EIN: 112785201
UEI: MDB9DF239VH8
Audited by: HMM, CPAS LLP
Oversight agency: 93 [Department of Health and Human Services]
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Data as of September 2, 2026
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on September 27, 2023. Under 2 CFR 200.521(d), a pass-through entity that provided federal funds to this organization for this audit period must issue a management decision on these findings by March 27, 2024 (890 days ago).
What is a management decision? →Finding No. 2022-001 Grantor: U.S. Department of Health and Human Services Program Names: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution (PRF) program Federal Assistance Listing Number: 93.498 Criteria: Management is required to report on the use of the Provider Relief Funds in portal submissions to the Department of Health and Human Services (HHS). Condition and Context: Management failed to report total other assistance received from FEMA in the amount of $1,237,253 for the Period 4 Provider Relief Fund Reporting Period. Cause: Management's unfamiliarity with the requirements of a federal award program and lack of internal controls over financial reporting for federal awards. Effect or potential effect: Management utilized lost revenues and infection control expenses in excess of the PRF funding received in Periods 1 through 4. The total expenditures reimbursed through FEMA were not reported correctly in Period 4. No PRF expenses reported in Period 4 were reimbursed from any other source. It is noted that at this time there is not a mechanism to amend the portal submission. Questioned Costs: None Recommendation: We recommend that management review its internal policies to ensure that all guidance is followed for each submission. Views of responsible officials: Management has acknowledged the PRF report submitted to the HRSA PRF reporting portal was missing other funding received from FEMA.
Show full finding ▾Hide full finding ▴Finding No. 2022-001 Grantor: U.S. Department of Health and Human Services Program Names: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution (PRF) program Federal Assistance Listing Number: 93.498 Criteria: Management is required to report on the use of the Provider Relief Funds in portal submissions to the Department of Health and Human Services (HHS). Condition and Context: Management failed to report total other assistance received from FEMA in the amount of $1,237,253 for the Period 4 Provider Relief Fund Reporting Period. Cause: Management's unfamiliarity with the requirements of a federal award program and lack of internal controls over financial reporting for federal awards. Effect or potential effect: Management utilized lost revenues and infection control expenses in excess of the PRF funding received in Periods 1 through 4. The total expenditures reimbursed through FEMA were not reported correctly in Period 4. No PRF expenses reported in Period 4 were reimbursed from any other source. It is noted that at this time there is not a mechanism to amend the portal submission. Questioned Costs: None Recommendation: We recommend that management review its internal policies to ensure that all guidance is followed for each submission. Views of responsible officials: Management has acknowledged the PRF report submitted to the HRSA PRF reporting portal was missing other funding received from FEMA.
Finding 2022-001 a. Comments on the Finding and Each Recommendation. Management agrees with the finding. Management also agrees with the recommendation, please see below for action taken. b. Action Taken on the Finding. Due to a prior finding, 2021-001, internal control procedures were updated and the FEMA assistance received was correctly reported in the Period 3 Provider Relief Fund Reporting Period. Even though the facility updated their internal control procedures they inadvertently failed to report the total amount of FEMA assistance received when reporting in the Period 4 Provider Relief Fund Reporting Period. It is noted that there is not a mechanism to amend the portal submission. Management will review their internal control procedures to enhance the review process of portal submissions. The facility did not inappropriately utilize funds and should not be at risk of having any funds returned to the Department of Health and Human Services. Management has maintained documentation of all eligible expenses and lost revenue calculations to support this assertion.
2021-001
Finding No. 2022-002 Grantor: U.S. Department of Health and Human Services Program Names: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution (PRF) program Federal Assistance Listing Number: 93.498 Criteria: Management is required to report on the use of the Provider Relief Funds in portal submissions to the Department of Health and Human Services (HHS). Condition and Context: Management failed to report the use of Provider Relief Funds for the proper year the expenses were incurred for the Period 4 Provider Relief Fund Reporting Period Expenses should have been allocated for the years 2020, 2021 and 2022. Cause: Management's unfamiliarity with the requirements of a federal award program and lack of internal controls over financial reporting for federal awards. Effect or potential effect: Management utilized lost revenues and infection control expenses in excess of the funding reported in Periods 1 through 4. No expenses reported in Period 4 were reimbursed from any other source. It is noted that at this time there is not a mechanism to amend the portal submission. Questioned Costs: None Recommendation: We recommend that management review its internal policies to ensure that all guidance is followed for each submission. Views of responsible officials: Management has acknowledged the PRF report submitted to the HRSA PRF reporting portal was not allocated properly for the periods expenses were incurred.
