INGHAM COUNTY MEDICAL CARE FACILITY Okemos, Michigan

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1 INGHAM COUNTY MEDICAL CARE FACILITY Okemos, Michigan FINANCIAL STATEMENTS For the Year Ended December 31, 2010

2 TABLE OF CONTENTS PAGE Independent Auditors Report 1 Financial Statements for the Year Ended December 31, 2010 Statement of Net Assets 2 Statement of Revenues, Expenses and Changes in Fund Net Assets 3 Statement of Cash Flows 4-5 Notes to Financial Statements 6-16 Required Supplementary Information Other Postemployment Benefits 17 Supplementary Financial Information Schedule of Net Patient Revenues 18 Schedule of Operating Expenses 19 Report on Internal Control Over Financial Reporting and on Compliance and Other Matters Based on an Audit of Financial Statements Performed in Accordance with Government Auditing Standards * * * * *

3 Rehmann Robson INDEPENDENT AUDITORS REPORT June 14, Robinson Rd. Jackson, MI Ph: Fx: To the Department of Human Services Board Ingham County Medical Care Facility Okemos, Michigan We have audited the accompanying financial statements of the Ingham County Medical Care Facility, an enterprise fund of Ingham County, Michigan, as of and for the year ended December 31, 2010, as listed in the table of contents. These financial statements are the responsibility of the Ingham County Medical Care Facility s management. Our responsibility is to express an opinion on these financial statements based on our audit. We conducted our audit in accordance with auditing standards generally accepted in the United States of America and the standards applicable to financial audits contained in Government Auditing Standards, issued by the Comptroller General of the United States. Those standards require that we plan and perform the audit to obtain reasonable assurance about whether the financial statements are free of material misstatement. An audit includes examining, on a test basis, evidence supporting the amounts and disclosures in the financial statements. An audit also includes assessing the accounting principles used and significant estimates made by management, as well as evaluating the overall financial statement presentation. We believe that our audit provides a reasonable basis for our opinion. As discussed in Note 1, the financial statements present only the Ingham County Medical Care Facility and do not purport to, and do not, present fairly the financial position of Ingham County, Michigan, as of December 31, 2010, and the changes in its financial position and its cash flows for the year then ended in conformity with accounting principles generally accepted in the United States of America. In our opinion, the financial statements referred to above present fairly, in all material respects, the financial position of the Ingham County Medical Care Facility as of December 31, 2010, and the changes in its financial position and its cash flows for the year then ended in conformity with accounting principles generally accepted in the United States of America. In accordance with Government Auditing Standards, we have also issued our report dated June 14, 2011, on our consideration of Ingham County Medical Care Facility s internal control over financial reporting and our tests of its compliance with certain provisions of laws, regulations, contracts, grant agreements and other matters. The purpose of that report is to describe the scope of our testing of internal control over financial reporting and compliance and the results of that testing, and not to provide an opinion on the internal control over financial reporting or on compliance. That report is an integral part of an audit performed in accordance with Government Auditing Standards and should be considered in assessing the results of our audit. Our audit was made for the purpose of forming an opinion on the financial statements taken as a whole. The other postemployment benefits information listed in the table of contents is not a required part of the basic financial statements but is supplementary information required by the Government Accounting Standards Board. The supplementary information listed in the table of contents is presented for purposes of additional analysis and is not a required part of the financial statements of the Ingham County Medical Care Facility. Such information has been subjected to the auditing procedures applied in the audit of the financial statements and, in our opinion, is fairly stated in all material respects in relation to the financial statements taken as a whole. -1-

4 FINANCIAL STATEMENTS

5 Statement of Net Assets December 31, 2010 Assets Current assets Pooled cash and investments $ 5,357,809 Pooled cash and investments - restricted 11,040,141 Patient receivables, net 2,890,529 Interest receivable 45,839 Inventory 12,958 Prepaid items 22,419 Total current assets 19,369,695 Capital assets, net 8,091,761 Total assets 27,461,456 Liabilities Current liabilities Accounts payable 703,468 Accrued expenses 324,004 Compensated absences 242,381 Due to other funds of Ingham County 78,306 Payable from restricted assets - patient trust liability 14,324 Total current liabilities 1,362,483 Noncurrent liabilities Worker's compensation claims 38,239 Compensated absences, net of current portion 161,588 Provision for contractual losses 349,500 Net other postemployment benefits obligation 1,409, ,432 Total noncurrent liabilities 2,361,874 Total liabilities 3,724,357 Net assets Invested in capital assets 8,091,761 Restricted 11,025,817 Unrestricted 4,619,521 Total net assets $ 23,737,099 The accompanying notes are an integral part of these financial statements. -2-

