EIN: 391027536
UEI: TWY8L4Q5VPD5
Data as of August 24, 2026
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on September 28, 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 28, 2023 (1246 days ago).
What is a management decision? →Black River Memorial Hospital, Inc. (the ?Hospital?) did not meet its requirements to use the funds to prevent, prepare for, and respond to coronavirus and that the payment shall reimburse the recipient only for health care related expenses or lost revenues that are attributable to coronavirus Criteria: The Provider Relief Funds were provided under the Coronavirus Aid, Relief, and Economic Security Act (Pub. L. No. 116-136, 134 Stat. 563) and are to be used to prevent, prepare for, and respond to coronavirus and that the funds shall reimburse the recipient only for health care related expenses or lost revenues that are attributable to coronavirus. Context: During the audit, it was determined that the payroll expenditures claimed as allowable COVID-19 expenses were reported on the submission of expenses to the Health Resources and Services Agency (HRSA) online forms without deducting for cost-reimbursement received from the Medicare program. The full amount of these payroll expenditures are not an allowable COVID expense under the Department of Health and Human Services guidelines for the use of Provider Relief Funds until after other applicable payor sources, such as Medicare program cost-reimbursement for being a Critical Access Hospital are accounted for. In addition, there was additional lost revenues that could have been reported which would have been a sufficient amount of lost revenue to cover the difference of the cost reimbursement that would have been deducted from expenses. As a result, there would not be expected to be any return of Provider Relief Funds and all could have been considered expended; however, the reporting by the Hospital may have needed updating. Cause: Management oversight. Effect: The Hospital is not in compliance with federal regulations and guidelines surrounding the use of the Provider Relief Funds. Recommendation: We recommend that management update its portal reporting with HRSA and track the additional lost revenue which will need to be utilized in the Phase I reporting as it may impact future Provider Relief Fund reports as well as uses of future distributions from the Provider Relief Funds. View of Responsible Officials: Management will estimate Medicare reimbursement using the applicable Medicare Cost report to determine allowability under the specific grant?s rules and regulations, and work to update past reporting to HRSA as well as track any required adjustments needed for future Provider Relief Fund distributions which may involve the use of lost revenue.
Show full finding ▾Hide full finding ▴Finding 2021-001 Program Name/CFDA Title: Provider Relief Fund Federal Assistance Listing Number: 93.498 Federal Agency: U.S. Department of Health and Human Services Type of Finding: Noncompliance, Significant Deficiency Compliance Requirement: Allowable Costs Condition: Black River Memorial Hospital, Inc. (the ?Hospital?) did not meet its requirements to use the funds to prevent, prepare for, and respond to coronavirus and that the payment shall reimburse the recipient only for health care related expenses or lost revenues that are attributable to coronavirus Criteria: The Provider Relief Funds were provided under the Coronavirus Aid, Relief, and Economic Security Act (Pub. L. No. 116-136, 134 Stat. 563) and are to be used to prevent, prepare for, and respond to coronavirus and that the funds shall reimburse the recipient only for health care related expenses or lost revenues that are attributable to coronavirus. Context: During the audit, it was determined that the payroll expenditures claimed as allowable COVID-19 expenses were reported on the submission of expenses to the Health Resources and Services Agency (HRSA) online forms without deducting for cost-reimbursement received from the Medicare program. The full amount of these payroll expenditures are not an allowable COVID expense under the Department of Health and Human Services guidelines for the use of Provider Relief Funds until after other applicable payor sources, such as Medicare program cost-reimbursement for being a Critical Access Hospital are accounted for. In addition, there was additional lost revenues that could have been reported which would have been a sufficient amount of lost revenue to cover the difference of the cost reimbursement that would have been deducted from expenses. As a result, there would not be expected to be any return of Provider Relief Funds and all could have been considered expended; however, the reporting by the Hospital may have needed updating. Cause: Management oversight. Effect: The Hospital is not in compliance with federal regulations and guidelines surrounding the use of the Provider Relief Funds. Recommendation: We recommend that management update its portal reporting with HRSA and track the additional lost revenue which will need to be utilized in the Phase I reporting as it may impact future Provider Relief Fund reports as well as uses of future distributions from the Provider Relief Funds. View of Responsible Officials: Management will estimate Medicare reimbursement using the applicable Medicare Cost report to determine allowability under the specific grant?s rules and regulations, and work to update past reporting to HRSA as well as track any required adjustments needed for future Provider Relief Fund distributions which may involve the use of lost revenue.
Management of the organization will work with HRSA to update its documentation as well as update its internal records to reflect allowable costs under the program. Although in 2021, the reporting of allowable payroll expenses without deducting for Medicare cost-reimbursement received on these items did not result in any change in amounts allowable for fudning by the Provider Relief Funds, this change may impact future calculations. The Hospital's accounting staff will review these necessary changes and ensure that lost revenue amounts are updated for use on the next Provider Relief Fund reporting due in early calendar year 2023. These steps will help to ensure that no amounts of lost revenue realized by the Hospital are reported in two reporting periods or claimed twice.
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