EIN: 716014562
UEI: DCYVWLHZ6CF5
Audited by: Forvis Mazars, 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 June 26, 2024. 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 26, 2024 (613 days ago).
What is a management decision? →FAC accepted this audit on September 20, 2022 — management decision was due March 20, 2023.
2021-002 COVID-19 Provider Relief Fund Assistance Listing No. 93.498 U.S. Department of Health and Human Services Criteria or Specific Requirement - Reporting (45 CFR 75.342) and Activities Allowed/Unallowed and Cost Principles (Pub. L. No. 116- 136, 134 Stat. 563 and Pub. L. No. 116-139, 134 Stat. 622 and 623). The System is required to prepare and submit period one provider relief fund report to the U.S. Department of Health and Human Services. This report is to be prepared using accurate financial information and submitted by the deadline established. The funds cannot be used for expenses reimbursed or obligated to be reimbursed by other sources. "Condition ? The System reported COVID-19-related expenditures within the HHS Provider Relief Fund (PRF) portal that did not have supporting documentation showing expenditures were related to the prevention, preparation or response to COVID-19, including allocated salaries and related fringe benefits and utility payments." Questioned Costs ? Unknown Context ? Management made certain estimates related to allowable program costs that did not have adequate underlying supporting documentation to determine correct allocation of claimed program expenditures and what portion, if any, was reimbursed by the 20% additional Medicare payment on COVID claims totaling approximately $261,000. These included a 10% estimate of time spent by certain employees on COVID related time, marginal increases in certain supply and other costs as well as utility costs. Cause ? Internal controls and review processes were not in place to ensure support was retained related to these expenditures. Identification as a Repeat Finding ? Not a repeat finding Recommendation ? Policies and procedures over federal grant reporting should be modified to ensure reports are prepared using estimates with supporting documentation retained. View of Responsible Officials and Planned Corrective Actions ? Management considers the assertion and estimates to be conservative expenditures reported to be in compliance with program regulations. Additionally, management contacted the HRSA Provider Support Line (866-869-3522) on 11/19/21 at 3:28p CST to get clarification related to utilities. Management was instructed that cost of utilities to maintain the facility to help prevent, prepare for or provide care of COVID patients should be reported which includes lighting, cooling/ventilation or related to infection control. Management agrees with the finding that additional supporting documentation should be retained. Going forward, for subsequent reporting periods related to the Provider Relief Funds management will retain more robust documentation of estimates and allocations of expenditures as required, by current guidance.
Show full finding ▾Hide full finding ▴2021-002 COVID-19 Provider Relief Fund Assistance Listing No. 93.498 U.S. Department of Health and Human Services Criteria or Specific Requirement - Reporting (45 CFR 75.342) and Activities Allowed/Unallowed and Cost Principles (Pub. L. No. 116- 136, 134 Stat. 563 and Pub. L. No. 116-139, 134 Stat. 622 and 623). The System is required to prepare and submit period one provider relief fund report to the U.S. Department of Health and Human Services. This report is to be prepared using accurate financial information and submitted by the deadline established. The funds cannot be used for expenses reimbursed or obligated to be reimbursed by other sources. "Condition ? The System reported COVID-19-related expenditures within the HHS Provider Relief Fund (PRF) portal that did not have supporting documentation showing expenditures were related to the prevention, preparation or response to COVID-19, including allocated salaries and related fringe benefits and utility payments." Questioned Costs ? Unknown Context ? Management made certain estimates related to allowable program costs that did not have adequate underlying supporting documentation to determine correct allocation of claimed program expenditures and what portion, if any, was reimbursed by the 20% additional Medicare payment on COVID claims totaling approximately $261,000. These included a 10% estimate of time spent by certain employees on COVID related time, marginal increases in certain supply and other costs as well as utility costs. Cause ? Internal controls and review processes were not in place to ensure support was retained related to these expenditures. Identification as a Repeat Finding ? Not a repeat finding Recommendation ? Policies and procedures over federal grant reporting should be modified to ensure reports are prepared using estimates with supporting documentation retained. View of Responsible Officials and Planned Corrective Actions ? Management considers the assertion and estimates to be conservative expenditures reported to be in compliance with program regulations. Additionally, management contacted the HRSA Provider Support Line (866-869-3522) on 11/19/21 at 3:28p CST to get clarification related to utilities. Management was instructed that cost of utilities to maintain the facility to help prevent, prepare for or provide care of COVID patients should be reported which includes lighting, cooling/ventilation or related to infection control. Management agrees with the finding that additional supporting documentation should be retained. Going forward, for subsequent reporting periods related to the Provider Relief Funds management will retain more robust documentation of estimates and allocations of expenditures as required, by current guidance.
Responsible Party: Roxane Stewart, CFO Finding 2021-002 Management made certain estimates related to allowable program costs that did not have adequate underlying supporting documentation to determine correct allocation of claimed program expenditures. Specifically, related to certain estimates of allowable costs including allocations of employee time spent and related fringe benefits responding to, preventing, or treatment of COVID-19 resulting in unknown questioned costs. Comments on the Finding and Recommendation Management is in agreement with this finding and the related recommendation. Action(s) Taken or Planned on the Finding Management will implement controls to ensure all reports based on time expended are supported by accurate, complete, and reviewed time-studies. Estimated completion and implementation date for the above-mentioned corrective action plan is September 30, 2022.
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