6 Statement of Revenues, Expenses and Changes in Fund Net Assets For the Year Ended December 31, 2010 Operating revenues Net patient revenues $ 22,022,193 Other operating revenues 99,480 Total operating revenues 22,121,673 Operating expenses Salaries 10,527,311 Depreciation expense 574,310 Other expenses 8,920,841 Total operating expenses 20,022,462 Operating income 2,099,211 Nonoperating revenues (expenses) Investment earnings 183,004 Provider supplement 1,656,591 Provider tax (1,437,675) Interest expense (5,593) Maintenance of effort payment (42,645) Total nonoperating revenues 353,682 Change in net assets 2,452,893 Net assets, beginning of year 21,284,206 Net assets, end of year $ 23,737,099 The accompanying notes are an integral part of these financial statements. -3-

7 Statement of Cash Flows For the Year Ended December 31, 2010 Cash flows from operating activities Receipts from patients and users $ 21,975,669 Payments to suppliers (8,241,551) Payments to employees (10,465,865) Payments to State of Michigan for maintenance of effort (42,645) Net cash provided by operating activities 3,225,608 Cash flows from noncapital financing activities Principal payment on advance from Ingham County (78,305) Cash flows from capital and related financing activities Acquisition and construction of capital assets (1,366,938) Interest paid on advance from Ingham County (5,593) Net cash used in capital and related financing activities (1,372,531) Cash flows from investing activities Interest received 186,958 Net increase in cash and cash equivalents 1,961,730 Cash and cash equivalents, beginning of year 14,436,220 Cash and cash equivalents, end of year $ 16,397,950 Reconciliation to the statement of net assets Pooled cash and investments $ 5,357,809 Pooled cash and investments - restricted $ 11,040,141 16,397,950 continued -4-

8 Statement of Cash Flows (concluded) For the Year Ended December 31, 2010 Reconciliation of operating income to net cash provided by operating activities Operating income $ 2,099,211 Adjustments to reconcile operating income to net cash provided by operating activities: Depreciation 574,310 Maintenance of effort payments (42,645) Quality assurance supplement 218,916 Change in assets and liabilities: Patient receivables (143,829) Inventory 622 Prepaid items (4,234) Accounts payable 191,830 Accrued expenses 28,948 Compensated absences 32,498 Due to other funds of Ingham County (2,175) Patient trust liability (3,818) Worker's compensation claims (23,597) Provision for contractual losses 174,500 Net other postemployment benefits obligation 125,071 Net cash provided by operating activities $ 3,225,608 The accompanying notes are an integral part of these financial statements. -5-

9 Okemos, Michigan Notes To Financial Statements 1. SUMMARY OF SIGNIFICANT ACCOUNTING POLICIES The financial statements of the Ingham County Medical Care Facility (ICMCF) have been prepared in conformity with generally accepted accounting principles (GAAP) as applied to governmental units. The Governmental Accounting Standards Board (GASB) is the accepted standard-setting body for establishing governmental accounting and financial reporting principles. The more significant of the ICMCF s accounting policies are described below. A. Financial Reporting Entity The ICMCF is an enterprise fund of Ingham County, Michigan (the County ) that provides long-term skilled care to residents of the County. A three-member board is responsible for establishing policies and oversight. The County appoints two board members and the State of Michigan appoints the third. An administrator manages the ICMCF s daily operations. B. Measurement Focus, Basis of Accounting and Basis of Presentation The ICMCF uses a fund (i.e., a separate accounting entity with a self-balancing set of accounts) to report its financial position and the changes in financial position. Fund accounting is designed to demonstrate legal compliance and to aid financial management by segregating transactions related to certain governmental functions and activities. The ICMCF is operated as an enterprise fund, a proprietary fund type, which is used to account for operations that are financed and operated in a manner similar to private business. Proprietary funds are accounted for on the flow of economic resources measurement focus and use the accrual basis of accounting. Under this method, revenues are recorded when earned and expenses are recorded at the time liabilities are incurred. Proprietary funds distinguish operating revenues and expenses from nonoperating items. Operating revenues and expenses generally result from providing services and producing and delivering goods in connection with a proprietary fund s principal ongoing operations. The principal operating revenues of the ICMCF are charges to patients for services. Operating expenses for enterprise funds include the cost of sales and services, administrative expenses, and depreciation on capital assets. All revenues and expenses not meeting this definition are reported as nonoperating revenues and expenses. -6-

