EIN: 560554222
UEI: GSA_MIGRATION
Data as of August 27, 2026
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on June 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 December 29, 2022 (1338 days ago).
What is a management decision? →During our testing, we noted that the Organization applied the concept of incremental expenses previously included in the frequently asked questions document provided by Health Resources & Services Administration (HRSA). Due to this, a portion of the expenses were calculated using average wages and estimated time spent on COVID-19 related activities. Questioned costs: None Context: During our testing, we noted that the Organization applied the concept of incremental expenses previously included in the frequently provided by HRSA. Therefore, a portion of the expenses could not be directly supported by specific invoices or individual payroll information. Cause: The Organization was following previously published information and was not following current guidance. Effect: The information in the submission could be incorrect. Recommendation: We recommend the organization adopt a formal policy that any expenditures to be compared against source documentation to ensure appropriate recording and that current guidance is used to determine proper documentation. The review should be formally documented and performed by someone other than the preparer. 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: Provider Relief Funding Assistance Listing Number: 93.498 Award Period: October 1, 2020 through September 30, 2021 Type of Finding: ? Significant Deficiency in Internal Control over Compliance ? Other Matters Criteria or specific requirement: The Provider Relief Funds were provided under the Coronavirus Aid, Relief, and Economic Security Act (Pub. L. No. 116-136, 134 Stat. 563) and are to be used to prevent, prepare for, and respond to coronavirus and that the funds shall reimburse the recipients only for health care related expenses or lost revenues that are attributable to coronavirus. Condition: During our testing, we noted that the Organization applied the concept of incremental expenses previously included in the frequently asked questions document provided by Health Resources & Services Administration (HRSA). Due to this, a portion of the expenses were calculated using average wages and estimated time spent on COVID-19 related activities. Questioned costs: None Context: During our testing, we noted that the Organization applied the concept of incremental expenses previously included in the frequently provided by HRSA. Therefore, a portion of the expenses could not be directly supported by specific invoices or individual payroll information. Cause: The Organization was following previously published information and was not following current guidance. Effect: The information in the submission could be incorrect. Recommendation: We recommend the organization adopt a formal policy that any expenditures to be compared against source documentation to ensure appropriate recording and that current guidance is used to determine proper documentation. The review should be formally documented and performed by someone other than the preparer. Views of responsible officials: There is no disagreement with the audit finding.
Provider Relief Funding - Assistance Listing No. 93.498 Recommendation: We recommend the organization adopt a formal policy that any expenditures to be compared against source documentation to ensure appropriate recording and that current guidance is used to determine proper documentation. The review should be formally documented and performed by someone other than the preparer. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Going forward, procedures are in place to ensure that expenditures are supported through appropriate source documentation for appropriate recording of expenses. Name(s) of the contact person(s) responsible for corrective action: Elizabeth Presnell, Chief Financial Officer Planned completion date for corrective action plan: 6/30/22
There is no documented review of the detail of expenditures accumulated or review that the submission for these federal funds was reviewed by anyone other than the preparer prior to submission. Questioned costs: None Context: During our testing, it was noted that the Organization was unable to provide documentation for review of the information contained within the report, as well as, the report prior to submission. Cause: Controls were not in place to review the detail listing of expenditures or reporting submission. Effect: Information included in the submission could be incorrect with no review process in place. Recommendation: We recommend that the Organization ensure there are proper procedures in place for future submissions and that a formal review occur by someone other than the preparer and documentation of that review is maintained. 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: October 1, 2020 through September 30, 2021 Type of Finding: ? Significant Deficiency in Internal Control over Compliance ? Other Matters 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: There is no documented review of the detail of expenditures accumulated or review that the submission for these federal funds was reviewed by anyone other than the preparer prior to submission. Questioned costs: None Context: During our testing, it was noted that the Organization was unable to provide documentation for review of the information contained within the report, as well as, the report prior to submission. Cause: Controls were not in place to review the detail listing of expenditures or reporting submission. Effect: Information included in the submission could be incorrect with no review process in place. Recommendation: We recommend that the Organization ensure there are proper procedures in place for future submissions and that a formal review occur by someone other than the preparer and documentation of that review is maintained. Views of responsible officials: There is no disagreement with the audit finding.
