EIN: 273993262
UEI: CLH9Y4WLUTH7
Audited by: Forvis Mazars, 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 January 16, 2026. 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 16, 2026 (49 days ago).
What is a management decision? →The Hospital reported COVID-19-related expenditures within the HHS Provider Relief Fund portal that were reimbursed via other sources. The Hospital’s compliance controls and report review processes were insufficient to prevent this reporting error. Questioned Costs: None Context: The Hospital is certified by Medicare as a critical access hospital. The Period 5 Provider Relief Fund report was tested. The Hospital’s calculation of allowable expenses did not consider the impact of cost reimbursement to reported healthcare expenses to document that Provider Relief Fund and American Rescue Plan (ARP) Distribution were not reimbursed by any other source. Effect: The Hospital submitted expenses under PRF that are obligated to be reimbursed by another source. Cause: The guidance provided by HHS to providers across the country as to how to report their COVID-19-related expenses and lost revenues is, at times, difficult to comprehend and apply. Internal controls were not in place to ensure the Hospital correctly applied the guidance. Recommendation: Policies and procedures over federal grant reporting should be modified to ensure reports that allowable expenses reported are not reimbursed by any other source. Identification as a Repeat Finding: Not a repeat finding. Views of Responsible Officials and Planned Corrective Actions: See attached corrective action plan for the Hospital’s response to finding.
Show full finding ▾Hide full finding ▴Federal Program: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution, Period 5 Assistance Living Number: 93.498 Federal Agencies: U.S. Department of Health and Human Services Criteria: Reporting (45 CFR 75.342) Condition: The Hospital reported COVID-19-related expenditures within the HHS Provider Relief Fund portal that were reimbursed via other sources. The Hospital’s compliance controls and report review processes were insufficient to prevent this reporting error. Questioned Costs: None Context: The Hospital is certified by Medicare as a critical access hospital. The Period 5 Provider Relief Fund report was tested. The Hospital’s calculation of allowable expenses did not consider the impact of cost reimbursement to reported healthcare expenses to document that Provider Relief Fund and American Rescue Plan (ARP) Distribution were not reimbursed by any other source. Effect: The Hospital submitted expenses under PRF that are obligated to be reimbursed by another source. Cause: The guidance provided by HHS to providers across the country as to how to report their COVID-19-related expenses and lost revenues is, at times, difficult to comprehend and apply. Internal controls were not in place to ensure the Hospital correctly applied the guidance. Recommendation: Policies and procedures over federal grant reporting should be modified to ensure reports that allowable expenses reported are not reimbursed by any other source. Identification as a Repeat Finding: Not a repeat finding. Views of Responsible Officials and Planned Corrective Actions: See attached corrective action plan for the Hospital’s response to finding.
We are in receipt of the Findings Required to be Reported by Government Auditing Standards, regarding Reporting. Management agrees with the finding. After correcting the calculation of expenses to include reimbursement from other sources, the Hospital still has sufficient lost revenues and expenses to cover the amount of provider relief funding received. Management will perform a detailed analysis of the reporting requirements in accordance with the final guidelines set by HRSA for future reporting periods. As deemed necessary, the Hospital will modify policies and procedures over federal grant reporting The CFO, Hong Wade, will be responsible to ensure this is accomplished. The corrective action plan will be implemented by December 31, 2025.
FAC accepted this audit on September 25, 2025 — management decision was due March 25, 2026.