10 Okemos, Michigan Notes To Financial Statements C. Assets, Liabilities and Equity 1. Deposits and Investments The ICMCF s pooled cash and investments include cash on hand, demand deposits and deposits in the Ingham County Treasurer s cash management pool. The Treasurer s cash management pool has the general characteristics of a demand deposit in that deposits and withdrawals may be made at any time without prior notice or penalty. State statutes authorize the ICMCF and the County to deposit in the accounts of federally insured banks, credit unions and savings and loan associations and to invest in obligations of the United States, certain commercial paper, repurchase agreements, bankers acceptances and mutual funds composed of otherwise legal investments. 2. Receivables Patient receivables are shown net of Medicaid advance payments and an allowance for uncollectible accounts. Approximately 84% of patient revenues are generated from services to patients covered by Medicare and Medicaid. Retroactive adjustments to the per diem rates established under those programs and by other third-party payors are accrued on an estimated basis in the period the related services are rendered and adjusted in future periods as final settlements are determined. 3. Interfund Receivables/Payables During the course of operations, numerous transactions occur between the ICMCF and Ingham County for goods provided or services rendered. Such transactions that are representative of lending/borrowing arrangements outstanding at year-end are referred to as advances to/from other funds. All other outstanding balances between funds including the current portion of any advances are reported as due to/from other funds on the statement of net assets. 4. Inventory and Prepaid Items Inventory is valued at cost using the first-in/first-out (FIFO) method. Certain payments to vendors reflect costs applicable to future accounting periods and are recorded as prepaid items. -7-

11 Okemos, Michigan Notes To Financial Statements 5. Restricted Assets Certain assets are classified as restricted assets on the statement of net assets because their use is limited to specific purposes as mandated by the State of Michigan or other third parties. These purposes include capital acquisitions and improvements, donations and patient trust monies. 6. Capital Assets Capital assets, which include property and equipment, are recorded at cost. Capital assets are defined by the ICMCF as assets with an individual cost of more than $5,000 and an estimated useful life in excess of two years. Donated property and equipment are recorded at their estimated fair value at the date of donation. Property and equipment are depreciated using the straight-line method over the estimated useful lives of the assets. The cost of normal maintenance and repairs that do not add to the value of the assets or materially extend their lives are charged to expense when incurred. Asset Category Useful Life in Years Land improvements 5 to 40 Building 40 Equipment 5 to Compensated Absences ICMCF employees are granted paid time off (PTO) in varying amounts based on length of service and are permitted to accumulate such earned but unused leave time subject to certain limitations. -8-

12 Okemos, Michigan Notes To Financial Statements 8. Patient Trust Liability The Michigan Department of Treasury requires facilities such as the ICMCF to administer and account for certain patient monies. Accordingly, the patient trust liability recorded in the statement of net assets represents those patient monies on deposit with the ICMCF at year-end. 9. Net Assets Restricted net assets are entirely restricted for capital improvements. 2. DEPOSITS At December 31, 2010, the carrying amount of the ICMCF s pooled cash and investments were composed of the following: Current Restricted Assets Assets Total On deposit with County $ 5,318,282 $11,025,817 $ 16,344,099 On deposit with bank 38,777 13,724 52,501 Cash on hand ,350 Total deposits $ 5,357,809 $11,040,141 $ 16,397,950 As of year end, none of the Facility s bank balance of $214,909 (book balance of $52,501) was exposed to custodial credit risk because it was uninsured and uncollateralized. The bank balance and federal deposit insurance coverage, if any, of the funds on deposit with County are not readily determinable inasmuch as those funds are deposited in the Ingham County Treasurer s cash management pool. -9-

