EIN: 450310462
UEI: L677JK2M1WX3
Audit also covers 2 related EINs: 450368330, 450395652 · unlinked EINs have no separate FAC filing
Audited by: Wipfli LLP
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 July 7, 2025. 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 January 7, 2026 (234 days ago).
What is a management decision? →FAC accepted this audit on September 25, 2024 — management decision was due March 25, 2025.
FAC accepted this audit on September 26, 2023 — management decision was due March 26, 2024.
FAC accepted this audit on March 28, 2023 — management decision was due September 28, 2023.
2021-001: Material Weakness U.S. Department of Health and Human Services, ALN 93.498 - Lost Revenue Calculation and Special Reporting Requirements Criteria 2 CFR 200.303(a) establishes that the auditee must establish and maintain effective internal control over the federal award that provides assurance that the entity is managing the federal award in compliance with federal statutes, regulations, and conditions of the federal award. Condition The amount reported as lost revenues was improperly reported for reporting periods one and two. Cause In the period one reporting, lost revenue was reported in error as other healthcare expenses instead of in the lost revenue section of the special report. In both periods, management?s calculation of lost revenues included formula errors, improper reconciliation to internal financial records, and lacked consideration for out-of-period adjustments. The corrected lost revenue calculation resulted in a decrease in lost revenue available for reimbursement and a decrease in the carryforward of lost review to future periods. The corrected lost revenue available for reimbursement did not result in any change in the amounts allowable for funding by the program. 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 overstated. Questioned costs None. The Organization has lost revenue to cover the funding received. Context The errors were present on the reporting submissions completed for reporting periods one and two. 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 and that there is documented evidence of the review and approval. We also recommend management update the portal reporting with the appropriate amounts as it will impact future Provider Relief Fund reports. 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. Repeat finding No
Show full finding ▾Hide full finding ▴2021-001: Material Weakness U.S. Department of Health and Human Services, ALN 93.498 - Lost Revenue Calculation and Special Reporting Requirements Criteria 2 CFR 200.303(a) establishes that the auditee must establish and maintain effective internal control over the federal award that provides assurance that the entity is managing the federal award in compliance with federal statutes, regulations, and conditions of the federal award. Condition The amount reported as lost revenues was improperly reported for reporting periods one and two. Cause In the period one reporting, lost revenue was reported in error as other healthcare expenses instead of in the lost revenue section of the special report. In both periods, management?s calculation of lost revenues included formula errors, improper reconciliation to internal financial records, and lacked consideration for out-of-period adjustments. The corrected lost revenue calculation resulted in a decrease in lost revenue available for reimbursement and a decrease in the carryforward of lost review to future periods. The corrected lost revenue available for reimbursement did not result in any change in the amounts allowable for funding by the program. 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 overstated. Questioned costs None. The Organization has lost revenue to cover the funding received. Context The errors were present on the reporting submissions completed for reporting periods one and two. 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 and that there is documented evidence of the review and approval. We also recommend management update the portal reporting with the appropriate amounts as it will impact future Provider Relief Fund reports. 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. Repeat finding No
2021-001 Contract Persons Derek Goebel, Interim Chief Financial Officer Management Response We agree with strengthening our internal controls and establishing a process to eliminate errors. Corrective Action Plan We implemented Workday, an enterprise resource planning software, in 2022 that eliminates human error and provides financial statement accuracy. By using Workday, we ensure the lost revenue calculation will be supported by the internal financial statements. We will enhance our internal control policies by implementing a secondary review and approval process over reports before submission to ensure all information is complete and meets the federal program's requirements. In period five reporting, we will correct lost revenues for periods one and two to the U.S. Department of Health and Human Services when the correction window becomes available. Anticipated Completion Date The Corrective Action Plan steps will be completed by June 30, 2023.