Show full finding ▾Hide full finding ▴Finding No. 2022-002 Grantor: U.S. Department of Health and Human Services Program Names: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution (PRF) program Federal Assistance Listing Number: 93.498 Criteria: Management is required to report on the use of the Provider Relief Funds in portal submissions to the Department of Health and Human Services (HHS). Condition and Context: Management failed to report the use of Provider Relief Funds for the proper year the expenses were incurred for the Period 4 Provider Relief Fund Reporting Period Expenses should have been allocated for the years 2020, 2021 and 2022. Cause: Management's unfamiliarity with the requirements of a federal award program and lack of internal controls over financial reporting for federal awards. Effect or potential effect: Management utilized lost revenues and infection control expenses in excess of the funding reported in Periods 1 through 4. No expenses reported in Period 4 were reimbursed from any other source. It is noted that at this time there is not a mechanism to amend the portal submission. Questioned Costs: None Recommendation: We recommend that management review its internal policies to ensure that all guidance is followed for each submission. Views of responsible officials: Management has acknowledged the PRF report submitted to the HRSA PRF reporting portal was not allocated properly for the periods expenses were incurred.
Finding 2022-002 a. Comments on the Finding and Each Recommendation. Management agrees with the finding. Management also agrees with the recommendation, please see below for action taken. b. Action Taken on the Finding. The infection control expenses were correctly reported in the Period 3 Provider Relief Fund Reporting Period. In the Period 4 Provider Relief Fund Reporting Period, the facility inadvertently failed to report infection control expenses utilized in their correct years. Management will review their internal control procedures to enhance the review process of portal submissions. There is not a mechanism to amend the portal submission and if given the opportunity management will correct it in a subsequent reporting period. Management has utilized lost revenues and infection control expenses in excess of the funding received in 2020 and 2021 and has maintained documentation of all eligible expenses and lost revenue calculations to support this assertion.
FAC accepted this audit on September 29, 2022 — management decision was due March 29, 2023.
Finding No. 2021-001 Criteria: Management is required to report on the use of the Provider Relief Funds in portal submissions to the Department of Health and Human Services (HHS). Condition and Context: Management failed to report other assistance received from FEMA in the amount of $656,801 for the Period 2 Provider Relief Fund Reporting Period. Cause: Management's unfamiliarity with the requirements of a federal award program and lack of internal controls over financial reporting for federal awards. Effect or potential effect: Management utilized lost revenues and infection control expenses in excess of the funding received in Period 1 and in Period 2, respectively. The expenditures reimbursed through FEMA were not reported in either Period. No expenses reported in either Period were reimbursed from any other source. It is noted that at this time there is not a mechanism to amend the portal submission. Questioned Costs: None Recommendation: We recommend that management review its internal policies to ensure that all guidance is followed for each submission. Views of responsible officials: Management has acknowledged the PRF report submitted to the HRSA PRF reporting portal was missing other funding received from FEMA, but has corrected this error in Period 3.
Show full finding ▾Hide full finding ▴Finding No. 2021-001 Criteria: Management is required to report on the use of the Provider Relief Funds in portal submissions to the Department of Health and Human Services (HHS). Condition and Context: Management failed to report other assistance received from FEMA in the amount of $656,801 for the Period 2 Provider Relief Fund Reporting Period. Cause: Management's unfamiliarity with the requirements of a federal award program and lack of internal controls over financial reporting for federal awards. Effect or potential effect: Management utilized lost revenues and infection control expenses in excess of the funding received in Period 1 and in Period 2, respectively. The expenditures reimbursed through FEMA were not reported in either Period. No expenses reported in either Period were reimbursed from any other source. It is noted that at this time there is not a mechanism to amend the portal submission. Questioned Costs: None Recommendation: We recommend that management review its internal policies to ensure that all guidance is followed for each submission. Views of responsible officials: Management has acknowledged the PRF report submitted to the HRSA PRF reporting portal was missing other funding received from FEMA, but has corrected this error in Period 3.
Management has reviewed its internal policies and plans to submit all future filings following the appropriate PRF guidance.
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