13 Okemos, Michigan Notes To Financial Statements 3. PATIENT RECEIVABLES The details of patient accounts receivable are as follows at December 31, 2010: Patient receivables $ 3,934,976 Adjust: Allowances for uncollectible accounts (165,000) Medicaid interim payments (879,447) Patient receivables, net $ 2,890, CAPITAL ASSETS Changes in the components of the capital assets are summarized as follows: Beginning Ending Balance Increases Decreases Balance Capital assets, not being depreciated: Land $ 132,832 $ - $ - $ 132,832 Construction in progress - 840, ,104 Total capital assets, not being depreciated 132, , ,936 Capital assets, being depreciated: Land improvements 276,502 33, ,509 Buildings 14,760, ,252 (21,000) 15,168,951 Equipment 576,462 64,575 (54,927) 586,110 Total capital assets being depreciated 15,613, ,834 (75,927) 16,064,570 Less accumulated depreciation for: Land improvements (242,890) (545) - (243,435) Buildings (7,850,962) (524,035) 21,000 (8,353,997) Equipment (353,510) (49,730) 54,927 (348,313) Total accumulated depreciation (8,447,362) (574,310) 75,927 (8,945,745) Total capital assets being depreciated, net 7,166,301 (47,476) - 7,118,825 Capital assets, net $ 7,299,133 $ 792,628 $ - $ 8,091,

14 Okemos, Michigan Notes To Financial Statements 5. RISK MANAGEMENT Through the County, the ICMCF is self-insured for workers compensation claims up to $300,000 per occurrence and insured for the amount of claims in excess of that limitation up to a maximum of $5 million. The change in the worker s compensation liability amount for the last two years is as follows: Claims liability at beginning of fiscal year $ 61,836 $ 52,264 Claims and changes in estimates 117, ,558 Claim payments (140,804) (136,986) Claims liability at end of year $ 38,239 $ 61,836 Also through the County, the ICMCF participates in the Michigan Municipal Risk Management Authority (MMRMA) for general and automobile liability, motor vehicle physical damage and property coverage. Under most circumstances, the maximum loss retention per occurrence is as follows: Type of Risk Maximum Retention Per Occurrence General and automobile liability $150,000 Motor vehicle physical damage $ 16,000 per vehicle $ 31,000 per occurrence Property coverage $ 11,000 Further information and disclosures regarding risk management is provided in the County s comprehensive annual financial report. 6. MAINTENANCE OF EFFORT Each month the ICMCF is billed by the State of Michigan for maintenance of effort in an amount equal to a specified rate times the number of Medicaid patient days approved by the State for that month. -11-

15 Okemos, Michigan Notes To Financial Statements 7. CONTINGENT LIABILITIES Amounts received or receivable from third-party payors, in particular Medicare and Medicaid, are subject to audit and adjustment by various intermediaries. The amount of such adjustments cannot be determined at this time although the ICMCF expects such amounts, if any, to be immaterial. In 1978, the ICMCF received a federal grant under the Hill-Burton Act to help finance construction of the facility. A provision of the grant is that the facility provide free of charge care to qualifying individuals in a total cumulative amount equal to the original grant amount adjusted for inflation. Through December 31, 2010, the ICMCF has not yet satisfied the charitable care obligations of the Hill-Burton Act. 8. EMPLOYEE RETIREMENT SYSTEM ICMCF employees participate, along with other Ingham County employees, in the Michigan Municipal Employees Retirement System (MERS). The plan is a multiple employer defined benefit plan administered by MERS. During 2010, employer contributions of $689,025 were made by the ICMCF in accordance with contribution requirements determined by an actuarial valuation of the plan as of December 31, Further information regarding the Ingham County plan including detailed trend information is presented in the County s 2010 comprehensive annual financial report, which is available to the public. 9. POSTEMPLOYMENT BENEFITS OTHER THAN PENSIONS ICMCF employees participate, along with other Ingham County employees, in the County s Retiree Health Care Plan (the Plan ), a single employer defined benefit healthcare plan administered by the Ingham County Retiree Health Care Board. The Plan provides postemployment healthcare and life insurance benefits to eligible retirees in accordance with labor contracts and personnel policies. -12-

