EIN: 510141617
UEI: ZBR6LJKHWLK7
Data as of August 20, 2026
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on September 27, 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 27, 2023, which was (1243 days ago).
What is a management decision? →2021 ? 001 Type of Finding: ? Material Weakness in Internal Control over Financial Reporting Criteria or specific requirement: Management is responsible for adopting sound accounting policies and establishing and maintaining a system of internal control for the fair presentation of the basic financial statements in accordance with accounting principles generally accepted in the United States of America. Condition: In conjunction with the completion of the annual financial statements, numerous entries were required to be made by management and the auditors in order to report accurate financial statements in accordance with accounting principles generally accepted in the United States of America. Adjustments were recorded by management and the auditors to correct balances based on reconciliation schedules provided as well as information the Organization received from various vendors subsequent to management?s close of the internal financial statements for 2021. These adjustments relate to prepaid expenses, fixed assets and accumulated depreciation, allowance for doubtful accounts, various accrued expense accounts, intercompany accounts, operating expenses, unrealized gain on investments, contributions, releases of net assets from restrictions, and net asset transfers. Certain of these adjustments impacted 2019 and 2020 expenses and net asset balances and resulted in a correction of errors disclosed in the consolidated financial statements. Cause: Management did not record all required journal entries in conjunction with the financial statement close process on a timely basis. Effect: The journal entries impacted several areas of the consolidated financial statements and adjusted the change in net assets by an amount that is considered material. Recommendation: We recommend that management evaluate the existing procedures to ensure a timely financial statement close process aligned with CJ Lifecare policies, ensure accurate financial reporting, and consider training to improve financial reporting. Views of responsible officials and planned corrective actions: During 2021, new internal review processes were implemented, including a detailed review of monthly financial statement drafts and a more extensive review of significant and / or high-risk accounts, such as accounts receivable and the related allowance for doubtful accounts. Although new processes were implemented, the Organization?s finance department also underwent significant turnover, which resulted in a period of time during which the Organization?s finance department was short-staffed, consistent with staffing challenges across all industries as a result of the COVID-19 pandemic. Open positions began to be filled in the late fall of 2021, at which time a number of corrections to previously issued internal and audited financial statements were noted and adjusted. During 2022, remaining positions have been filled with highly experienced individuals, including an additional certified public accountant. Additional processes and procedures are also being implemented to ensure that adequate training and review of supporting schedules and monthly financial statements is completed. Management believes that with the implementation of these additional processes and procedures, in addition to additional staffing, material entries will be noted and recorded on a timely basis.
2021 ?001 ? Material Adjusting Journal Entries / Restatement of Previously Issued Financial Statements Name of contact person: Jennifer Santerre, Chief Financial Officer Corrective Action: During 2021, new internal review processes were implemented, including a detailed review of monthly financial statement drafts and a more extensive review of significant and / or high-risk accounts. Although new processes were implemented, the Organization?s finance department also underwent significant turnover, which resulted in a period of time during which the Organization?s finance department was short-staffed, consistent with staffing challenges across all industries as a result of the COVID-19 pandemic. Open positions began to be filled in the fall of 2021, at which time a number of corrections to previously issued internal and audited financial statements were noted and adjusted. During 2022, remaining positions have been filled with highly experienced individuals, including an additional certified public accountant. Additional processes and procedures are also being implemented to ensure adequate training and review of supporting schedules and monthly financial statements is completed. Management believes that with the implementation of these additional processes and procedures, in addition to additional staffing, material entries will be noted and recorded on a timely basis. Proposed Completion Date: Existing policies and procedures were reviewed and revised during the first two quarters of 2022. Additional policies and procedures are expected to be fully implemented no later than December 31, 2022.
2021 ? 002 Federal Agency: U.S. Department of Health and Human Services Federal Program Name: COVID-19 Provider Relief Fund Assistance Listing Number: 93.498 Award Period: April 10, 2020 through December 31, 2020 Type of Finding: ? Significant deficiency in Internal Control over Compliance Criteria or specific requirement: COVID-19 Provider Relief Fund terms and conditions require accurate report submissions to the Provider Relief Fund (PRF) Reporting Portal. Condition: For one of its skilled nursing facilities? Period 1 reporting submissions, the Organization included $294,639 of Mortgage/Rent expenses as Other PRF Expenses. After the reporting portal was closed, the Organization determined that these expenses should have been shown on the Supplies and Fringe Benefits lines rather than as Mortgage/Rent. Total Other PRF Expenses for Period 1 was accurate based on the Organization?s internal records. Questioned costs: None Context: The Organization's intention was to use and report Supplies and Fringe Benefits towards PRF funds received for Period 1 reporting rather than Mortgage/Rent. Cause: The Organization did not have an adequate internal control policy in place to ensure proper review of the report prior to submission. Effect: The Organization?s Period 1 reporting is not accurate and does not match the Organization?s internal records of uses of PRF funding. Repeat Finding: No Recommendation: We recommend that the Organization enhance internal control policies to ensure that reports are reviewed and approved prior to submitting the PRF reporting to the federal agency. Views of responsible officials: The Organization carefully reviewed the expenditures submitted through the Department of Health and Human Services Provider Relief Fund Reporting Portal, however inadvertently used an outdated supporting schedule to input the information into the Reporting Portal, resulting in a mismatch between actual usage and reported usage. It should be noted that although reported inaccurately, all funds expended were used for allowable costs under the program guidance. For future reporting periods, management has reviewed and revised internal reporting schedules utilized in preparing information submitted through the Reporting Portal.