The Hospital reported COVID-19-related expenditures within the Disaster Grants – Public Assistance (Presidentially Declared Disasters) (FEMA) portal that were reimbursed via other sources. Questioned Costs: Questioned costs were estimated by taking the total amount of acceptable expenditures for each of the programs multiplied by the Hospital’s internally-calculated Medicare reimbursement rate. See costs by applicable assistance listing number below: Program: Presidentially Declared Disasters; Assistance Listing No. 97.036; Questioned Costs: $173,180 Context: The Hospital is certified by Medicare as a critical access hospital. The period one provider relief fund report and FEMA payments were tested. The Hospital’s calculation of allowable expenses did not consider the impact of cost reimbursement to reported health care expenses to document that FEMA payments were not reimbursed by any other source. Effect: The Hospital submitted expenses under the FEMA program that are obligated to be reimbursed by another source. Cause: The guidance provided by DHS to providers across the country as to how to report their COVID-19-related expenses and lost revenues is, at times, difficult to comprehend and apply. Internal controls were not in place to ensure the Hospital correctly applied the guidance. Identification as a repeat finding: This is a repeat finding. See 2021-002. Recommendation: Policies and procedures over federal grant reporting should be modified to ensure that allowable expenses reported are not reimbursed by any other source. Views of responsible officials and planned corrective actions: See corrective action plan for the Hospital’s response to finding.
Show full finding ▾Hide full finding ▴Federal Programs: Disaster Grants – Public Assistance (Presidentially Declared Disasters) Assistance Listing Numbers 97.036 Federal Agencies: U.S. Department of Homeland Security Pass-Through Entity, Applicable Only to Disaster Grants – Public Assistance (Presidentially Declared Disasters): Texas Division of Emergency Management Criteria: Reporting (45 CFR 75.342 and 2 CFR 200.303) and Activities Allowed or Unallowed and Allowable Costs/Cost Principles (Pub. L. No. 116-136, 134 Stat. 563 and Pub. L. No. 116-139, 134 Stat. 622 and 623 and 44 CFR 206.228). Condition: The Hospital reported COVID-19-related expenditures within the Disaster Grants – Public Assistance (Presidentially Declared Disasters) (FEMA) portal that were reimbursed via other sources. Questioned Costs: Questioned costs were estimated by taking the total amount of acceptable expenditures for each of the programs multiplied by the Hospital’s internally-calculated Medicare reimbursement rate. See costs by applicable assistance listing number below: Program: Presidentially Declared Disasters; Assistance Listing No. 97.036; Questioned Costs: $173,180 Context: The Hospital is certified by Medicare as a critical access hospital. The period one provider relief fund report and FEMA payments were tested. The Hospital’s calculation of allowable expenses did not consider the impact of cost reimbursement to reported health care expenses to document that FEMA payments were not reimbursed by any other source. Effect: The Hospital submitted expenses under the FEMA program that are obligated to be reimbursed by another source. Cause: The guidance provided by DHS to providers across the country as to how to report their COVID-19-related expenses and lost revenues is, at times, difficult to comprehend and apply. Internal controls were not in place to ensure the Hospital correctly applied the guidance. Identification as a repeat finding: This is a repeat finding. See 2021-002. Recommendation: Policies and procedures over federal grant reporting should be modified to ensure that allowable expenses reported are not reimbursed by any other source. Views of responsible officials and planned corrective actions: See corrective action plan for the Hospital’s response to finding.
We are in receipt of the Findings Required to be Reported by Government Auditing Standards, regarding Reporting and Activities Allowed/Unallowed and Cost Principles. Management agrees with the finding. After correcting the calculation of expenses to include reimbursement from other sources, the Hospital still has sufficient lost revenues and expenses to cover the amount of provider relief funding received. Management will perform a detailed analysis of the reporting requirements in accordance with the final guidelines set by HRSA for future reporting periods. As deemed necessary, the Hospital will modify policies and procedures over federal grant reporting The CFO, Hong Wade, will be responsible to ensure this is accomplished. The corrective action plan will be implemented by December 31, 2025.
2021-002
FAC accepted this audit on June 20, 2023 — management decision was due December 20, 2023.