16 Okemos, Michigan Notes To Financial Statements Funding Policy. The contribution requirements of plan members and the Facility are established and may be amended by the County Board of Commissioners, subject to applicable labor contracts. Plan members are not required to contribute; however, plan members receiving healthcare benefits pay for half of the health care insurance premium over an annually established level (which was approximately $365 per month for 2010) and for 100% of the additional premium cost for spousal and dependent coverage. The Facility may contribute the annual required contribution of the employer (ARC), an amount actuarially determined in accordance with the parameters of GASB Statement 45, Accounting and Financial Reporting by Employers for Postemployment Benefits Other Than Pensions. The ARC represents a level of funding that, if paid on an ongoing basis, is projected to cover the normal cost each year and amortize any unfunded actuarial liabilities (or funding excess) over a period not to exceed thirty years. Annual OPEB Cost and Net OPEB Obligation. For 2010, the components of the ICMCF s annual OPEB (other postemployment benefit) cost for the year, the amount actually contributed to the Plan, and changes in the ICMCF s net OPEB obligation to the Plan are as follows: Annual required contribution $ 278,821 Interest on net OPEB obligation 57,782 Adjustment to annual required contribution (44,277) Annual OPEB cost 292,326 Contributions made (167,255) Increase in net OPEB obligation 125,071 Net OPEB obligation, beginning of year 1,284,044 Net OPEB obligation, end of year $ 1,409,115 The Facility s annual OPEB cost, the percentage of annual OPEB cost contributed to the plan, and the net OPEB obligation for the last three years were as follows: Year Ended OPEB Cost Net OPEB Obligation 12/31/08 $ 856,179 $ 1,163,647 12/31/09 277,620 1,284,044 12/31/10 292,326 1,409,

17 Okemos, Michigan Notes To Financial Statements Funded Status and Funding Progress. The funded status of the Plan as of December 31, 2008, the date of the most recent actuarial valuation, is as follows: Actuarial accrued liability (AAL) (1) $ 4,290,944 Actuarial value of assets (2) - Unfunded AAL (UAAL) (3) $ 4,290,944 (1) - (2) Funded ratio (4) 0.0% (2) / (1) Covered payroll (5) $ 8,953,011 UAAL as % of covered payroll (6) 47.9% (3) / (5) The schedules of funding progress, presented as required supplementary information following the notes to the financial statements, present multiyear trend information about whether the actuarial values of plan assets are increasing or decreasing over time relative to the actuarial accrued liabilities for benefits. The accompanying schedules of employer contributions present trend information about the amounts contributed to the plan by employers in comparison with the ARC, an amount that is actuarially determined in accordance with the parameters of GASB Statement 43. The ARC represents a level of funding that, if paid on an ongoing basis, is projected to cover normal cost for each year and amortize any unfunded actuarial liabilities (or funding excess) over a period not to exceed 30 years. Actuarial Methods and Assumptions. Actuarial valuations of an ongoing plan involve estimates of the value of reported amounts and assumptions about the probability of potential occurrences of certain events in the future. Examples include assumption about future employment, mortality, healthcare costs trends, inflation, etc. Amounts determined regarding the funded status of the plan and the annual required contributions of the Facility are subject to constant changes and modifications as actual results are compared with past expectations and new estimates and assumptions are formed regarding the future. Projections of retiree benefits for financial reporting purposes are based on current plan activities as it is handled by the Facility and the benefits are received by the eligible plan members and include the types of benefits provided at the time of each valuation and the historical pattern of sharing of benefit costs between the Facility and plan members. -14-