2021-002: Material Weakness U.S. Department of Health and Human Services, ALN 93.498 - Activities Allowed or Unallowed, Allowable Costs/Costs Principles, and Reporting Criteria 2 CFR 200.303(a) establishes that the auditee must establish and maintain effective internal control over the federal award that provides assurance that the entity is managing the federal award in compliance with federal statutes, regulations, and conditions of the federal award. Condition The Organization?s final expenditure listing, lost revenue calculation identified as eligible and claimed under the Provider Relief Fund Program, and special report submitted to the Department of Health and Human Services for Periods 1 and 2 did not have evidence of being reviewed and approved by a separate individual outside of the preparer. Cause The Organization did not have an adequate internal control policy in place to ensure review and approval over the final expenditure listing, the lost revenue calculation, or preparation of HHS Period 1 and Period 2 reporting were documented. Effect The lack of adequate policies governing the review and approval of the expenditure listing, lost revenue calculation and the HHS Period 1 and 2 reports increases the risk that employees participating in the federal award administration may not be able to detect and correct noncompliance in a timely manner. Without a secondary review and approval, there is a possibility that ineligible expenditures may be claimed under the program. Questioned Costs None reported. Context The overall expense worksheet, lost revenue worksheet and the special report submitted to the Department of Health and Human Services for Periods 1 and 2 did not have evidence of a review by someone other than the preparer (i.e., population of two). Recommendation We recommend The Organization implement a control process which includes a secondary review and approval of the final expenditure listing and lost revenue calculation used to claim the allowable costs under the federal program and that there is documented evidence of the review and approval. In addition, the special Reports submitted to HHS should have a secondary review and approval that is documented. 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. Repeat finding No
Show full finding ▾Hide full finding ▴2021-002: Material Weakness U.S. Department of Health and Human Services, ALN 93.498 - Activities Allowed or Unallowed, Allowable Costs/Costs Principles, and Reporting Criteria 2 CFR 200.303(a) establishes that the auditee must establish and maintain effective internal control over the federal award that provides assurance that the entity is managing the federal award in compliance with federal statutes, regulations, and conditions of the federal award. Condition The Organization?s final expenditure listing, lost revenue calculation identified as eligible and claimed under the Provider Relief Fund Program, and special report submitted to the Department of Health and Human Services for Periods 1 and 2 did not have evidence of being reviewed and approved by a separate individual outside of the preparer. Cause The Organization did not have an adequate internal control policy in place to ensure review and approval over the final expenditure listing, the lost revenue calculation, or preparation of HHS Period 1 and Period 2 reporting were documented. Effect The lack of adequate policies governing the review and approval of the expenditure listing, lost revenue calculation and the HHS Period 1 and 2 reports increases the risk that employees participating in the federal award administration may not be able to detect and correct noncompliance in a timely manner. Without a secondary review and approval, there is a possibility that ineligible expenditures may be claimed under the program. Questioned Costs None reported. Context The overall expense worksheet, lost revenue worksheet and the special report submitted to the Department of Health and Human Services for Periods 1 and 2 did not have evidence of a review by someone other than the preparer (i.e., population of two). Recommendation We recommend The Organization implement a control process which includes a secondary review and approval of the final expenditure listing and lost revenue calculation used to claim the allowable costs under the federal program and that there is documented evidence of the review and approval. In addition, the special Reports submitted to HHS should have a secondary review and approval that is documented. 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. Repeat finding No
2021-002 Contract Persons Derek Goebel, Interim Chief Financial Officer Management Response Due to lack of personnel, we did not have a secondary review process in place during the time of reporting submission. However, we have since hired additional personnel to fulfill our team and implement an efficient internal control process. Corrective Action Plan We have hired additional personnel to support our internal control process that provide expertise in this area and hold a Certified Public Accountant license. In addition, we will enhance our internal control policies by implementing a secondary review and approval process over reports before submission to ensure all information is complete and meets the federal program's requirements. Anticipated Completion Date The Corrective Action Plan has been implemented for 2022.
