Finding Reference Number 2023-001 Finding The Hospital’s internal control processes regarding usage of funds received under the Provider Relief Fund allocation within the American Rescue Plan Act, 2021, did not provide for adequate segregation of duties. Internal controls around approving, tracking, and reporting expenses were not sufficient. Management agrees with the finding. Corrective Action Plan In September 2023, the Hospital implemented a policy regarding the usage of grant funding received through HRSA. This policy includes review of program guidelines, education of responsible staff, maintenance of separate general ledger accounts for program expenditures, approval of purchase orders by appropriate levels of management, and establishment of logs for program expenditures. It also provides for review of general ledger accounts and review of reports submitted to granting agencies. These changes were implemented to ensure allowable costs are properly approved, tracked, reviewed, and reported in accordance with federal requirements and to provide for adequate segregation of duties in these responsibilities. Responsible Personnel Lisa Hart, former Chief Executive Officer (responsible for implementation of corrective action). Megan Corbin, Chief Executive Officer (current contact for any follow-up regarding corrective action). Completion Date Corrective action was completed in September 2023.