18 Okemos, Michigan Notes To Financial Statements The actuarial methods and assumptions used include techniques that are designed to reduce the effects of short-term volatility in actuarial accrued liabilities and the actuarial value of assets, consistent with the long-term perspective of the calculations. In the December 31, 2008, actuarial valuation, the individual entry age normal actuarial cost method was used. The actuarial assumptions include a 4.5% a year rate of investment return, compounded annually net after investment expense, which is the expected long-term investment return on plan assets, and a base payroll growth rate of 4.5%. There were also merit and seniority salary rate increase assumptions taken into consideration and those are detailed in the actuarial study and are based on age. There was also an inflationary rate assumption factored into the calculation. Per the actuarial study, the assumed rate ranges from 9.0% in the short-term to 4.5% in the long-term for health care related costs. The UAAL is being amortized as a level percentage of active member payroll over a period of 30 years on an open basis. 10. ADVANCES PAYABLE TO INGHAM COUNTY In 1996, ICMCF borrowed $1.5 million from the County for a capital expansion and renovation project. The loan agreement provides for repayment of the advance over 20 years with interest at one percent (1%) per annum on the outstanding principal balance. Repayment requirements to maturity are as follows: Year Ending December 31, Principal Interest 2011 $ 78,306 $ 4, ,089 4, ,880 3, ,678 2, ,485 1, , Total $ 481,738 $ 17,000 The principal amount due in 2011 ($78,306) is reported in the statement of net assets with the amounts due to other funds of Ingham County. The remaining principal balance of $403,432 is reported in the noncurrent liabilities under advances from other funds of Ingham County. -15-

19 Okemos, Michigan Notes To Financial Statements 11. COMPENSATED ABSENCES Changes in compensated absences for the year ended December 31, 2010, were as follows: Due Beginning Ending Within Balance Increases Decreases Balance One Year Compensated absences $ 371,471 $ 733,968 $ 701,470 $ 403,969 $ 242, CONSTRUCTION COMMITMENT The Facility has an active construction project as of December 31, 2010 with a remaining contractual commitment of $864,762. The Facility expects the project to be completed during * * * * * -16-

20 REQUIRED SUPPLEMENTARY INFORMATION

21 Retiree Health Care Plan Required Supplementary Information SCHEDULE OF EMPLOYER CONTRIBUTIONS Annual Required Actual Year Ended Contribution Contribution Percentage Contributed 12/31/08 $ 850,595 $ 223, % 12/31/09 266, , /31/10 278, ,

22 SUPPLEMENTARY FINANCIAL INFORMATION

23 Schedule of Net Patient Revenues For the Year Ended December 31, 2010 Daily Room Services Medicaid $ 9,728,673 Medicare 8,860,185 Other 3,018,222 Total daily room services 21,607,080 Ancillary Services Pharmacy and IV 1,013,690 Physical therapy 1,573,165 Occupational therapy 1,569,667 Speech therapy 292,758 Medical supplies 168,762 Total ancillary services 4,618,042 Total patient revenue 26,225,122 Revenue deductions Provision for contractual discounts (4,202,929) Net patient revenues $ 22,022,

24 Schedule of Operating Expenses For the Year Ended December 31, 2010 Salaries Other Total Administration $ 411,483 $ 326,059 $ 737,542 Human resources 148,417 76, ,920 Maintenance 176, , ,860 Laundry 170,565 62, ,428 Housekeeping 361, , ,237 Dietary 803, ,004 1,565,578 Central supply 53, ,809 Pharmacy - 773, ,551 Nursing 7,604, ,295 8,364,889 Physical therapy - 977, ,596 Occupational therapy - 900, ,267 Psychosocial services 518,912 33, ,765 Admissions and marketing 146,844 73, ,065 Vehicles Physician services - 50,756 50,756 Nurse aide training 77,036 16,552 93,588 In-service education 53,589 1,328 54,917 Speech therapy - 158, ,402 Fringe benefits - 3,095,747 3,095,747 Depreciation - 574, ,310 Prior year cost settlement - (6,526) (6,526) Total expenses $ 10,527,311 $ 9,495,151 $ 20,022,

