EIN: 521654803
UEI: GSA_MIGRATION
Audited by: BAKER TILLY US, 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 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 March 28, 2023 (1252 days ago).
What is a management decision? →Finding 2021-001 ? Significant Deficiency in Internal Control - Reporting Assistance Listing No.: 93.498 COVID-19 - Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Program Federal Agency: U.S. Department of Health and Human Services Pass-through Agency: Not applicable Award Number / Year: N/A / 2020 Compliance Requirement: Reporting Criteria: All recipients of Provider Relief Fund (PRF) payments must comply with the reporting requirements described in the PRF terms and conditions and specified in the directions issued by the U.S. Department of Health and Human Services (HHS). Condition/Context: The Organization did not complete the PRF reporting for Period one in accordance with the HHS guidance. The Organization incorrectly classified approximately $53,000 of housekeeping credits as utilities/operations expenses in their submission instead of as lost revenue. Effect: The amounts report to Health Resources & Services Administration (HRSA) were not in accordance with established U.S. Department of Health and Human Services reporting guidance. Questioned Costs: Not determinable. Cause: Management misinterpreted the HHS guidance and failed identify that housekeeping credits should be included as lost revenues instead of other PRF expenses during their review of the Period one submission. Recommendation: We recommend that management implement procedures to ensure that the most recent guidance is reviewed and understood and that information used in preparation of the reports is reviewed, with errors addressed, prior to reporting. Views of Responsible Officials: The Organization agrees with the finding.
Show full finding ▾Hide full finding ▴Finding 2021-001 ? Significant Deficiency in Internal Control - Reporting Assistance Listing No.: 93.498 COVID-19 - Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Program Federal Agency: U.S. Department of Health and Human Services Pass-through Agency: Not applicable Award Number / Year: N/A / 2020 Compliance Requirement: Reporting Criteria: All recipients of Provider Relief Fund (PRF) payments must comply with the reporting requirements described in the PRF terms and conditions and specified in the directions issued by the U.S. Department of Health and Human Services (HHS). Condition/Context: The Organization did not complete the PRF reporting for Period one in accordance with the HHS guidance. The Organization incorrectly classified approximately $53,000 of housekeeping credits as utilities/operations expenses in their submission instead of as lost revenue. Effect: The amounts report to Health Resources & Services Administration (HRSA) were not in accordance with established U.S. Department of Health and Human Services reporting guidance. Questioned Costs: Not determinable. Cause: Management misinterpreted the HHS guidance and failed identify that housekeeping credits should be included as lost revenues instead of other PRF expenses during their review of the Period one submission. Recommendation: We recommend that management implement procedures to ensure that the most recent guidance is reviewed and understood and that information used in preparation of the reports is reviewed, with errors addressed, prior to reporting. Views of Responsible Officials: The Organization agrees with the finding.
Section II ? COVID-19 - Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Program Findings and Questioned Costs Finding 2021-001 ? Significant Deficiency in Internal Control - Reporting Assistance Listing No.: 93.498 COVID-19 - Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Program Federal Agency: U.S. Department of Health and Human Services Pass-through Agency: Not applicable Award Number / Year: N/A / 2020 Compliance Requirement: Reporting Criteria: All recipients of Provider Relief Fund (PRF) payments must comply with the reporting requirements described in the PRF terms and conditions and specified in the directions issued by the U.S. Department of Health and Human Services (HHS). Condition/Context: The Organization did not complete the PRF reporting for Period one in accordance with the HHS guidance. The Organization incorrectly classified approximately $53,000 of housekeeping credits as utilities/operations expenses in their submission instead of as lost revenue. Effect: The amounts report to Health Resources & Services Administration (HRSA) were not in accordance with established U.S. Department of Health and Human Services reporting guidance. Questioned Costs: Not determinable. Cause: Management misinterpreted the HHS guidance and failed to identify that housekeeping credits should be included as lost revenues instead of as other PRF expenses during their review of the Period one submission. Recommendation: We recommend that management implement procedures to ensure that the most recent guidance is reviewed and understood and that information used in preparation of the reports is reviewed, with errors addressed, prior to reporting. Views of Responsible Officials: The Organization agrees with the finding. Responsible Party: Jamie Spencer, Chief Financial Officer Estimated Time to Completion: December 31, 2022Corrective Action Not Started or In Progress: Management will ensure that all HHS guidance is regularly reviewed and will confirm their understanding of changes in regulations to prevent future misinterpretations of guidance so all reports are prepared and reviewed, with errors addressed, in advance of required reporting periods.
