EIN: 272999718
UEI: TJDWD2HENMF7
Audited by: CARR, RIGGS & INGRAM, LLC
Oversight agency: 93 [Department of Health and Human Services]
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Data as of August 28, 2026
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on April 1, 2024. 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 October 1, 2024 (697 days ago).
What is a management decision? →Item 2023‐001 Allowable Costs/Activities Allowed Medical Assistance Program – Assistance Listing # 93.778 U.S. Department of Health and Human Services Passed through the State of Georgia Board of Health Care Workforce Pass-through Grant No. Family Medicine (7/1/2022 – 6/30/2023) COVID-19 Provider Relief Fund – Assistance Listing # 93.498 U.S. Department of Health and Human Services Federal Assistance Identification Number – PRF20200001 Federal Award Year - 2020 Condition/Perspective – Adequate human resource controls were not in place to document that two payroll expenditures was for allowable costs and activities prior to payment, resulting in the following: • COVID-19 Provider Relief Fund – Assistance Listing # 93.498 - One out of 40 employee payroll disbursements were paid without the proper approval of the supporting time sheet. Our sample was a statistically valid sample. • Medical Assistance Program – Assistance Listing # 93.778 - One out of 20 employee payroll disbursements were paid without the proper approval of the supporting time sheet and supporting pay rate. Our sample was a statistically valid sample. Criteria – Grantees should have controls in place to ensure that grant monies are for allowable costs and allowable activities. 2 CFR 200.303 requires the non‐Federal entity to “(a) establish and maintain effective internal controls over the Federal award that provides reasonable assurance that the non‐Federal entity is managing the Federal statutes, regulations, and the terms and conditions of the Federal award.” Grantees must follow the requirements of 2 CFR 200.430(i)(1-8) Standards for Documentation of Personnel Expenses. Cause – Lack of sufficient human resource controls to ensure there is evidence of review and approval of supporting time sheet and pay rate documentation prior to payment. Questioned Costs – Not applicable. Identification of Repeat Findings – Not a repeat finding Effect – Lack of proper review and approval could result in disallowed costs. Recommendation – We recommend the implementation of procedures necessary to ensure there is evidence of review and approval of supporting pay rate documentation and supporting time sheets of payroll disbursements prior to payment. Management’s Response – See “Corrective Action Plan”
Show full finding ▾Hide full finding ▴Item 2023‐001 Allowable Costs/Activities Allowed Medical Assistance Program – Assistance Listing # 93.778 U.S. Department of Health and Human Services Passed through the State of Georgia Board of Health Care Workforce Pass-through Grant No. Family Medicine (7/1/2022 – 6/30/2023) COVID-19 Provider Relief Fund – Assistance Listing # 93.498 U.S. Department of Health and Human Services Federal Assistance Identification Number – PRF20200001 Federal Award Year - 2020 Condition/Perspective – Adequate human resource controls were not in place to document that two payroll expenditures was for allowable costs and activities prior to payment, resulting in the following: • COVID-19 Provider Relief Fund – Assistance Listing # 93.498 - One out of 40 employee payroll disbursements were paid without the proper approval of the supporting time sheet. Our sample was a statistically valid sample. • Medical Assistance Program – Assistance Listing # 93.778 - One out of 20 employee payroll disbursements were paid without the proper approval of the supporting time sheet and supporting pay rate. Our sample was a statistically valid sample. Criteria – Grantees should have controls in place to ensure that grant monies are for allowable costs and allowable activities. 2 CFR 200.303 requires the non‐Federal entity to “(a) establish and maintain effective internal controls over the Federal award that provides reasonable assurance that the non‐Federal entity is managing the Federal statutes, regulations, and the terms and conditions of the Federal award.” Grantees must follow the requirements of 2 CFR 200.430(i)(1-8) Standards for Documentation of Personnel Expenses. Cause – Lack of sufficient human resource controls to ensure there is evidence of review and approval of supporting time sheet and pay rate documentation prior to payment. Questioned Costs – Not applicable. Identification of Repeat Findings – Not a repeat finding Effect – Lack of proper review and approval could result in disallowed costs. Recommendation – We recommend the implementation of procedures necessary to ensure there is evidence of review and approval of supporting pay rate documentation and supporting time sheets of payroll disbursements prior to payment. Management’s Response – See “Corrective Action Plan”
Item 2023‐001 – Allowable Costs/Activities Contact person: Wendy Stephens, Senior Accounting Manager Management’s Response – Management’s controls over approval of time sheets operated effectively 97.5% of the time prior to processing of payroll. The payroll expenditures allocated to the COVID-19 Provider Relief Fund – Assistance Listing 93.498 were allocated to the Provider Relief Funding and including in reporting of expenditures based on management review of guidance provided by HRSA in determination of the portion of the payroll costs allocated as qualifying and allowable expenditures under the program. The guidance on allowable costs was determined by HRSA subsequent to disbursement of the funds by HRSA and after incurrence of the expenditures given the immediacy of the COVID-19 pandemic providing of funds and incurrence of costs. Management will perform an annual review of expenditures allocated to a grant to confirm the allowability of the costs under the respective program. Management’s controls over approval of time sheets operated effectively 97% of the time prior to processing payroll. The payroll expenditures related to the 1 time sheet not approved prior to payment of payroll are for an employee assigned to work specifically on the program funded by Assistance Listing #93.778. Management will perform an annual review of expenditures allocated to a grant to confirm the allowability of the costs under the respective program. Management expects the corrective actions described above to be complete no later than June 30, 2024.
