EIN: 210633410
UEI: FS2AVKD6LJJ6
Data as of August 20, 2026
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on January 12, 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 July 12, 2023, which was (1136 days ago).
What is a management decision? →Finding 2022-001 - Significant Deficiency in Internal Control - Reporting Assistance Listing Number: 93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Federal Agency: U.S. Department of Health and Human Services Pass-through Agency: Not Applicable Award Number/Year: Not Applicable / 2020 Criteria: Non-federal entities in receipt of federal funds must comply with the requirements of 2 CFR 200.303(a), which require an entity to establish and maintain effective internal control over the Federal award to ensure compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. Recipients of Provider Relief Funds (PRF) payments must comply with the reporting requirements described in the PRF terms and conditions and specified in directions issued by the U.S. Department of Health and Human Services (HHS). Condition/Context: For the reports tested, the Company excluded from patient care revenue the amount attributable to independent living and assisted living related services provided to residents. The Company also inadvertently used data from the wrong period when preparing the lost revenue calculation. As a result of these adjustments, the lost revenue increased from $970,102 to $1,977,744. Additionally, the reports tested did not contain a documented review and approval of the reports prior to submission. Effect: The amounts reported to Health Resources & Services Administration (HRSA) were not in accordance with the established HHS Reporting Requirements. Questioned Costs: None reported. Cause: An oversight by management resulted in using data from the wrong period when preparing their lost revenue calculation. In addition, management believed that the most appropriate option to select was Option i, not Option iii, based on their interpretation of the guidance. Recommendation: We recommend that management review and update, as needed, their procedure for completion of the reporting to ensure that a review and approval of such reporting is completed and documented prior to submission. Additionally, we recommend that management change their selected reporting option from Option i to Option iii in the next required submission, if revenue attributable to independent living related services will continue to be excluded from patient care revenues. Views of Responsible Officials: The Company will implement procedures to ensure an individual who is responsible for reporting will remain current on compliance requirements and review final reports and the related inputs prior to submission. Specifically, the Company will verify Residential Living (IL) revenues and Amortization Income are included in the lost revenue calculation.
Finding 2022-001 Condition For the reports tested, the Company excluded from patient care revenue the amount attributable to independent living and assisted living related services provided to residents. The Company also inadvertently used data from the wrong period when preparing the lost revenue calculation. As a result of these adjustments, the lost revenue increased from $970,102 to $1,977,744. Additionally, the reports tested did not contain a documented review and approval of the reports prior to submission. Corrective Action Plan The Company agrees with the finding and will implement procedures to ensure an individual who is responsible for reporting will remain current on compliance requirements and review final reports and the related inputs prior to submission. Specifically, the Company will verify Residential Living (IL) revenues and Amortization Income are included in the lost revenue calculation. Name(s) of Contact Person(s) Responsible for Corrective Action Abby Loftus, Chief Financial Officer Anticipated Completion Date December 31, 2022
Finding 2022-002 - Significant Deficiency in Internal Control - Activities Allowed and Unallowed; Allowable Costs/Cost Principles Assistance Listing Number: 93.498 COVID-19 - Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Program Federal Agency: U.S. Department of Health and Human Services (HHS) Pass-Through Agency: Not applicable Award Number/Year: N/A / 2020 Criteria: Non-federal entities in receipt of federal funds must comply with the requirements of 2 CFR 200.303(a), which require an entity to establish and maintain effective internal control over the Federal award to ensure compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. Provider Relief Fund (PRF) payments must be used for allowable expenses and lost revenue described in the PRF terms and conditions and specified in guidance issued by HHS. Activities allowed have been defined as health care related expenses used to prevent, prepare for, and respond to coronavirus or lost revenues that are attributable to coronavirus. Condition/Context: A sample of 40 items were selected for testing. During our testing, we noted one item selected for testing that was deemed an unallowable expense as it was not used to prevent, prepare for, and respond to coronavirus. This was not a statistically valid sample. Effect: There were costs charged to the program that were for unallowable purposes. Questioned Costs: $40,323 related to the items that were not clearly identified as being used to prevent, prepare for, or respond to coronavirus, and the invoice that did not contain any supporting documentation. Cause: The Company lacked formal approved policies and procedures related to the administration of the award. Recommendation: We recommend that management develop and implement formal policies and procedures for administration of the federal award program that includes assigning an individual with the appropriate skills, knowledge, and expertise of the award to review and approve expenditures prior to being allocated to the program. Views of Responsible Officials: The Company will implement procedures to ensure an individual who is reviewing and approving invoices has the appropriate skill set to ensure costs that are incurred are being used to prevent, prepare for, or respond to the coronavirus.
Finding 2022-002 Condition A sample of 40 items were selected for testing. During our testing, we noted one item selected for testing was not deemed an expense used to prevent, prepare for, and respond to coronavirus. This was not a statistically valid sample. Corrective Action Plan The Company will implement procedures to ensure an individual who is reviewing and approving invoices has the appropriate skill set to ensure costs that are incurred are being used to prevent, prepare for, or respond to the coronavirus. Name(s) of Contact Person(s) Responsible for Corrective Action Abby Loftus, Chief Financial Officer Anticipated Completion Date December 31, 2022
Data source: This information comes from the Federal Audit Clearinghouse, the official repository of Single Audit data. All data is public domain. Verify this organization's audit history at fac.gov.
Track your findings and corrective action plans across audit cycles.
Start tracking findings →Monitor subrecipient audit findings and compliance status.
Start monitoring →Single Audit Intelligence is an independent tool powered by Federal Audit Clearinghouse data. Not affiliated with GSA, OMB, or any federal agency.