The Hospital reported COVID-19-related expenditures within the HHS Provider Relief Fund and American Rescue Plan (ARP) Distribution (PRF) and the Disaster Grants ? Public Assistance (Presidentially Declared Disasters) (FEMA) portal that were reimbursed via other sources. Questioned Costs: Questioned costs were estimated by taking the total amount of acceptable expenditures for each of the programs multiplied by the Hospital?s internally-calculated Medicare reimbursement rate. See costs by applicable assistance listing number below: See Schedule of Findings and Questioned Costs for chart/table Context: The Hospital is certified by Medicare as a critical access hospital. The period one provider relief fund report and FEMA payments were tested. The Hospital?s calculation of allowable expenses did not consider the impact of cost reimbursement to reported health care expenses to document that Provider Relief Fund and American Rescue Plan (ARP) Distribution and FEMA payments were not reimbursed by any other source. Effect: The Hospital submitted expenses under the PRF and FEMA programs that are obligated to be reimbursed by another source. Cause: The guidance provided by HHS to providers across the country as to how to report their COVID-19-related expenses and lost revenues is, at times, difficult to comprehend and apply. Internal controls were not in place to ensure the Hospital correctly applied the guidance. Identification as a repeat finding: Not a repeat finding. Recommendation: Policies and procedures over federal grant reporting should be modified to ensure that allowable expenses reported are not reimbursed by any other source. Views of responsible officials and planned corrective actions: See corrective action plan for the Hospital?s response to finding.
Show full finding ▾Hide full finding ▴Federal Programs: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution and Disaster Grants ? Public Assistance (Presidentially Declared Disasters) Assistance Listing Numbers: 93.498 and 97.036 Federal Agencies: U.S. Department of Health and Human Services and U.S. Department of Homeland Security Pass-Through Entity, Applicable Only to Disaster Grants ? Public Assistance (Presidentially Declared Disasters): Texas Division of Emergency Management Criteria: Reporting (45 CFR 75.342 and 2 CFR 200.303) and Activities Allowed or Unallowed and Allowable Costs/Cost Principles (Pub. L. No. 116-136, 134 Stat. 563 and Pub. L. No. 116-139, 134 Stat. 622 and 623 and 44 CFR 206.228). Condition: The Hospital reported COVID-19-related expenditures within the HHS Provider Relief Fund and American Rescue Plan (ARP) Distribution (PRF) and the Disaster Grants ? Public Assistance (Presidentially Declared Disasters) (FEMA) portal that were reimbursed via other sources. Questioned Costs: Questioned costs were estimated by taking the total amount of acceptable expenditures for each of the programs multiplied by the Hospital?s internally-calculated Medicare reimbursement rate. See costs by applicable assistance listing number below: See Schedule of Findings and Questioned Costs for chart/table Context: The Hospital is certified by Medicare as a critical access hospital. The period one provider relief fund report and FEMA payments were tested. The Hospital?s calculation of allowable expenses did not consider the impact of cost reimbursement to reported health care expenses to document that Provider Relief Fund and American Rescue Plan (ARP) Distribution and FEMA payments were not reimbursed by any other source. Effect: The Hospital submitted expenses under the PRF and FEMA programs that are obligated to be reimbursed by another source. Cause: The guidance provided by HHS to providers across the country as to how to report their COVID-19-related expenses and lost revenues is, at times, difficult to comprehend and apply. Internal controls were not in place to ensure the Hospital correctly applied the guidance. Identification as a repeat finding: Not a repeat finding. Recommendation: Policies and procedures over federal grant reporting should be modified to ensure that allowable expenses reported are not reimbursed by any other source. Views of responsible officials and planned corrective actions: See corrective action plan for the Hospital?s response to finding.
We are in receipt of the Findings Required to be Reported by Government Auditing Standards, regarding Reporting and Activities Allowed/Unallowed and Cost Principals. Management agrees with the finding . After correcting the calculation of expenses to include reimbursement from other sources, the Hospital still has sufficient lost revenues and expenses to cover the amount of provider relief funding received. Management will perform a detailed analysis of the reporting requirements in accordance with the final guidelines set by HRSA for future reporting periods. As deemed necessary, the Hospital will modify policies and procedures over federal grant reporting. The CFO, Hong Wade, will be responsible to ensure this is accomplished. The corrective action plan will be implemented by December 31, 2023.
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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