FAC accepted this audit on March 29, 2023 — management decision was due September 29, 2023.
FAC accepted this audit on September 27, 2022 — management decision was due March 27, 2023.
Item 2021-001 Allowable Costs/Activities COVID-19 Provider Relief Fund ? Assistance Listing # 93.498 U.S. Department of Health and Human Services Federal Assistance Identification Number ? PRF20200001 Federal Award Year - 2020 Condition ? Adequate human resource controls were not in place to document that the payroll expenditure was for allowable costs and activities prior to payment, resulting in two out of 40 employee payroll disbursements being paid without the proper approval of the supporting pay rate documentation by management. Criteria ? Grantees should have controls in place to ensure that grant monies are for allowable costs and allowable activities. 2 CFR 200.303 requires the non-Federal entity to ?(a) establish and maintain effective internal controls over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal statutes, regulations, and the terms and conditions of the Federal award.? Grantees must follow the requirements of 2 CFR 200.430(i)(1-8) Standards for Documentation of Personnel Expenses. Cause ? Lack of sufficient human resource controls to ensure there is evidence of review and approval of supporting pay rate documentation for allowable costs and activities prior to payment. Questioned Costs ? Not applicable. Effect ? Lack of proper review and approval could result in disallowed costs. Recommendation ? We recommend the implementation of procedures necessary to ensure there is evidence of review and approval of supporting pay rate documentation of payroll disbursements prior to payment. Management?s Response ? The Health System has put into place controls that will provide assurance of proper review and approval of supporting documentation of payroll disbursements prior to payment. The AVP of Human Resources will be responsible for this corrective action. The corrective action was put into place after an internal HR assessment of Warm Springs HR processes was performed in January and February 2022.
Show full finding ▾Hide full finding ▴Item 2021-001 Allowable Costs/Activities COVID-19 Provider Relief Fund ? Assistance Listing # 93.498 U.S. Department of Health and Human Services Federal Assistance Identification Number ? PRF20200001 Federal Award Year - 2020 Condition ? Adequate human resource controls were not in place to document that the payroll expenditure was for allowable costs and activities prior to payment, resulting in two out of 40 employee payroll disbursements being paid without the proper approval of the supporting pay rate documentation by management. Criteria ? Grantees should have controls in place to ensure that grant monies are for allowable costs and allowable activities. 2 CFR 200.303 requires the non-Federal entity to ?(a) establish and maintain effective internal controls over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal statutes, regulations, and the terms and conditions of the Federal award.? Grantees must follow the requirements of 2 CFR 200.430(i)(1-8) Standards for Documentation of Personnel Expenses. Cause ? Lack of sufficient human resource controls to ensure there is evidence of review and approval of supporting pay rate documentation for allowable costs and activities prior to payment. Questioned Costs ? Not applicable. Effect ? Lack of proper review and approval could result in disallowed costs. Recommendation ? We recommend the implementation of procedures necessary to ensure there is evidence of review and approval of supporting pay rate documentation of payroll disbursements prior to payment. Management?s Response ? The Health System has put into place controls that will provide assurance of proper review and approval of supporting documentation of payroll disbursements prior to payment. The AVP of Human Resources will be responsible for this corrective action. The corrective action was put into place after an internal HR assessment of Warm Springs HR processes was performed in January and February 2022.