2021 ?002 ? Reporting Name of contact person: Jennifer Santerre, Chief Financial Officer Corrective Action: The Organization carefully reviewed the expenditures submitted through the Department of Health and Human Services Provider Relief Fund Reporting Portal, however inadvertently used an outdated supporting schedule to input the information into the Reporting Portal, resulting in a mismatch between actual usage and reported usage. It should be noted that although reported inaccurately, all funds expended were used for allowable costs under the program guidance. For future reporting periods, management has reviewed and revised internal reporting schedules utilized in preparing information submitted through the Reporting Portal. Proposed Completion Date: September 30, 2022
2021 ? 003 Federal Agency: U.S. Department of Health and Human Services Federal Program Name: COVID-19 Provider Relief Fund Assistance Listing Number: 93.498 Award Period: April 10, 2020 through December 31, 2020 Type of Finding: ? Significant deficiency in Internal Control over Compliance ? Other Matters Criteria or specific requirement: Costs claimed against the grant must meet allowable cost rules under 2 CFR Subpart E - Cost Principles. Condition: In a sample of 32 cash disbursements tested, 1 sample selected claimed a PRF related cost of $248 against the grant that was not an allowable cost based on review of the related invoice. Questioned costs: $248 Context: In a statistically valid sample of 32 cash disbursements, the auditor identified 1 instance of noncompliance in cash disbursements tested. Cause: The condition was caused by an accounting error in the coding of the expense to the wrong general ledger account. Effect: The effect of the condition was $248 of costs claimed in excess of actual cost incurred. This is mitigated by that fact that for this particular entity, this cost was related to PRF Period 1 reporting which had additional lost revenue that was not claimed by the Organization but which could have been claimed for Period 1. Repeat Finding: No Recommendation: We recommend that the Organization review and improve its procedures for tracking costs and related tracking mechanisms, ensuring that all costs claimed are fully supported. Views of responsible officials: The Organization carefully reviewed and coded allowable costs under the Department of Health and Human Services Provider Relief Fund Program. Due to an internal oversight, one vendor invoice for $248 was miscoded as an allowable cost while coding other allowable costs under the program. The Organization had significant lost revenue that was not claimed by the Organization, however could have been, therefore, although coded incorrectly, the Organization had other costs that could be appropriately used. For future reporting periods, management has reviewed and revised invoice coding and the review thereof, to ensure costs are appropriately reflected and reported.
2021 ?003 ? Allowable Costs Name of contact person: Jennifer Santerre, Chief Financial Officer Corrective Action: The Organization carefully reviewed and coded allowable costs under the Department of Health and Human Services Provider Relief Fund Program. Due to an internal oversight, one vendor invoice for $248 was miscoded as an allowable cost while coding other allowable costs under the program. The Organization had significant lost revenue that was not claimed by the Organization, however could have been, therefore, although coded incorrectly, the Organization had other costs that could be appropriately used. For future reporting periods, management has reviewed and revised invoice coding and the review thereof, to ensure costs are appropriately reflected and reported. Proposed Completion Date: September 30, 2022
2021 ? 004 Federal Agency: U.S. Department of Health and Human Services Federal Program Name: COVID-19 Provider Relief Fund Assistance Listing Number: 93.498 Award Period: April 10, 2020 through December 31, 2020 Type of Finding: ? Significant deficiency in Internal Control over Compliance ? Other Matters Criteria or specific requirement: When utilizing the Budgeted Revenue Lost Revenue Reporting Methodology, all budgeted revenue being reported on must be part of an Organization's budget that was established and approved prior to March 27, 2020. Condition: In the Organization's lost revenue calculation, the 2021 budget utilized was established and approved subsequent to March 27, 2020. Questioned costs: None Context: In a statistically valid sample where the auditor tested the entire population of ten PRF reports submitted for the five subsidiaries under this consolidated PRF audit, one finding was noted. The finding noted is isolated to the calculation of lost revenue associated with the 2021 period, and did not impact the calculation of the 2020 period. Cause: The condition was caused by confusion on the ability to use a 2021 budget, which, based on the Organization?s fiscal year-end, could not have been established prior to March 27, 2020. Effect: No adverse effect noted. The calculated lost revenue for the 2021 was not applied against and grant funding, and only lost revenue associated with the 2020 period was applied against grant funds. Repeat Finding: No Recommendation: We recommend that the Organization review the lost revenue calculation methodologies available, and submit future lost revenue calculations utilizing one of the options that are viable for the Organization. Views of responsible officials: Since the establishment of the Provider Relief Fund program, regulations and guidelines related to the program have consistently been modified and / or clarified, with the latest clarification occurring in July 2022. As a result of the speed of which program regulations and guidelines were changing, there was confusion as to which budget period should be utilized in the calculation of lost revenues. Management has since reviewed applicable guidance and has revised the lost revenue calculation utilizing the correct budget period. Management has noted that the utilization of the incorrect budget period had no adverse effect of the usage of funds.
2021 ?004 ? Other Matters Name of contact person: Jennifer Santerre, Chief Financial Officer Corrective Action: Since the establishment of the Provider Relief Fund program, regulations and guidelines related to the program have consistently been modified and / or clarified, with the latest clarification occurring in July 2022. As a result of the speed of which program regulations and guidelines were changing, there was confusion as to which budget period should be utilized in the calculation of lost revenues. Management has since reviewed applicable guidance and has revised the lost revenue calculation utilizing the correct budget period. Management has noted that the utilization of the incorrect budget period had no adverse effect of the usage of funds. Proposed Completion Date: September 15, 2022
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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