EIN: 560845824
UEI: GSA_MIGRATION
Data as of August 21, 2026
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on July 26, 2023. 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 26, 2024 (939 days ago).
What is a management decision? →During our testing, we noted that the Organization could not support the expenses reported on the submission and that the amount of lost revenues included in the submission differed from the lost revenues calculated in the supporting schedules. Questioned costs: $1,385,904 Context: During our testing, we noted that the Organization could not provide a listing of expenses that reconciled to the PRF submission. Cause: The Organization did not properly track COVID related expenses. Effect: The total amount of expenses and lost revenues reported in the PRF submission was higher than the total amount of expenses and lost revenues provided in supporting schedules. Recommendation: We recommend the organization adopt a formal policy that tracks COVID related expenses as they are incurred and that review of those COVID related expenses is performed and documented. Views of responsible officials and planned corrective actions: There is no disagreement with the audit finding. Any future funds received for special projects will be tracked as expensed in real time. These expenses will be validated and reviewed by someone independent. All funds will be managed according to the requirements of the funding source. Name of the contact person responsible for the corrective action: Susan Daniels, CFO Planned completion date for the corrective action plan: October 1, 2023
Show full finding ▾Hide full finding ▴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: ? Material Weakness 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 could not support the expenses reported on the submission and that the amount of lost revenues included in the submission differed from the lost revenues calculated in the supporting schedules. Questioned costs: $1,385,904 Context: During our testing, we noted that the Organization could not provide a listing of expenses that reconciled to the PRF submission. Cause: The Organization did not properly track COVID related expenses. Effect: The total amount of expenses and lost revenues reported in the PRF submission was higher than the total amount of expenses and lost revenues provided in supporting schedules. Recommendation: We recommend the organization adopt a formal policy that tracks COVID related expenses as they are incurred and that review of those COVID related expenses is performed and documented. Views of responsible officials and planned corrective actions: There is no disagreement with the audit finding. Any future funds received for special projects will be tracked as expensed in real time. These expenses will be validated and reviewed by someone independent. All funds will be managed according to the requirements of the funding source. Name of the contact person responsible for the corrective action: Susan Daniels, CFO Planned completion date for the corrective action plan: October 1, 2023
2021-003 Provider Relief Funding ? Assistance Listing No. 93.498 Recommendation: We recommend the organization adopt a formal policy that tracks COVID related expenses as they are incurred and that review of those COVID related expenses is performed and documented. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Any future funds received for special projects will be tracked as expensed in real time. These expenses will be validated and reviewed by someone independent. All funds will be managed according to the requirements of the funding source. Name of the contact person responsible for corrective action: Susan Daniels, CFO Planned completion date for corrective action plan: October 1, 2023
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: $679,458 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 and planned corrective actions: There is no disagreement with the audit finding. Any future funds received for special projects will be tracked as expensed in real time. These expenses will be validated and reviewed by someone independent. All funds will be managed according to the requirements of the funding source. Someone from management and independent of the preparer will review the compilation of the information required to be reported through the provider relief submission portal before the information is formally submitted. Formal documentation of that review will be maintained. Name of the contact person responsible for the corrective action: Susan Daniels, Interim CFO Planned completion date for the corrective action plan: October 1, 2023
Show full finding ▾Hide full finding ▴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: ? Material Weakness 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: $679,458 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 and planned corrective actions: There is no disagreement with the audit finding. Any future funds received for special projects will be tracked as expensed in real time. These expenses will be validated and reviewed by someone independent. All funds will be managed according to the requirements of the funding source. Someone from management and independent of the preparer will review the compilation of the information required to be reported through the provider relief submission portal before the information is formally submitted. Formal documentation of that review will be maintained. Name of the contact person responsible for the corrective action: Susan Daniels, Interim CFO Planned completion date for the corrective action plan: October 1, 2023
2021-004 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: Any future funds received for special projects will be tracked as expensed in real time. These expenses will be validated and reviewed by someone independent. All funds will be managed according to the requirements of the funding source. Someone from management and independent of the preparer will review the compilation of the information required to be reported through the provider relief submission portal before the information is formally submitted. Formal documentation of that review will be maintained. Name of the contact person responsible for corrective action: Susan Daniels, CFO Planned completion date for corrective action plan: October 1, 2023
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 and planned corrective actions: There is no disagreement with the audit finding. Any future funds received for special projects will be tracked as expensed in real time. These expenses will be validated and reviewed by someone independent. All funds will be managed according to the requirements of the funding source. Someone from management and independent of the preparer will review the compilation of the information required to be reported through the provider relief submission portal before the information is formally submitted. Formal documentation of that review will be maintained. Name of the contact person responsible for the corrective action: Susan Daniels, CFO Planned completion date for the corrective action plan: October 1, 2023
Show full finding ▾Hide full finding ▴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 and planned corrective actions: There is no disagreement with the audit finding. Any future funds received for special projects will be tracked as expensed in real time. These expenses will be validated and reviewed by someone independent. All funds will be managed according to the requirements of the funding source. Someone from management and independent of the preparer will review the compilation of the information required to be reported through the provider relief submission portal before the information is formally submitted. Formal documentation of that review will be maintained. Name of the contact person responsible for the corrective action: Susan Daniels, CFO Planned completion date for the corrective action plan: October 1, 2023
2021-005 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: Any future funds received for special projects will be tracked as expensed in real time. These expenses will be validated and reviewed by someone independent. All funds will be managed according to the requirements of the funding source. Someone from management and independent of the preparer will review the compilation of the information required to be reported through the provider relief submission portal before the information is formally submitted. Formal documentation of that review will be maintained. Name of the contact person responsible for corrective action: Susan Daniels, CFO Planned completion date for corrective action plan: October 1, 2023
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