EIN: 231405633
UEI: TLTJV1F36753
Audit also covers 2 related EINs: 261485070, 270941380
Audited by: Baker Tilly US, LLP
Oversight agency: 93 [Department of Health and Human Services]
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Data as of September 7, 2026
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on October 3, 2025. 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 April 3, 2026 (159 days ago).
What is a management decision? →FAC accepted this audit on August 8, 2024 — management decision was due February 8, 2025.
FAC accepted this audit on March 5, 2024 — management decision was due September 5, 2024.
FAC accepted this audit on January 26, 2023 — management decision was due July 26, 2023.
Federal Program: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Program Assistance Listing Number: 93.498 Federal Agency: U.S. Department of Health and Human Services Award Number: N/A Award Year: 2020 Compliance Requirements: Activities Allowed and Unallowed; and Allowable Costs/Cost Principles Questioned Costs: $929,442 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 Funds (PRF) payments must be used for allowable expenses and lost revenue described in the PRF terms and conditions and specified in guidance issued by the U.S. Department of Health and Human Services. Activities allowed have been defined as expense used to prevent, prepare for, and respond to coronavirus, domestically or internationally, for necessary expenses to reimburse, through grants or other mechanisms, eligible health care providers for health care related expenses or lost revenues that are attributable to coronavirus. Condition and Context: Upon review of the initial population of expenses claimed for reimbursement from the Period 1 and 2 submission, it was noted that there were certain items of cost that did not meet criteria of an allowable expenses as defined by the U.S. Department of Health and Human Services guidance. Such items included: ? $759,282 of expenditures related to costs that were not specifically used to prevent, prepare for, and respond to the coronavirus. ? $170,160 of accruals or estimates that did not meet the definition of an incurred cost or eligible expense under the program requirements and were lacking supporting documentation to demonstrate expense eligibility. Of this amount, $85,820 was reported under infection control payments. The amounts determined above were not part of a sample but were derived from review of the expense populations. The remaining population of $324,720 which was used to claim general and infection control payments was sampled and tested without exception. Effect: The Corporations' claimed expenses that were not in accordance with established U.S. Department of Health and Human Services guidance and are therefore deemed unallowable. Cause: Management misinterpreted the guidance established by U.S. Department of Health and Human Services and claimed unallowable expenses in their reporting of qualified expenses. Recommendation: We recommend that management implement procedures to ensure that the most recent guidance is reviewed and understood and that information used in accumulating allowable expenses is reviewed, with errors addressed. Procedures should be performed on a monthly basis with previously recognized expenses being reviewed to ensure they qualify as an allowable expense under the most recent guidance. Views of Responsible Officials: Management agrees with the finding and will correct in future submissions but acknowledges that it has sufficient lost revenues and infection control expenses to cover the questioned costs.
Show full finding ▾Hide full finding ▴Federal Program: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Program Assistance Listing Number: 93.498 Federal Agency: U.S. Department of Health and Human Services Award Number: N/A Award Year: 2020 Compliance Requirements: Activities Allowed and Unallowed; and Allowable Costs/Cost Principles Questioned Costs: $929,442 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 Funds (PRF) payments must be used for allowable expenses and lost revenue described in the PRF terms and conditions and specified in guidance issued by the U.S. Department of Health and Human Services. Activities allowed have been defined as expense used to prevent, prepare for, and respond to coronavirus, domestically or internationally, for necessary expenses to reimburse, through grants or other mechanisms, eligible health care providers for health care related expenses or lost revenues that are attributable to coronavirus. Condition and Context: Upon review of the initial population of expenses claimed for reimbursement from the Period 1 and 2 submission, it was noted that there were certain items of cost that did not meet criteria of an allowable expenses as defined by the U.S. Department of Health and Human Services guidance. Such items included: ? $759,282 of expenditures related to costs that were not specifically used to prevent, prepare for, and respond to the coronavirus. ? $170,160 of accruals or estimates that did not meet the definition of an incurred cost or eligible expense under the program requirements and were lacking supporting documentation to demonstrate expense eligibility. Of this amount, $85,820 was reported under infection control payments. The amounts determined above were not part of a sample but were derived from review of the expense populations. The remaining population of $324,720 which was used to claim general and infection control payments was sampled and tested without exception. Effect: The Corporations' claimed expenses that were not in accordance with established U.S. Department of Health and Human Services guidance and are therefore deemed unallowable. Cause: Management misinterpreted the guidance established by U.S. Department of Health and Human Services and claimed unallowable expenses in their reporting of qualified expenses. Recommendation: We recommend that management implement procedures to ensure that the most recent guidance is reviewed and understood and that information used in accumulating allowable expenses is reviewed, with errors addressed. Procedures should be performed on a monthly basis with previously recognized expenses being reviewed to ensure they qualify as an allowable expense under the most recent guidance. Views of Responsible Officials: Management agrees with the finding and will correct in future submissions but acknowledges that it has sufficient lost revenues and infection control expenses to cover the questioned costs.
