EIN: 521305909
UEI: GSA_MIGRATION
Audited by: CLIFTONLARSONALLEN, 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 September 29, 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 29, 2023 (1250 days ago).
What is a management decision? →Expenses attributable to infection control funds received were incorrectly reported as part of the Organization?s Period 1 reporting of total expenses. The expenses were also correctly reported as part of the Organization?s Period 2 reporting related to infection control funds that were received. Questioned costs: None Context: During our testing, it was noted that the Organization reported the same infection control related expenses on both its Period 1 and Period 2 reporting submissions. Cause: The Organization had lost revenues in excess of funding received and was unaware that the reporting of the expenses on both submissions was incorrect. Controls were not in place to ensure any infection control related expenses were excluded on its Period 1 reporting and held for submission for Period 2. Effect: Infection control related expenses were reported on both its Period 1 and Period 2 reporting submissions. Recommendation: We recommend the Organization review all expense information prior to any future submissions to ensure expenses are appropriately reported. If certain expenses will need to be reported for a specific purpose as part of an additional or future submission, those expenses should be excluded. Views of responsible officials: There is no disagreement with the audit finding.
Show full finding ▾Hide full finding ▴2021-001 Federal Agency: U.S. Department of Health and Human Services Federal Program Title: COVID-19 Provider Relief Funds Assistance Listing Number: 93.498 Award Period: January 1, 2020 through December 31, 2021 Type of Finding: ? Significant Deficiency in Internal Control over Compliance Criteria or specific requirement: The Provider Relief Funds are required to be reported through the Provider Relief Fund Reporting Portal and include key line items for Nursing Home Infection Control Expenses, Other Provider Relief Fund Expenses, and Calculation of Lost Revenues Attributable to Coronavirus. Condition: Expenses attributable to infection control funds received were incorrectly reported as part of the Organization?s Period 1 reporting of total expenses. The expenses were also correctly reported as part of the Organization?s Period 2 reporting related to infection control funds that were received. Questioned costs: None Context: During our testing, it was noted that the Organization reported the same infection control related expenses on both its Period 1 and Period 2 reporting submissions. Cause: The Organization had lost revenues in excess of funding received and was unaware that the reporting of the expenses on both submissions was incorrect. Controls were not in place to ensure any infection control related expenses were excluded on its Period 1 reporting and held for submission for Period 2. Effect: Infection control related expenses were reported on both its Period 1 and Period 2 reporting submissions. Recommendation: We recommend the Organization review all expense information prior to any future submissions to ensure expenses are appropriately reported. If certain expenses will need to be reported for a specific purpose as part of an additional or future submission, those expenses should be excluded. Views of responsible officials: There is no disagreement with the audit finding.
Department of Health and Human Services 2021-001 Provider Relief Funding ? Assistance Listing No. 93.498 Recommendation: We recommend the Organization review all expense information prior to any future submissions to ensure expenses are appropriately reported. If certain expenses will need to be reported for a specific purpose as part of an additional or future submission, those expenses should be excluded. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Going forward, expenses included within a submission will be reviewed by an individual within the accounting department to ensure those expenses are reported appropriately within the correct period and for the appropriate filing. Name(s) of the contact person(s) responsible for corrective action: Juanita Parks, CFO Planned completion date for corrective action plan: 9/30/2022
Lost revenue Option 2 required that all budgets used for the lost revenue calculation were approved prior to 3/27/20. The fiscal year 2021 budget was not approved prior to 3/27/20 related to the Organization?s Period 1 reporting. Questioned costs: None Context: During our testing, it was noted that the Organization did not set up the lost revenue calculation correctly under Option 2 within its Period 1 reporting. Option 3, the correct option, was selected for the Organization?s subsequent Period 2 reporting. Cause: The Organization did not think it would be an issue for Period 1 as the selection of Option 2 for lost revenue presentation did not materially change the lost revenue calculation. As noted above, the correction was made with the Organization?s Period 2 reporting. Effect: The lost revenue calculation in the submission for Period 1 was incorrectly presented under Option 2. Recommendation: We recommend that the Organization document that Option 3 was the appropriate lost revenue method to select as part of its filing. The Organization should put together the required narrative for its records of how the lost revenue calculation was set up and that the alternative method (Option 3) was used. The Organization did make this correction with its Period 2 filing. The Organization should ensure the correct lost revenue method is selected for any future submissions. Views of responsible officials: There is no disagreement with the audit finding.
Show full finding ▾Hide full finding ▴2021 ? 002 Federal Agency: U.S. Department of Health and Human Services Federal Program Title: Provider Relief Funding Assistance Listing Number: 93.498 Award Period: January 1, 2020 through December 31, 2021 Type of Finding: ? Significant Deficiency in Internal Control over Compliance Criteria or specific requirement: The Provider Relief Funds are required to be reported through the Provider Relief Fund Reporting Portal and include key line items for Nursing Home Infection Control Expenses, Other Provider Relief Fund Expenses, and Calculation of Lost Revenues Attributable to Coronavirus. Condition: Lost revenue Option 2 required that all budgets used for the lost revenue calculation were approved prior to 3/27/20. The fiscal year 2021 budget was not approved prior to 3/27/20 related to the Organization?s Period 1 reporting. Questioned costs: None Context: During our testing, it was noted that the Organization did not set up the lost revenue calculation correctly under Option 2 within its Period 1 reporting. Option 3, the correct option, was selected for the Organization?s subsequent Period 2 reporting. Cause: The Organization did not think it would be an issue for Period 1 as the selection of Option 2 for lost revenue presentation did not materially change the lost revenue calculation. As noted above, the correction was made with the Organization?s Period 2 reporting. Effect: The lost revenue calculation in the submission for Period 1 was incorrectly presented under Option 2. Recommendation: We recommend that the Organization document that Option 3 was the appropriate lost revenue method to select as part of its filing. The Organization should put together the required narrative for its records of how the lost revenue calculation was set up and that the alternative method (Option 3) was used. The Organization did make this correction with its Period 2 filing. The Organization should ensure the correct lost revenue method is selected for any future submissions. Views of responsible officials: There is no disagreement with the audit finding.
2021-002 Provider Relief Funding ? Assistance Listing No. 93.498 Recommendation: We recommend that the Organization document that Option 3 was the appropriate lost revenue method to select as part of its filing. The Organization should put together the required narrative for its records of how the lost revenue calculation was set up and that the alternative method (Option 3) was used. The Organization did make this correction with its Period 2 filing. The Organization should ensure the correct lost revenue method is selected for any future submissions. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Going forward, any calculations for submissions will be prepared under the correct lost revenue method. The correct lost revenue calculation has been documented in our files and we have compiled the appropriate required narrative in our records. This correction was made and completed for the Period 2 filing. Name of the contact person responsible for corrective action: Juanita Parks, CFO Planned completion date for corrective action plan: 9/30/2022
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