25 Rehmann Robson 675 Robinson Rd. Jackson, MI Ph: Fx: INDEPENDENT AUDITORS REPORT ON INTERNAL CONTROL OVER FINANCIAL REPORTING AND ON COMPLIANCE AND OTHER MATTERS BASED ON AN AUDIT OF FINANCIAL STATEMENTS PERFORMED IN ACCORDANCE WITH GOVERNMENT AUDITING STANDARDS June 14, 2011 To the Department of Human Services Board Ingham County Medical Care Facility Okemos, Michigan We have audited the financial statements of the Ingham County Medical Care Facility (the Facility ), an enterprise fund of Ingham County, Michigan, as of and for the year ended December 31, 2010, and have issued our report thereon dated June 14, We conducted our audit in accordance with auditing standards generally accepted in the United States of America and the standards applicable to financial audits contained in Government Auditing Standards, issued by the Comptroller General of the United States. Internal Control Over Financial Reporting In planning and performing our audit, we considered the Facility s internal control over financial reporting as a basis for designing our auditing procedures for the purpose of expressing our opinions on the financial statements, but not for the purpose of expressing an opinion on the effectiveness of the Facility s internal control over financial reporting. Accordingly, we do not express an opinion on the effectiveness of the Facility s internal control over financial reporting. A deficiency in internal control exists when the design or operation of a control does not allow management or employees, in the normal course of performing their assigned functions, to prevent, or detect and correct misstatements on a timely basis. A material weakness is a deficiency, or a combination of deficiencies, in internal control such that there is a reasonable possibility that a material misstatement of the entity s financial statements will not be prevented, or detected and corrected on a timely basis. Our consideration of internal control over financial reporting was for the limited purpose described in the first paragraph of this section and was not designed to identify all deficiencies in internal control over financial reporting that might be deficiencies, significant deficiencies or material weaknesses. We did not identify any deficiencies in internal control over financial reporting that we consider to be material weaknesses, as defined above. -20-

26 Compliance and Other Matters As part of obtaining reasonable assurance about whether the Facility s financial statements are free of material misstatement, we performed tests of its compliance with certain provisions of laws, regulations, contracts, and grant agreements, noncompliance with which could have a direct and material effect on the determination of financial statement amounts. However, providing an opinion on compliance with those provisions was not an objective of our audit, and accordingly, we do not express such an opinion. The results of our tests disclosed no instances of noncompliance or other matters that are required to be reported under Government Auditing Standards. In addition, we noted a certain matter that we reported to management of the Facility in a separate letter dated June 14, This report is intended solely for the information and use of management, the Department of Human Services Board, and others within the entity and is not intended to be and should not be used by anyone other than these specified parties. -21-

27 Rehmann Robson 675 Robinson Rd. Jackson, MI Ph: Fx: June 14, 2011 To the Human Services Board Ingham County Medical Care Facility We have audited the financial statements of the Ingham County Medical Care Facility (the Facility ), an enterprise fund of Ingham County, Michigan for the year ended December 31, 2010, and have issued our report thereon dated June 14, Professional standards require that we provide you with the following information related to our audit. Our Responsibility Under Auditing Standards Generally Accepted in the United States of America and Government Auditing Standards As stated in our engagement letter dated January 20, 2011, our responsibility, as described by professional standards, is to express opinions about whether the financial statements prepared by management with your oversight are fairly presented, in all material respects, in conformity with accounting principles generally accepted in the United States of America. Our audit of the financial statements does not relieve you or management of your responsibilities. As part of our audit, we considered the internal control of the Facility. Such considerations were solely for the purpose of determining our audit procedures and not to provide any assurance concerning such internal control. As part of obtaining reasonable assurance about whether the financial statements are free of material misstatement, we performed tests of Facility s compliance with certain provisions of laws, regulations, contracts and grants. However, the objective of our tests was not to provide an opinion on compliance with such provisions. Planned Scope and Timing of the Audit We performed the audit according to the planned scope and timing previously communicated to you in our engagement letter and our meeting about planning matters on March 30, 2011.