Recommendation: Management should implement procedures to ensure that the most recent guidance is reviewed and understood and that information used in accumulating allowable expenses is reviewed, with errors addressed. Procedures should be performed on a monthly basis with previously recognized expenses being reviewed to ensure they qualify as an allowable expense under the most recent guidance. Action Taken: We concur with the recommendation. Management misinterpreted the guidance established by U.S. Department of Health and Human Services and claimed unallowable expenses in their reporting of qualified expenses. Of the total questioned costs identified of $929,442, $85,820 was reported as infection control payments. Management believes that it has sufficient unreported infection control payments that were not reported that could have been. The remaining questioned costs was reported under the general distributions and the Corporations have substantially more lost revenues that should have been utilized. Procedures will be performed immediately moving forward on a monthly basis with recognized expenses being viewed to ensure they qualify as an allowable expense under the most recent guidance.
Federal Program: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Program Assistance Listing Number: 93.498 Federal Agency: U.S. Department of Health and Human Services Award Number: N/A Award Year: 2020 Compliance Requirement: Reporting Questioned Costs: Not determinable Criteria: Provider Relief Fund (PRF) payment amounts (excluding Skilled Nursing Facility (SNF) and Nursing Home Infection Control Distribution payments) not fully expended on health care-related expenses attributable to coronavirus may be applied to patient care lost revenues, if applicable. Recipients may choose to apply PRF payments toward lost revenues using one of three options: Option i: of the difference between actual patient care revenues; Option ii: of the difference between budgeted and actual patient care revenues; Option iii: calculated by any reasonable method of estimating revenues. Condition and Context: The Corporations selected option ii to calculate lost revenues for their Period 1 and Period 2 reporting submissions. However, the Corporations did not have an approved budget prior to March 27, 2020 covering the period of availability for the relevant submission as required by the U.S. Department of Health and Human Services reporting guidance and accordingly, should have selected option i, or option iii. Effect: The amounts reported to Health Resources & Services Administration (HRSA) were not in accordance with established U.S. Department of Health and Human Services reporting guidance. Cause: The Corporations' have insufficient controls in place to identify and correct errors before reporting is completed. Recommendation: We recommend that management revise their reporting submission to utilize option i or option iii to calculate lost revenues and implement additional review procedures to ensure that the most recent guidance is reviewed and understood, and that information used in preparation of the reports is reviewed, with errors addressed, prior to reporting. View of Responsible Officials: Management agrees with the finding and will correct on future filings.
Show full finding ▾Hide full finding ▴Federal Program: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Program Assistance Listing Number: 93.498 Federal Agency: U.S. Department of Health and Human Services Award Number: N/A Award Year: 2020 Compliance Requirement: Reporting Questioned Costs: Not determinable Criteria: Provider Relief Fund (PRF) payment amounts (excluding Skilled Nursing Facility (SNF) and Nursing Home Infection Control Distribution payments) not fully expended on health care-related expenses attributable to coronavirus may be applied to patient care lost revenues, if applicable. Recipients may choose to apply PRF payments toward lost revenues using one of three options: Option i: of the difference between actual patient care revenues; Option ii: of the difference between budgeted and actual patient care revenues; Option iii: calculated by any reasonable method of estimating revenues. Condition and Context: The Corporations selected option ii to calculate lost revenues for their Period 1 and Period 2 reporting submissions. However, the Corporations did not have an approved budget prior to March 27, 2020 covering the period of availability for the relevant submission as required by the U.S. Department of Health and Human Services reporting guidance and accordingly, should have selected option i, or option iii. Effect: The amounts reported to Health Resources & Services Administration (HRSA) were not in accordance with established U.S. Department of Health and Human Services reporting guidance. Cause: The Corporations' have insufficient controls in place to identify and correct errors before reporting is completed. Recommendation: We recommend that management revise their reporting submission to utilize option i or option iii to calculate lost revenues and implement additional review procedures to ensure that the most recent guidance is reviewed and understood, and that information used in preparation of the reports is reviewed, with errors addressed, prior to reporting. View of Responsible Officials: Management agrees with the finding and will correct on future filings.