Finding 2021-002 ? Significant Deficiency in Internal Control - Activities Allowed and Unallowed; Reporting Assistance Listing No.: 93.498 COVID-19 - Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Program Federal Agency: U.S. Department of Health and Human Services Pass-through Agency: Not applicable Award Number / Year: N/A / 2020 Compliance Requirement: Activities Allowed and Unallowed; Reporting Criteria: Non-federal entities in receipt of federal funds must comply with the requirements of 2 CFR 200.303(a), which require an entity to establish and maintain effective internal control over the Federal award to ensure compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. Provider Relief Fund (PRF) payments must be used for allowable expenses and lost revenue described in the PRF terms and conditions and specified in guidance issued by the U.S. Department of Health and Human Services (HHS). Activities allowed have been defined as health care related expenses used to prevent, prepare for, and respond to coronavirus or lost revenues that are attributable to coronavirus. Additionally, all recipients of PRF payments must comply with the reporting requirements described in the PRF terms and conditions and specified in directions issued by HHS. Condition/Context: The Organization included expenses that did not meet the criteria of an allowable expense as defined by the HHS guidance. The Organization included $10,000 of personnel expenses associated with the facility that were not specifically used to prevent, prepare for, and respond to the coronavirus. Additionally, 2 out of 17 healthcare related expenses selected for testing were missing proof of review and approval. These 2 healthcare related expenses were for allowable expenses described in the PRF terms and conditions and specified in guidance issued by HHS. This was not a statistically valid sample. Effect: The Organization claimed expenses that were not in accordance with established HHS guidance and are therefore deemed unallowable. As a result, the amounts reported on the Schedule of Stimulus Grant Revenue of HHS Award and to the Health Resources and Services Administration (HRSA) were not in accordance with established HHS reporting guidance. Additionally, internal controls over the Federal award to ensure compliance with Federal statutes, regulations, and the terms and conditions of the Federal award were designed appropriately, but were not observed for 2 out of 17 items selected for testing. Questioned Costs: $10,000 Cause: Management misinterpreted the guidance established by the U.S. Department of Health and Human Services and claimed unallowable expenses in their reporting of qualified expenses. Additionally, management failed to follow established internal control procedures. Recommendation: We recommend that management implement procedures to ensure that the most recent guidance is reviewed and understood and that information used in accumulating allowable expenses is reviewed, with errors addressed. Procedures should be performed on a monthly basis, at a minimum, with previously recognized expenses being formally reviewed to ensure they qualify as an allowable expense under the most recent guidance. Views of Responsible Officials: The Organization agrees with the finding. The Organization had total receipts of $833,205. Total claimed expenses were $833,205; however, the Organization also had total unreimbursed expenses attributable to coronavirus of $632,725 and lost revenues in excess of total receipts.
Show full finding ▾Hide full finding ▴Finding 2021-002 ? Significant Deficiency in Internal Control - Activities Allowed and Unallowed; Reporting Assistance Listing No.: 93.498 COVID-19 - Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Program Federal Agency: U.S. Department of Health and Human Services Pass-through Agency: Not applicable Award Number / Year: N/A / 2020 Compliance Requirement: Activities Allowed and Unallowed; Reporting Criteria: Non-federal entities in receipt of federal funds must comply with the requirements of 2 CFR 200.303(a), which require an entity to establish and maintain effective internal control over the Federal award to ensure compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. Provider Relief Fund (PRF) payments must be used for allowable expenses and lost revenue described in the PRF terms and conditions and specified in guidance issued by the U.S. Department of Health and Human Services (HHS). Activities allowed have been defined as health care related expenses used to prevent, prepare for, and respond to coronavirus or lost revenues that are attributable to coronavirus. Additionally, all recipients of PRF payments must comply with the reporting requirements described in the PRF terms and conditions and specified in directions issued by HHS. Condition/Context: The Organization included expenses that did not meet the criteria of an allowable expense as defined by the HHS guidance. The Organization included $10,000 of personnel expenses associated with the facility that were not specifically used to prevent, prepare for, and respond to the coronavirus. Additionally, 2 out of 17 healthcare related expenses selected for testing were missing proof of review and approval. These 2 healthcare related expenses were for allowable expenses described in the PRF terms and conditions and specified in guidance issued by HHS. This was not a statistically valid sample. Effect: The Organization claimed expenses that were not in accordance with established HHS guidance and are therefore deemed unallowable. As a result, the amounts reported on the Schedule of Stimulus Grant Revenue of HHS Award and to the Health Resources and Services Administration (HRSA) were not in accordance with established HHS reporting guidance. Additionally, internal controls over the Federal award to ensure compliance with Federal statutes, regulations, and the terms and conditions of the Federal award were designed appropriately, but were not observed for 2 out of 17 items selected for testing. Questioned Costs: $10,000 Cause: Management misinterpreted the guidance established by the U.S. Department of Health and Human Services and claimed unallowable expenses in their reporting of qualified expenses. Additionally, management failed to follow established internal control procedures. Recommendation: We recommend that management implement procedures to ensure that the most recent guidance is reviewed and understood and that information used in accumulating allowable expenses is reviewed, with errors addressed. Procedures should be performed on a monthly basis, at a minimum, with previously recognized expenses being formally reviewed to ensure they qualify as an allowable expense under the most recent guidance. Views of Responsible Officials: The Organization agrees with the finding. The Organization had total receipts of $833,205. Total claimed expenses were $833,205; however, the Organization also had total unreimbursed expenses attributable to coronavirus of $632,725 and lost revenues in excess of total receipts.
