Department of Homeland Security Pass-Through Entity, Applicable Only to Disaster Grants – Public Assistance (Presidentially Declared Disasters): Texas Division of Emergency Management Criteria: Reporting (45 CFR 75.342 and 2 CFR 200.303) and Activities Allowed or Unallowed and Allowable Costs/Cost Principles (Pub. L. No. 116-136, 134 Stat. 563 and Pub. L. No. 116-139, 134 Stat. 622 and 623 and 44 CFR 206.228). Condition: The Hospital reported COVID-19-related expenditures within the Disaster Grants – Public Assistance (Presidentially Declared Disasters) (FEMA) portal that were reimbursed via other sources. Questioned Costs: Questioned costs were estimated by taking the total amount of acceptable expenditures for each of the programs multiplied by the Hospital’s internally-calculated Medicare reimbursement rate. See costs by applicable assistance listing number below: Program: Presidentially Declared Disasters; Assistance Listing No. 97.036; Questioned Costs: $173,180 Context: The Hospital is certified by Medicare as a critical access hospital. The period one provider relief fund report and FEMA payments were tested. The Hospital’s calculation of allowable expenses did not consider the impact of cost reimbursement to reported health care expenses to document that FEMA payments were not reimbursed by any other source. Effect: The Hospital submitted expenses under the FEMA program that are obligated to be reimbursed by another source. Cause: The guidance provided by DHS to providers across the country as to how to report their COVID-19-related expenses and lost revenues is, at times, difficult to comprehend and apply. Internal controls were not in place to ensure the Hospital correctly applied the guidance. Identification as a repeat finding: This is a repeat finding. See 2021-002. Recommendation: Policies and procedures over federal grant reporting should be modified to ensure that allowable expenses reported are not reimbursed by any other source. Views of responsible officials and planned corrective actions: See corrective action plan for the Hospital’s response to finding.

Corrective Action Plan

We are in receipt of the Findings Required to be Reported by Government Auditing Standards, regarding Reporting and Activities Allowed/Unallowed and Cost Principles. Management agrees with the finding. After correcting the calculation of expenses to include reimbursement from other sources, the Hospital still has sufficient lost revenues and expenses to cover the amount of provider relief funding received. Management will perform a detailed analysis of the reporting requirements in accordance with the final guidelines set by HRSA for future reporting periods. As deemed necessary, the Hospital will modify policies and procedures over federal grant reporting The CFO, Hong Wade, will be responsible to ensure this is accomplished. The corrective action plan will be implemented by December 31, 2025.

Categories

Questioned Costs Allowable Costs / Cost Principles Subrecipient Monitoring Cash Management Reporting

Programs in Audit

ALN Program Name Expenditures
10.766 Usda Community Facilities Loans and Grants $1.00M
97.036 Disaster Grants - Public Assistance (presidentially Declared Disasters) $565,347
93.697 Covid-19 Rhc Payments $200,000
93.912 Covid-19 Rhc Vaccine Confidence (rhcvc) $99,058
93.301 Covid-19 Small Rural Hospital Improvement Grant Program $10,969