ENDLESS MOUNTAINS HEALTH SYSTEMS, INC.

EIN: 232720289

UEI: SQ1GZTXQ9NK8

Data as of August 24, 2026

ENDLESS MOUNTAINS HEALTH SYSTEMS, INC.4 audit years1 findings
4
Audit Years
1
Total Findings
0
Repeat Findings

FY 2021-12-31

Management decision deadline — for entities that funded this organization

The FAC accepted this audit on September 29, 2022. 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 29, 2023 (1245 days ago).

What is a management decision? →
2021-001
Reporting

Finding 2021-001 Assistance Listing No.: 93.498 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: 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. Recipients of Provider Relief Fund (PRF) payments must also 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. Condition/Context: The Corporation did not complete the PRF reporting in accordance with the U.S. Department of Health and Human Services guidance. During our testing, we noted that the Corporation included expenses related to Other Assistance Received as Other PRF Expenses, which led to expenses reimbursed by another source being included as eligible expenses in reporting period 1. The Corporation believed that entering expenses reimbursed by another source as Other PRF Expenses would match those expenses with the funds reported as Other Assistance Received. The Corporation had total lost revenues of $6,048,952 on total distributions of PRF funding of $3,962,722. Effect: As a result of the error, $1,670,298 of expenses were incorrectly included as Other PRF Expenses in reporting period 1. 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. Questioned Costs: Not determinable Cause: Management misinterpreted the guidance established by U.S. Department of Health and Human Services and claimed expenses related to Other Assistance Received as Other PRF 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. Additionally, we recommend that management review the procedures for filing their required reporting to ensure only expenses related to PRF payments are reported as Other PRF Expenses. Views of Responsible Officials: Management concurs with the finding and will contact HRSA for guidance on updating the previously submitted report.

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Full finding narrative

Finding 2021-001 Assistance Listing No.: 93.498 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: 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. Recipients of Provider Relief Fund (PRF) payments must also 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. Condition/Context: The Corporation did not complete the PRF reporting in accordance with the U.S. Department of Health and Human Services guidance. During our testing, we noted that the Corporation included expenses related to Other Assistance Received as Other PRF Expenses, which led to expenses reimbursed by another source being included as eligible expenses in reporting period 1. The Corporation believed that entering expenses reimbursed by another source as Other PRF Expenses would match those expenses with the funds reported as Other Assistance Received. The Corporation had total lost revenues of $6,048,952 on total distributions of PRF funding of $3,962,722. Effect: As a result of the error, $1,670,298 of expenses were incorrectly included as Other PRF Expenses in reporting period 1. 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. Questioned Costs: Not determinable Cause: Management misinterpreted the guidance established by U.S. Department of Health and Human Services and claimed expenses related to Other Assistance Received as Other PRF 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. Additionally, we recommend that management review the procedures for filing their required reporting to ensure only expenses related to PRF payments are reported as Other PRF Expenses. Views of Responsible Officials: Management concurs with the finding and will contact HRSA for guidance on updating the previously submitted report.

Corrective Action Plan

Finding 2021-001 Condition: The Corporation did not complete the PRF reporting in accordance with the U.S. Department of Health and Human Services guidance. During our testing, we noted that the Corporation included expenses related to Other Assistance Received as Other PRF Expenses, which led to expenses reimbursed by another source being included as eligible expenses in reporting period 1. The Corporation believed that entering expenses reimbursed by another source as Other PRF Expenses would match those expenses with the funds reported as Other Assistance Received. The Corporation had total lost revenues of $6,048,952 on total distributions of PRF funding of $3,962,722. Corrective Action Planned: EMHS will work with the Dept. of Health and Human Services to correct the error in reporting of expenses not related to the PRF. EMHS will contact the Dept. of Health and Human Services for instructions on how to correct the PRF reporting through the PRF portal or other means. Name(s) of Contact Person(s) Responsible for Corrective Action: Loren Stone, CEO, will be responsible for completing the Corrective Action Plan. Anticipated Completion Date: EMHS anticipates completion of this Corrective Action Plan no later than November 30th as long as there is cooperation and follow-up by the Department of Health and Human Services.

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