Finding 2021-002 ? Significant Deficiency in Internal Control - Activities Allowed and Unallowed; Reporting Assistance Listing No.: 93.498 COVID-19 - Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Program Federal Agency: U.S. Department of Health and Human Services Pass-through Agency: Not applicable Award Number / Year: N/A / 2020 Compliance Requirement: Activities Allowed and Unallowed; Reporting Criteria: Non-federal entities in receipt of federal funds must comply with the requirements of 2 CFR 200.303(a), which require an entity to establish and maintain effective internal control over the Federal award to ensure compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. Provider Relief Fund (PRF) payments must be used for allowable expenses and lost revenue described in the PRF terms and conditions and specified in guidance issued by the U.S. Department of Health and Human Services (HHS). Activities allowed have been defined as health care related expenses used to prevent, prepare for, and respond to coronavirus or lost revenues that are attributable to coronavirus. Additionally, all recipients of PRF payments must comply with the reporting requirements described in the PRF terms and conditions and specified in directions issued by HHS. Condition/Context: The Organization included expenses that did not meet the criteria of an allowable expense as defined by the HHS guidance. The Organization included $10,000 of personnel expenses associated with the facility that were not specifically used to prevent, prepare for, and respond to the coronavirus. Additionally, 2 out of 17 healthcare related expenses selected for testing were missing proof of review and approval. These 2 healthcare related expenses were for allowable expenses described in the PRF terms and conditions and specified in guidance issued by HHS. This was not a statistically valid sample. Effect: The Organization claimed expenses that were not in accordance with established HHS guidance and are therefore deemed unallowable. As a result, the amounts reported on the Schedule of Stimulus Grant Revenue of HHS Award and to the Health Resources and Services Administration (HRSA) were not in accordance with established HHS reporting guidance. Additionally, internal controls over the Federal award to ensure compliance with Federal statutes, regulations, and the terms and conditions of the Federal award were designed appropriately, but were not observed for 2 out of 17 items selected for testing. Questioned Costs: $10,000 Cause: Management misinterpreted the guidance established by the U.S. Department of Health and Human Services and claimed unallowable expenses in their reporting of qualified expenses. Additionally, management failed to follow established internal control procedures. Recommendation: We recommend that management implement procedures to ensure that the most recent guidance is reviewed and understood and that information used in accumulating allowable expenses is reviewed, with errors addressed. Procedures should be performed on a monthly basis, at a minimum, with previously recognized expenses being formally reviewed to ensure they qualify as an allowable expense under the most recent guidance. Views of Responsible Officials: The Organization agrees with the finding. The Organization had total receipts of $833,205. Total claimed expenses were $833,205; however, the Organization also had total unreimbursed expenses attributable to coronavirus of $632,725 and lost revenues in excess of total receipts. Responsible Party: Jamie Spencer, Chief Financial Officer Estimated Time to Completion: December 31, 2022 Corrective Action Not Started or In Progress: Management will ensure that all HHS guidance is regularly reviewed and will confirm their understanding of changes in regulations to prevent future misinterpretations of guidance. In addition, Management will implement better internal control processes around the approval of recognized expenses to ensure that they are allowable under the most recent HRSA guidance.
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