Item 2021-001 ? Allowable Costs/Activities Contact person: Lisa Mitchum, AVP of Human Resources Management?s Response ? The Health System has changed the reporting relationship of the human resources function of all entities whereby they have a dotted line to the Health System Human Resources department. Human Resources for each entity will follow the same processes and procedures. The Health System procedures vary based on the type of adjustment. This could include a written letter from the department leader to compensation, a Retro Pay form, submission of an Employee Information Form (EIF) or letter to file from Compensation. Documentation of the pay adjustment is placed in the employees? personnel record. The corrective action was put into place after an internal HR assessment of Warm Springs HR processes was performed in January and February 2022.
FAC accepted this audit on September 29, 2021 — management decision was due March 29, 2022.
Item 2020-001 Allowable Costs/Activities Medical Assistance Program CFDA # 93.778 U.S. Department of Health and Human Services Passed through the State of Georgia Board of Health Care Workforce Pass-through Grant No. Family Medicine (7/1/2019 ? 6/30/2020) Criteria ? Grantees should have controls in place to ensure that grant monies are for allowable costs and allowable activities. 2 CFR 200.303 requires the non-Federal entity to ?(a) establish and maintain effective internal controls over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal statutes, regulations, and the terms and conditions of the Federal award.? Grantees must follow the requirements of 2 CFR 200.430(i)(1-8) Standards for Documentation of Personnel Expenses. Condition ? Adequate controls were not in place to document that a payroll expenditure was for allowable costs and activities prior to payment, resulting in a payroll disbursement being paid without the proper approval of the supporting time sheet by management. Cause ? Lack of sufficient controls to ensure there is evidence of review and approval of supporting documentation for allowable costs and activities prior to payment. Questioned Costs ? Not determinable. Effect ? Lack of proper review and approval could result in disallowed costs. However, our audit disclosed no instances of unallowable costs. Recommendation ? We recommend the implementation of procedures necessary to ensure there is evidence of review and approval of supporting time sheets of payroll disbursements prior to payment. Management?s Response ? The Health System will put into place controls that will provide assurance of proper review and approval of supporting documentation of payroll disbursements prior to payment. The Senior Accounting Manager will be responsible for this corrective action and anticipates completion of corrective action will be taken before September 30, 2021.
Show full finding ▾Hide full finding ▴Item 2020-001 Allowable Costs/Activities Medical Assistance Program CFDA # 93.778 U.S. Department of Health and Human Services Passed through the State of Georgia Board of Health Care Workforce Pass-through Grant No. Family Medicine (7/1/2019 ? 6/30/2020) Criteria ? Grantees should have controls in place to ensure that grant monies are for allowable costs and allowable activities. 2 CFR 200.303 requires the non-Federal entity to ?(a) establish and maintain effective internal controls over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal statutes, regulations, and the terms and conditions of the Federal award.? Grantees must follow the requirements of 2 CFR 200.430(i)(1-8) Standards for Documentation of Personnel Expenses. Condition ? Adequate controls were not in place to document that a payroll expenditure was for allowable costs and activities prior to payment, resulting in a payroll disbursement being paid without the proper approval of the supporting time sheet by management. Cause ? Lack of sufficient controls to ensure there is evidence of review and approval of supporting documentation for allowable costs and activities prior to payment. Questioned Costs ? Not determinable. Effect ? Lack of proper review and approval could result in disallowed costs. However, our audit disclosed no instances of unallowable costs. Recommendation ? We recommend the implementation of procedures necessary to ensure there is evidence of review and approval of supporting time sheets of payroll disbursements prior to payment. Management?s Response ? The Health System will put into place controls that will provide assurance of proper review and approval of supporting documentation of payroll disbursements prior to payment. The Senior Accounting Manager will be responsible for this corrective action and anticipates completion of corrective action will be taken before September 30, 2021.
Item 2020-001 ? Allowable Costs/Activities Contact person: Wendy Stephens, Senior Accounting Manager Management?s Response ? The Health System will put into place controls that will provide assurance that there is proper review and approval of supporting documentation of payroll disbursements prior to payment. The family medicine department has developed an approval log which is to be reviewed and approved each pay period by a supervisor/manager. The payroll department will be adding another level of verification before pay period ends by running a check of all grant departments for approvals, then notifying that department if there are any discrepancies. The Senior Accounting Manager will be responsible for this corrective action and anticipates completion of corrective action will be taken before September 30, 2021.
FAC accepted this audit on October 24, 2019 — management decision was due April 24, 2020.
FAC accepted this audit on October 28, 2018 — management decision was due April 28, 2019.
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