Finding Text
Condition – It was noted that due to changes in personnel, in particular the replacing of the Organization’s Chief Financial Officer, among other items such as working through the change in affiliation, clinic integration, and other significant initiatives, the Organization failed to file its annual audited financial statements within the required 120 days following the end of its fiscal year end. Criteria – There is a requirement within the mortgage agreement that the Organization will make every effort to complete and file its annual audited financial statements within 120 days of year end. Effect – Reporting of financial information may not occur in a timely manner if reports are filed late. Recommendation – As the Organization continues to improve in processes and as time allows, completion of the annual audit and required work earlier in the year to allow for more timely reporting will assist in relieving this compliance finding. Management’s Response – The Organization will work to establish policies and procedure, and management took steps in 2026 to change personnel within the finance functions and hired a new Chief Financial Officer in 2026 with extensive hospital finance and accounting experience. The Chief Financial Officer’s duties will include additional reviews and assistance with account reconciliations as well as training of current staff and process improvements in this area, with a goal of removing this deficiency in the future.