Recommendation: Management should revise their reporting submission to utilize option i or option iii to calculate lost revenues and implement additional review procedures to ensure that the most recent guidance is reviewed and understood, and that information used in preparation of the reports is reviewed, with errors addressed, prior to reporting. Action Taken: Management agrees with the finding and agrees it should have utilized option i to calculate lost revenues on an actual basis. Management will correct the error in future filings.
FAC accepted this audit on March 8, 2022 — management decision was due September 8, 2022.
The Corporations have determined, based on undiscounted cash flows, that the carrying value of the property and equipment of their Johnstown, Pennsylvania location may exceed its fair value. Management has elected not to determine the fair value of such assets as of December 31, 2020. Criteria: Accounting principles generally accepted in the United States of America require that property and equipment be evaluated for impairment whenever events or changes in circumstances indicate the carrying value of an asset may not be recoverable from the estimated future cash flows expected to result from its use and eventual disposition. If expected cash flows are less than the carrying value, an impairment loss should be recognized equal to an amount by which the carrying value exceeds the fair value of the assets Cause: Due to the uncertainties in the current economic environment, management has determined that it is impractical to determine the fair value of its property and equipment located in Johnstown, Pennsylvania as of December 31, 2020. Effect: The effects of any impairment loss on the consolidated financial statements have not been determined. A qualified opinion was issued on the Corporations consolidated financial statements. Recommendation: Management should adopt policies and procedures to determine fair value based on quoted market values, discounted cash flows or internal and external appraisals as applicable, and record any impairment loss in accordance with accounting principles generally accepted in the United States of America. View of Responsible Officials: Due to the current economic environment, management believes that is impractical at the current time to obtain an accurate fair value of its property and equipment in Johnstown, Pennsylvania. Management plans to begin the process of obtaining an accurate fair value when we believe the market has settled, and an accurate fair value can be determined, hopefully within 2021.
Show full finding ▾Hide full finding ▴Impairment of Property and Equipment: Condition: The Corporations have determined, based on undiscounted cash flows, that the carrying value of the property and equipment of their Johnstown, Pennsylvania location may exceed its fair value. Management has elected not to determine the fair value of such assets as of December 31, 2020. Criteria: Accounting principles generally accepted in the United States of America require that property and equipment be evaluated for impairment whenever events or changes in circumstances indicate the carrying value of an asset may not be recoverable from the estimated future cash flows expected to result from its use and eventual disposition. If expected cash flows are less than the carrying value, an impairment loss should be recognized equal to an amount by which the carrying value exceeds the fair value of the assets Cause: Due to the uncertainties in the current economic environment, management has determined that it is impractical to determine the fair value of its property and equipment located in Johnstown, Pennsylvania as of December 31, 2020. Effect: The effects of any impairment loss on the consolidated financial statements have not been determined. A qualified opinion was issued on the Corporations consolidated financial statements. Recommendation: Management should adopt policies and procedures to determine fair value based on quoted market values, discounted cash flows or internal and external appraisals as applicable, and record any impairment loss in accordance with accounting principles generally accepted in the United States of America. View of Responsible Officials: Due to the current economic environment, management believes that is impractical at the current time to obtain an accurate fair value of its property and equipment in Johnstown, Pennsylvania. Management plans to begin the process of obtaining an accurate fair value when we believe the market has settled, and an accurate fair value can be determined, hopefully within 2021.
U.S. Department of Housing and Urban Development Allegheny Lutheran Social Ministries and Controlled Entities respectfully submits the following corrective action plan for the year ended December 31, 2020. Name and address of independent public accounting firm: Baker Tilly U.S., LLP 1570 Fruitville Pike, Lancaster, PA 17601 Audit period: Year Ending December 31, 2020 The findings from the December 31, 2020 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINANCIAL STATEMENT FINDINGS Finding 2020-001 - Impairment of Property and Equipment Recommendation: Management should adopt policies and procedures to determine fair value based on quoted market values, discounted cash flows or internal and external appraisals as applicable, and record any impairment loss in accordance with accounting principles generally accepted in the United States of America. View of Responsible Officials: Due to the current economic environment, management believes that is impractical at the current time to obtain an accurate fair value of its property and equipment in Johnstown, Pennsylvania. Management plans to begin the process of obtaining an accurate fair value when we believe the market has settled, and an accurate fair value can be determined, hopefully within 2021. FEDERAL AWARD FINDINGS None Noted
2019-001
FAC accepted this audit on May 12, 2020 — management decision was due November 12, 2020.