Provider Relief Funding - Assistance Listing No. 93.498 Recommendation: We recommend that the Organization ensure there are proper procedures in place for future submissions and that a formal review occur by someone other than the preparer and documentation of that review is maintained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Going forward, proper procedures will be put into place to ensure that all submissions are formally reviewed by another party other than the preparer. Name(s) of the contact person(s) responsible for corrective action: Elizabeth Presnell, Chief Financial Officer Planned completion date for corrective action plan: 6/30/22
Lost revenue Option 1 required the comparison of the 2020 actual revenues to the 2019 actual revenues. The Organization excluded certain revenues that were present in 2020 that were not present in 2019. Questioned costs: None Context: During our testing, it was noted that the Organization did not set up the lost revenue calculation correctly under Option 1 as certain revenue was excluded. Cause: The Organization did not think it would be an issue because the revenue removed from 2020 did not exist in 2019. Effect: The lost revenue calculation in the submission was incorrectly presented under Option 1. Recommendation: We recommend that the Organization document that Option 3 was the appropriate lost revenue method to select as part its filing. The Organization should put together the required narrative of how the lost revenue calculation was set up and that the alternative method (Option 3) was used. Views of responsible officials: There is no disagreement with the audit finding.
Show full finding ▾Hide full finding ▴2021 ? 003 Federal Agency: U.S. Department of Health and Human Services Federal Program Title: Provider Relief Funding Assistance Listing Number: 93.498 Award Period: October 1, 2020 through September 30, 2021 Type of Finding: ? Significant Deficiency in Internal Control over Compliance ? Other Matters 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 1 required the comparison of the 2020 actual revenues to the 2019 actual revenues. The Organization excluded certain revenues that were present in 2020 that were not present in 2019. Questioned costs: None Context: During our testing, it was noted that the Organization did not set up the lost revenue calculation correctly under Option 1 as certain revenue was excluded. Cause: The Organization did not think it would be an issue because the revenue removed from 2020 did not exist in 2019. Effect: The lost revenue calculation in the submission was incorrectly presented under Option 1. Recommendation: We recommend that the Organization document that Option 3 was the appropriate lost revenue method to select as part its filing. The Organization should put together the required narrative of how the lost revenue calculation was set up and that the alternative method (Option 3) was used. Views of responsible officials: There is no disagreement with the audit finding.
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 its filing. The Organization should put together the required narrative of how the lost revenue calculation was set up and that the alternative method (Option 3) was used. 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. Name(s) of the contact person(s) responsible for corrective action: Elizabeth Presnell, Chief Financial Officer Planned completion date for corrective action plan: 6/30/22
The Organization is a critical access hospital and therefore are reimbursed a percentage of operating costs through the annual process of filing a cost report. The Organization did not take into consideration the amounts that will be reimbursed through the filing of the cost report. Questioned costs: Unknown Context: During our testing, it was noted that the Organization did not consider the impact of costs that will be reimbursed through the filing of the cost report. Cause: The Organization did not consider the impact. Effect: The reported expenses may be overstated. Recommendation: We recommend that the client review the expenses reported and the impact of expenses reimbursed from other sources. Views of responsible officials: There is no disagreement with the audit finding.
Show full finding ▾Hide full finding ▴2021 ? 004 Federal Agency: U.S. Department of Health and Human Services Federal Program Title: Provider Relief Funding Assistance Listing Number: 93.498 Award Period: October 1, 2020 through September 30, 2021 Type of Finding: ? Significant Deficiency in Internal Control over Compliance ? Other Matters Criteria or specific requirement: The Provider Relief Funds were provided under the Coronavirus Aid, Relief, and Economic Security Act (Pub. L. No. 116-136, 134 Stat. 563) and are to be used to prevent, prepare for, and respond to coronavirus and that the funds shall reimburse the recipients only for health care related expenses or lost revenues that are attributable to coronavirus. Condition: The Organization is a critical access hospital and therefore are reimbursed a percentage of operating costs through the annual process of filing a cost report. The Organization did not take into consideration the amounts that will be reimbursed through the filing of the cost report. Questioned costs: Unknown Context: During our testing, it was noted that the Organization did not consider the impact of costs that will be reimbursed through the filing of the cost report. Cause: The Organization did not consider the impact. Effect: The reported expenses may be overstated. Recommendation: We recommend that the client review the expenses reported and the impact of expenses reimbursed from other sources. Views of responsible officials: There is no disagreement with the audit finding.
Provider Relief Funding - Assistance Listing No. 93.498 Recommendation: We recommend that the client review the expenses reported and the impact of expenses reimbursed from other sources. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. However, Management believes that since only the incremental portion of expenses were reported, that the total expenses that could have been reported would have exceeded the amount reimbursed through the cost report process. Action taken in response to finding: Going forward, expenses will be reported after consideration of cost-based reimbursement for Medicare and Medicaid through the cost report process. Name(s) of the contact person(s) responsible for corrective action: Elizabeth Presnell, Chief Financial Officer Planned completion date for corrective action plan: 6/30/22
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