EIN: 410745522
UEI: NM47LZ5ZK9F1
Data as of August 21, 2026
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on June 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 December 28, 2022 (1332 days ago).
What is a management decision? →The reported expenses included expenses that had been reimbursed by other sources and were obligated to be reimbursed through Medicare and Medicaid cost-based reimbursement. Management also identified expenses eligible for reimbursement that were not reported in the PRF reporting portal. Cause: Controls in place did not operate effectively to substantiate that the funds were not reimbursed from other sources and other sources were not obligated to reimburse them. Additionally, controls in place did not identify all eligible expense meeting the terms and conditions of the award. Effect: Expenses reported included expense that were reimbursed or obligated to be reimbursed. Expenses reported excluded expenses that were eligible to be reimbursed by the award. Questioned costs: None Context: The error was present on the reporting submission completed for reporting period one. Repeat finding? No Recommendation: We recommend management review and strengthen its internal control review process over identification and tracking of eligible expenses and the reporting process. Views of Responsible Officials of the Auditee: Management agrees with the finding, has prepared an assessment of the root causes of this material weakness, and has developed a corrective action plan.
Show full finding ▾Hide full finding ▴Federal programs: U.S. Department of Health and Human Services, ALN 93.498 Criteria: 2 CFR Part 200.303(a) states that the auditee must establish and maintain effective internal control over the federal award that provides reasonable assurance that the auditee is managing the federal award in compliance with federal statutes, regulations, and terms and conditions of the federal award. Specific criteria are established by the U.S. Department of Health and Human Services (HHS) with respect to activities allowed or unallowed for this program, including: - That these funds may not be used to reimburse expenses or losses that have been reimbursed from other sources or that other sources are obligated to reimburse. Condition: The reported expenses included expenses that had been reimbursed by other sources and were obligated to be reimbursed through Medicare and Medicaid cost-based reimbursement. Management also identified expenses eligible for reimbursement that were not reported in the PRF reporting portal. Cause: Controls in place did not operate effectively to substantiate that the funds were not reimbursed from other sources and other sources were not obligated to reimburse them. Additionally, controls in place did not identify all eligible expense meeting the terms and conditions of the award. Effect: Expenses reported included expense that were reimbursed or obligated to be reimbursed. Expenses reported excluded expenses that were eligible to be reimbursed by the award. Questioned costs: None Context: The error was present on the reporting submission completed for reporting period one. Repeat finding? No Recommendation: We recommend management review and strengthen its internal control review process over identification and tracking of eligible expenses and the reporting process. Views of Responsible Officials of the Auditee: Management agrees with the finding, has prepared an assessment of the root causes of this material weakness, and has developed a corrective action plan.
Identifying Number: 2021-002 Finding: The reported expenses included expenses that had been reimbursed by other sources and were obligated to be reimbursed through Medicare and Medicaid cost-based reimbursement. Management also identified expenses eligible for reimbursement that were not reported in the PRF reporting portal. Corrective Actions Taken or Planned: We were constantly learning more about the eligible expenses for the Provider Relief Funds, as well as other federal or state grants. We did a good job of tracking the potential universe of eligible expenses for all of our grants, but guidance and FAQs for PRF and other grants were constantly changing, and continue to change to this day, in fact. As a result, our understanding at the time of filing was different than our understanding now as to how to allocate which eligible expenses to which grant without being covered twice, and still meeting all the eligibility requirements for each grant. Now that we have a clearer picture, we believe we actually had more eligible expenses than we did when we filled out the information in the portal, and we don?t have any payback due, so if anything, we were overly conservative when we filled out the portal information, and I?m not sure that giving what we knew and understood at the time, I don?t know that we?d do it any differently. Many colleagues have expressed to me similar feelings, and they have run into similar issues as more guidance has come out. In terms of corrective action, we continue to document our eligible expenses and assign them to specific grants that have matching eligibility requirements to make sure all funds are accounted for, and will file subsequent portal filings to reflect the current allocation of those funds to the various grants assigned. Casey Johnson, CFO was responsible for the implementation of this corrective action plan. As of June 15, 2022, the corrective actions have been fully implemented.
The amount reported as lost revenues was improperly reported for reporting period one. Cause: Managements calculation of lost revenues included formula errors, improper reconciliation to internal financial records, and lacked consideration for significant out-of-period adjustments. The corrected lost revenue calculation resulted in an increase in lost revenue available for reimbursement. Effect: The calculation of lost revenue did not comply with the Terms and Conditions of the federal program, and total allowable costs reported in the PRF reporting portal were understated. Questioned costs: None Context: The errors were present on the reporting submissions completed for reporting period one. Repeat finding? No Recommendation: We recommend management review and strengthen its internal control review process over the calculation of lost revenues attributable to Coronavirus in accordance with the terms and conditions of the grant and the process over reporting. Views of Responsible Officials of the Auditee: Management agrees with the finding, has prepared an assessment of the root causes of this material weakness, and has developed a corrective action plan.
Show full finding ▾Hide full finding ▴Federal programs: U.S. Department of Health and Human Services, ALN 93.498 Criteria: Per the Health Resources and Services Administration (HRSA) reporting guidance, providers who accepted PRF payments agreed to the Terms and Conditions of the program, which included a requirement to report on the use of funds. Providers who received one or more payments totaling greater than $10,000 in the aggregate during a payment received period must report on use of funds in each applicable reporting period. Specific criteria are established by the U.S. Department of Health and Human Services (HHS) with respect to special reporting requirements for this program, including: - Proper reporting of critical information, including the calculation of lost revenues attributable to Coronavirus. - Each cell reported in the lost revenue calculation, using the alternative method, agrees to the entity?s narrative and underlying supporting documentation. - Provider Relief Fund recipients shall exclude from the reporting of net patient revenue payments received or payments made to third parties relating to care not provided in 2019, 2020, or 2021. Condition: The amount reported as lost revenues was improperly reported for reporting period one. Cause: Managements calculation of lost revenues included formula errors, improper reconciliation to internal financial records, and lacked consideration for significant out-of-period adjustments. The corrected lost revenue calculation resulted in an increase in lost revenue available for reimbursement. Effect: The calculation of lost revenue did not comply with the Terms and Conditions of the federal program, and total allowable costs reported in the PRF reporting portal were understated. Questioned costs: None Context: The errors were present on the reporting submissions completed for reporting period one. Repeat finding? No Recommendation: We recommend management review and strengthen its internal control review process over the calculation of lost revenues attributable to Coronavirus in accordance with the terms and conditions of the grant and the process over reporting. Views of Responsible Officials of the Auditee: Management agrees with the finding, has prepared an assessment of the root causes of this material weakness, and has developed a corrective action plan.
Identifying Number: 2021-003 Finding: The amount reported as lost revenues was improperly reported for reporting period one. Corrective Actions Taken or Planned: Again, we misinterpreted the guidance on lost revenue calculations, as well as the interest income associated with the lost revenue. I don?t know that, given the information and guidance we had at the time of filing, we would have done it any different. That said, our understanding and the guidance available has changed, and as a result, we actually had more lost revenue and less interest income than originally reported. Again, it was an error on the conservative side of the ledger, and we are not in a payback situation as a result. In terms of corrective action, in the same manner as the expenses, we have updated internal documentation to reflect the updated calculations of lost revenues and interest income, and future filings will correct the previous entries into the portal, but we will not need to pay anything back as a result. Casey Johnson, CFO, was responsible for the implementation of this corrective action plan. As of June 15, 2022, the corrective actions have been fully implemented.
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