The Corporations have determined, based on undiscounted cash flows, that the carrying value of the property and equipment of their Johnstown, Pennsylvania location may exceed its fair value. Management has elected not to determine the fair value of such assets as of December 31, 2019. Criteria: Accounting principles generally accepted in the United States of America require that property and equipment be evaluated for impairment whenever events or changes in circumstances indicate the carrying value of an asset may not be recoverable from the estimated future cash flows expected to result from its use and eventual disposition. If expected cash flows are less than the carrying value, an impairment loss should be recognized equal to an amount by which the carrying value exceeds the fair value of the assets Cause: Due to the uncertainties in the current economic environment, management has determined that it is impractical to determine the fair value of its property and equipment located in Johnstown, Pennsylvania as of December 31, 2019. Effect: The effects of any impairment loss on the consolidated financial statements have not been determined. A qualified opinion was issued on the Corporations consolidated financial statements. Recommendation: Management should adopt policies and procedures to determine fair value based on quoted market values, discounted cash flows or internal and external appraisals as applicable, and record any impairment loss in accordance with accounting principles generally accepted in the United States of America. View of Responsible Officials: Due to the current economic environment, management believes that is impractical at the current time to obtain an accurate fair value of its property and equipment in Johnstown, Pennsylvania. Management plans to begin the process of obtaining an accurate fair value when we believe the market has settled, and an accurate fair value can be determined, hopefully within 2020
Show full finding ▾Hide full finding ▴Impairment of Property and Equipment Condition: The Corporations have determined, based on undiscounted cash flows, that the carrying value of the property and equipment of their Johnstown, Pennsylvania location may exceed its fair value. Management has elected not to determine the fair value of such assets as of December 31, 2019. Criteria: Accounting principles generally accepted in the United States of America require that property and equipment be evaluated for impairment whenever events or changes in circumstances indicate the carrying value of an asset may not be recoverable from the estimated future cash flows expected to result from its use and eventual disposition. If expected cash flows are less than the carrying value, an impairment loss should be recognized equal to an amount by which the carrying value exceeds the fair value of the assets Cause: Due to the uncertainties in the current economic environment, management has determined that it is impractical to determine the fair value of its property and equipment located in Johnstown, Pennsylvania as of December 31, 2019. Effect: The effects of any impairment loss on the consolidated financial statements have not been determined. A qualified opinion was issued on the Corporations consolidated financial statements. Recommendation: Management should adopt policies and procedures to determine fair value based on quoted market values, discounted cash flows or internal and external appraisals as applicable, and record any impairment loss in accordance with accounting principles generally accepted in the United States of America. View of Responsible Officials: Due to the current economic environment, management believes that is impractical at the current time to obtain an accurate fair value of its property and equipment in Johnstown, Pennsylvania. Management plans to begin the process of obtaining an accurate fair value when we believe the market has settled, and an accurate fair value can be determined, hopefully within 2020
Condition During the year ended December 31, 2019, the Corporations determined that the expected cash flows of it operations in Johnstown, Pennsylvania may not be recoverable, and the carrying value of its property and equipment may exceed its fair value. Management did not determine the fair value in accordance with accounting principles generally accepted in the United States of America. Corrective Action Plan Corrective Action Planned: Due to the current economic environment, management believes that is impractical at the current time to obtain an accurate fair value of its property and equipment in Johnstown, Pennsylvania. Management plans to begin the process of obtaining an accurate fair value when we believe the market has settled, and an accurate fair value can be determined, hopefully within 2020. Name(s) of Contact Person(s) Responsible for Corrective Action: Christopher Reighard, Chief Financial Officer Anticipated Completion Date: Management plans to begin the process of obtaining an accurate fair value when we believe the market has settled, and an accurate fair value can be determined, hopefully within 2020.
FAC accepted this audit on April 24, 2019 — management decision was due October 24, 2019.
FAC accepted this audit on April 30, 2018 — management decision was due October 30, 2018.
FAC accepted this audit on July 27, 2017 — management decision was due January 27, 2018.
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.
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