2021-003: Material Weakness U.S. Department of Health and Human Services, ALN 93.498 - Lost Revenue Calculation and Special Reporting Requirements Criteria 2 CFR 200.303(a) establishes that the auditee must establish and maintain effective internal control over the federal award that provides assurance that the entity is managing the federal award in compliance with federal statutes, regulations, and conditions of the federal award. Condition The Organization claimed lost revenues that were incorrectly supported. These were improperly included within the reports and caused the reports to be inaccurate. Cause The Organization claimed lost revenues under Option ii and did have an approved budget prior to March 27, 2020 for fiscal year 2020, but the approved budget did not cover the entire period of availability. Effect The lack of adequate policies over the report preparation and submission increases the risk that employees participating in the federal award administration may not be able to detect and correct noncompliance in a timely manner. This resulted in lost revenue that was reported in periods which did not have an approved budget prior to March 27, 2020. Questioned Costs None. The Organization has lost revenue to cover the funding received. Context The report section, lost revenues, included lost revenue calculations that were not supported by an approved budget for the entire period of availability. Recommendation We recommend The Organization implement a control process which includes a secondary review and approval of the final expenditure listing and lost revenue calculation used to claim the allowable costs under the federal program and that there is documented evidence of the review and approval. In addition, the special Reports submitted to HHS should have a secondary review and approval that is documented. 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. Repeat finding No
Show full finding ▾Hide full finding ▴2021-003: Material Weakness U.S. Department of Health and Human Services, ALN 93.498 - Lost Revenue Calculation and Special Reporting Requirements Criteria 2 CFR 200.303(a) establishes that the auditee must establish and maintain effective internal control over the federal award that provides assurance that the entity is managing the federal award in compliance with federal statutes, regulations, and conditions of the federal award. Condition The Organization claimed lost revenues that were incorrectly supported. These were improperly included within the reports and caused the reports to be inaccurate. Cause The Organization claimed lost revenues under Option ii and did have an approved budget prior to March 27, 2020 for fiscal year 2020, but the approved budget did not cover the entire period of availability. Effect The lack of adequate policies over the report preparation and submission increases the risk that employees participating in the federal award administration may not be able to detect and correct noncompliance in a timely manner. This resulted in lost revenue that was reported in periods which did not have an approved budget prior to March 27, 2020. Questioned Costs None. The Organization has lost revenue to cover the funding received. Context The report section, lost revenues, included lost revenue calculations that were not supported by an approved budget for the entire period of availability. Recommendation We recommend The Organization implement a control process which includes a secondary review and approval of the final expenditure listing and lost revenue calculation used to claim the allowable costs under the federal program and that there is documented evidence of the review and approval. In addition, the special Reports submitted to HHS should have a secondary review and approval that is documented. 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. Repeat finding No
2021-003 Contract Persons Derek Goebel, Interim Chief Financial Officer Management Response We agree with strengthening our internal controls and restating our reports submitted to the U.S. Department of Health and Human Services. Corrective Action Plan We will enhance our internal control policies by implementing a secondary review and approval process over reports before submission to ensure all information is complete and meets the federal program's requirements. In period five reporting, we will adopt Option iii: Alternative Reasonable Methodology defining the methodology as a use of budget to actual for all periods presented based on calendar year budgets. We will restate this change for all periods presented to the U.S Department of Health and Human Services when the correction window becomes available. Anticipated Completion Date The Corrective Action Plan steps will be completed by reporting period 5.
2021-004: Material Weakness - Untimely Filing of Data Collection Form Program: All federal programs Criteria The Organization needs to ensure timely filing of the annual data collection form. Condition The Organization is required to submit the data collection form electronically to the Federal Audit Clearinghouse. This is to be completed within 30 days of report issuance or nine months after year-end (December 31), whichever is earlier. The data collection forms for the years ending December 31, 2021 and 2020 were not timely filed. Cause The Organization had not completed its audits as of the due date, therefore the data collection forms were not filed timely. Effect The Organization was not in compliance with the requirements for filing of the data collection form. Recommendation We recommend that the Organization ensure that the audit is completed in a timely manner and the data collection form is filed within the required timeline. Views of Responsible Officials and Planned Corrective Actions Management agrees with the finding, has prepared an assessment of the root causes of this material weakness, and has developed a corrective action plan. Repeat Finding No
Show full finding ▾Hide full finding ▴2021-004: Material Weakness - Untimely Filing of Data Collection Form Program: All federal programs Criteria The Organization needs to ensure timely filing of the annual data collection form. Condition The Organization is required to submit the data collection form electronically to the Federal Audit Clearinghouse. This is to be completed within 30 days of report issuance or nine months after year-end (December 31), whichever is earlier. The data collection forms for the years ending December 31, 2021 and 2020 were not timely filed. Cause The Organization had not completed its audits as of the due date, therefore the data collection forms were not filed timely. Effect The Organization was not in compliance with the requirements for filing of the data collection form. Recommendation We recommend that the Organization ensure that the audit is completed in a timely manner and the data collection form is filed within the required timeline. Views of Responsible Officials and Planned Corrective Actions Management agrees with the finding, has prepared an assessment of the root causes of this material weakness, and has developed a corrective action plan. Repeat Finding No
2021-004 Contract Persons Derek Goebel, Interim Chief Financial Officer Management Response We understand the significance of timely filing our data collection form. Due to personnel turnover and shifting of job duties, there was a delay in meeting this requirement. Corrective Action Plan We will establish internal deadlines to meet our audit due date. As a result, we will adhere to the filing date of the data collection form. Anticipated Completion Date The Corrective Action Plan has been implemented for 2022.
FAC accepted this audit on April 28, 2022 — management decision was due October 28, 2022.
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