EIN: 480642318
UEI: MKGDEK2DG6V5
Data as of August 27, 2026
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on July 25, 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 January 25, 2025 (580 days ago).
What is a management decision? →Finding: Reporting Department of Health and Human Services Direct Program: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution – 93.498 Criteria or specific requirement – Reporting (45 CFR 75.342). The Organization is required to prepare and submit provider relief fund reports to the U.S. Department of Health and Human Services. The reports are to be prepared using accurate financial information and submitted by the deadline established. The funds cannot be used for expenses reimbursed or obligated to be reimbursed by other sources. Condition – The Organization reported COVID-19 related expenditures within the HHS Provider Relief Fund and American Rescue Plan (ARP) Distribution portal that were covered in a previous period (period 2). Questioned costs – None. Context – The Organization had turnover in the CFO role. The CFO that completed the Period 4 reporting believed that expenses were to be reported on a cumulative basis, similar to how lost revenue is reported. The expenses were deemed to be allowable costs in Period 2 reporting but should not have been repeated on the Period 4 reporting as those expenses had already been reimbursed/claimed on Period 2. Effect – The Organization submitted expenses under the PRF program that were obligated to be reimbursed by other sources (Claimed/Reported on PRF Period 2). Cause – Turnover at the CFO position (person responsible for overseeing and reporting of the PRF) lead to unfamiliarity with the reporting portal and proper reporting of expenses for the current period (Period 4). Internal controls were not in place to ensure the Organization correctly applied the guidance. Identification as a repeat finding, if applicable – N/A Recommendation – The Organization should continue to improve understanding of the guidance related to this type of reporting and work to identify areas for improvement prior to submission to the Provider Relief Fund reporting portal. Management should ensure proper internal controls are put into place to ensure that allowable expenses reported are not reimbursed by other sources or in previous period submissions. View of responsible officials and planned corrective actions – The Organization agrees with this finding. See separate auditee document for planned corrective action.
Show full finding ▾Hide full finding ▴Finding: Reporting Department of Health and Human Services Direct Program: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution – 93.498 Criteria or specific requirement – Reporting (45 CFR 75.342). The Organization is required to prepare and submit provider relief fund reports to the U.S. Department of Health and Human Services. The reports are to be prepared using accurate financial information and submitted by the deadline established. The funds cannot be used for expenses reimbursed or obligated to be reimbursed by other sources. Condition – The Organization reported COVID-19 related expenditures within the HHS Provider Relief Fund and American Rescue Plan (ARP) Distribution portal that were covered in a previous period (period 2). Questioned costs – None. Context – The Organization had turnover in the CFO role. The CFO that completed the Period 4 reporting believed that expenses were to be reported on a cumulative basis, similar to how lost revenue is reported. The expenses were deemed to be allowable costs in Period 2 reporting but should not have been repeated on the Period 4 reporting as those expenses had already been reimbursed/claimed on Period 2. Effect – The Organization submitted expenses under the PRF program that were obligated to be reimbursed by other sources (Claimed/Reported on PRF Period 2). Cause – Turnover at the CFO position (person responsible for overseeing and reporting of the PRF) lead to unfamiliarity with the reporting portal and proper reporting of expenses for the current period (Period 4). Internal controls were not in place to ensure the Organization correctly applied the guidance. Identification as a repeat finding, if applicable – N/A Recommendation – The Organization should continue to improve understanding of the guidance related to this type of reporting and work to identify areas for improvement prior to submission to the Provider Relief Fund reporting portal. Management should ensure proper internal controls are put into place to ensure that allowable expenses reported are not reimbursed by other sources or in previous period submissions. View of responsible officials and planned corrective actions – The Organization agrees with this finding. See separate auditee document for planned corrective action.
Criteria or Specific Requirement – Reporting (Reference number 2023-001) Recommendation – The Organization should continue to improve understanding of the guidance related to this type of reporting and work to identify areas for improvement prior to submission to the Provider Relief Fund reporting portal. Management should ensure proper internal controls are put into place to ensure that allowable expenses reported are not reimbursed by other sources or in previous submission period. Views of Responsible Officials and Corrective Action Plan – Management agrees with the finding. The reporting discrepancy was due to a misunderstanding of how the cost portion of the report should have been presented. The presentation was submitted with the same methodology as the lost revenue presentation, which was on a cumulative basis vs. the incremental period required for costs. In addition, staff turnover, including the responsible official (CFO), during this period of time impacted the execution of the last repoting requirement and improper reporting to HHS. The Organization believes that it had sufficient lost revenues to justify retention of all PRF Period 4 funds. There is no expected future reporting for the Provider Relief Funds. Personnel Responsible – John Hydock, Interim CFO Timeline – There is no expected future PRF submissions, but in the event one is required, the Organization will have a quality control process in place to review reporting of expenses to ensure no duplication or carry-over of expenses occurs.
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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