28 Page 2 Significant Audit Observations Qualitative Aspects of Accounting Practices Management is responsible for the selection and use of appropriate accounting policies. In accordance with the terms of our engagement letter, we will advise management about the appropriateness of accounting policies and their application. The significant accounting policies used by the Facility are described in Note 1 to the financial statements. No new accounting policies were adopted and the application of existing policies was not changed during the year. We noted no transactions entered into by the Facility during the year for which there is a lack of authoritative guidance or consensus. There are no significant transactions that have been recognized in the financial statements in a different period than when the transaction occurred. Accounting estimates are an integral part of the financial statements prepared by management and are based on management s knowledge and experience about past and current events and assumptions about future events. Certain accounting estimates are particularly sensitive because of their significance to the financial statements and because of the possibility that future events affecting them may differ significantly from those expected. The most sensitive estimates affecting the financial statements were: Management s estimate of the useful lives of depreciable capital assets is based on the length of time it is believed that those assets will provide some economic benefit in the future. Management s estimate of the liability for uninsured risks, including incurred but not reported claims, for self-insured workers compensation coverage. We relied upon the work of a third-party administrator and the analysis of the County in determining that the liability is reasonable in relation to the financial statements taken as a whole. Management s estimate of the collectability of patient receivables from first and third party payers. We evaluated the key factors and assumptions used to develop the allowances for uncollectable accounts in determining that they are reasonable in relation to the basic financial statements taken as a whole. Management s estimate of other postemployment benefits and pension contributions are based on current covered payroll. We evaluated the key factors and assumptions used to develop these estimates in determining that they are reasonable in relation to the financial statements taken as a whole. Difficulties Encountered in Performing the Audit We encountered no significant difficulties in dealing with management in performing and completing our audit.

29 Page 3 Corrected and Uncorrected Misstatements Professional standards require us to accumulate all known and likely misstatements identified during the audit, other than those that are trivial, and communicate them to the appropriate level of management. Management has corrected all such misstatements. In addition, none of the misstatements detected as a result of audit procedures and corrected by management were material, either individually or in the aggregate, to the financial statements taken as a whole. Disagreements with Management For purposes of this letter, professional standards define a disagreement with management as a financial accounting, reporting, or auditing matter, whether or not resolved to our satisfaction, that could be significant to the financial statements or the auditor s report. We are pleased to report that no such disagreements arose during the course of our audit. Management Representations We have requested certain representations from management that are included in the attached management representation letter dated June 14, Management Consultations with Other Independent Accountants In some cases, management may decide to consult with other accountants about auditing and accounting matters, similar to obtaining a second opinion on certain situations. If a consultation involves application of an accounting principle to the entity s financial statements or a determination of the type of auditor s opinion that may be expressed on those statements, our professional standards require the consulting accountant to check with us to determine that the consultant has all the relevant facts. To our knowledge, there were no such consultations with other accountants. Other Audit Findings or Issues We generally discuss a variety of matters, including the application of accounting principles and auditing standards, with management each year prior to retention as the governmental unit s auditors. However, these discussions occurred in the normal course of our professional relationship and our responses were not a condition to our retention.

30 This information is intended solely for the use of the governing body and management of the Ingham County Medical Care Facility and is not intended to be and should not be used by anyone other than these specified parties. Very truly yours, Page 4

31 Ingham County Medical Care Facility Attachment A - Consideration of Internal Control Over Financial Reporting For the Year Ended December 31, 2010 In planning and performing our audit of the financial statements of the Ingham County Medical Care Facility (the Facility ) as of and for the year ended December 31, 2010, in accordance with auditing standards generally accepted in the United States of America, we considered the Facility s internal control over financial reporting (internal control) as a basis for designing our auditing procedures for the purpose of expressing our opinion on the financial statements, but not for the purpose of expressing an opinion on the effectiveness of the Facility s internal control. Accordingly, we do not express an opinion on the effectiveness of the Facility s internal control. A deficiency in internal control exists when the design or operation of a control does not allow management or employees, in the normal course of performing their assigned functions, to prevent, or detect and correct misstatements on a timely basis. A material weakness is a deficiency, or combination of deficiencies in internal control, such that there is a reasonable possibility that a material misstatement of the entity s financial statements will not be prevented, or detected and corrected on a timely basis. Our consideration of internal control was for the limited purpose described in the first paragraph and was not designed to identify all deficiencies in internal control that might be significant deficiencies or material weaknesses and, therefore, there can be no assurance that all such deficiencies have been identified. We did not identify any deficiencies in internal control that we consider to be material weaknesses. Other Matters Cash Receipting Process. During our audit we considered the internal controls relating to cash receipting. From our procedures, we noted that the same individual prepares the deposits, takes the deposits to the bank and prepares the bank reconciliations. We recommend the Facility implement a procedure to ensure that more than one individual is involved in the cash receipting and reconciliation process. * * * * *

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