EIN: 810304870
UEI: JDJAPEVA1HS6
Audited by: THOMAS & COMPANY CPA PA
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 August 3, 2026. 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 February 3, 2027 (157 days from today).
What is a management decision? →FAC accepted this audit on July 22, 2025 — management decision was due January 22, 2026.
Finding 2023-001: Year-End Close and Review - Condition and Criteria: Under GAAP, expenses and related liabilities should be recorded in the period in which they are incurred, regardless of when the invoice is received or paid. During our audit procedures over year-end accounts payable, we identified $416,492 in invoices related to the fiscal year ended September 30, 2023 that were not recorded until the subsequent fiscal year. This resulted in a material understatement of liabilities and fixed assets as of year-end.
Show full finding ▾Hide full finding ▴Finding 2023-001: Year-End Close and Review - Condition and Criteria: Under GAAP, expenses and related liabilities should be recorded in the period in which they are incurred, regardless of when the invoice is received or paid. During our audit procedures over year-end accounts payable, we identified $416,492 in invoices related to the fiscal year ended September 30, 2023 that were not recorded until the subsequent fiscal year. This resulted in a material understatement of liabilities and fixed assets as of year-end.
Finding 2023-001: Year-End Close and Review - Recommendation: We recommend the Organization perform a thorough year-end close and review by reviewing current balances compared to the prior year, reviewing bank reconciliations for any large outstanding items, and reviewing details of account balances, as necessary, prior to providing the trial balance for audit. Management’s Response: We agree with the recommendation and recognize the importance of a thorough year-end close and review process. Management will implement procedures to compare current year account balances to the prior year, ensure all bank reconciliations are completed and reviewed for significant outstanding items, and analyze account details as needed. These steps will be incorporated into our year-end closing checklist to help ensure the accuracy and completeness of the trial balance prior to submission for audit.
2021-001
Finding 2023-002: Federal Expenditures Reported Under Incorrect Assistance Listing Number (ALN) - Condition and Criteria: The SEFA must accurately identify all federal awards expended during the year, including the correct Assistance Listing Number (ALN) for each program. Our review of the SEFA for the year ended September 30, 2023, identified misclassifications in ALNs and reported expenditures that exceeded actual revenue received for several programs.
Show full finding ▾Hide full finding ▴Finding 2023-002: Federal Expenditures Reported Under Incorrect Assistance Listing Number (ALN) - Condition and Criteria: The SEFA must accurately identify all federal awards expended during the year, including the correct Assistance Listing Number (ALN) for each program. Our review of the SEFA for the year ended September 30, 2023, identified misclassifications in ALNs and reported expenditures that exceeded actual revenue received for several programs.
Finding 2023-002: Federal Expenditures Reported Under Incorrect Assistance Listing Number (ALN) - Recommendation: We recommend the Organization establish a formal review process for SEFA preparation to ensure expenditures are accurately reported under the correct ALNs. Management’s Response: We agree with the recommendation. Management will establish a formal review process for the preparation of the SEFA to ensure federal expenditures are accurately reported under the correct Assistance Listing Numbers (ALNs). This process will include a detailed review of grant agreements, coordination with program staff, and reconciliation to the general ledger to help ensure accuracy and compliance with federal reporting requirements.
Finding 2023-003: Overstatement of Gross Revenue and Contractual Allowances in the General Ledger - Condition and Criteria: GAAP require that revenue and related deductions such as contractual allowances be recorded accurately and supported by underlying records. During our testing of patient service revenue, we noted that both gross revenue and contractual allowances were overstated in the general ledger. Although the net patient service revenue was ultimately stated correctly, the individual components were not accurately supported by the billing or patient accounting system.
Show full finding ▾Hide full finding ▴Finding 2023-003: Overstatement of Gross Revenue and Contractual Allowances in the General Ledger - Condition and Criteria: GAAP require that revenue and related deductions such as contractual allowances be recorded accurately and supported by underlying records. During our testing of patient service revenue, we noted that both gross revenue and contractual allowances were overstated in the general ledger. Although the net patient service revenue was ultimately stated correctly, the individual components were not accurately supported by the billing or patient accounting system.
Finding 2023-003: Overstatement of Gross Revenue and Contractual Allowances in the General Ledger - Recommendation: We recommend the Organization improve its reconciliation procedures between the PSR reports, billing system, and general ledger to ensure both gross revenue and contractual allowances are accurately reported. Management’s Response: We agree with the recommendation. Management will enhance reconciliation procedures between the PSR reports, billing system, and general ledger to ensure gross revenue and contractual allowances are accurately recorded. This will include regular reconciliation schedules, improved documentation of adjustments, and coordination between finance and program staff to ensure consistency and accuracy in financial reporting.
Finding 2023-004: Late Submission of the Single Audit Reporting Package to the Federal Audit Clearinghouse - Condition and Criteria: The audit for the current year ended September 30, 2023 was not submitted to the Federal Audit Clearinghouse within the statutory deadline of the earlier of nine months after the end of the fiscal year or thirty days after the date of the auditors' report. Internal controls should be in place to provide reasonable assurance that accounting records and information pertaining to the audit process are finalized and made available to allow adequate time to complete the audit prior to the statutory deadline.
Show full finding ▾Hide full finding ▴Finding 2023-004: Late Submission of the Single Audit Reporting Package to the Federal Audit Clearinghouse - Condition and Criteria: The audit for the current year ended September 30, 2023 was not submitted to the Federal Audit Clearinghouse within the statutory deadline of the earlier of nine months after the end of the fiscal year or thirty days after the date of the auditors' report. Internal controls should be in place to provide reasonable assurance that accounting records and information pertaining to the audit process are finalized and made available to allow adequate time to complete the audit prior to the statutory deadline.
Finding 2023-004: Late Submission of the Single Audit Reporting Package to the Federal Audit Clearinghouse - Recommendation: We recommend the Organization implement procedures to ensure the accounting records and information pertaining to the audit process are finalized and made available to the auditors to allow adequate time to complete the audit prior to the statutory deadline. Management’s Response: We agree with the recommendation. Management will implement procedures to ensure accounting records and supporting documentation are finalized in a timely manner and made available to the auditors early in the audit process. This includes establishing internal deadlines for closing the books, preparing audit schedules, and coordinating with relevant departments to allow sufficient time for audit completion prior to the statutory deadline.
Finding 2023-005: Restricted Net Assets Restatement - Condition and Criteria: The Organization must maintain accurate records and internal controls to ensure that financial statements are free of material misstatement, including the proper classification of net assets. During the audit, material adjustments were required to correct restricted net assets for prior years. The adjustments were necessary due to contributions and/or grant funds that had been incorrectly classified as unrestricted rather than donor-restricted. This misstatement resulted in a material errors in previously issued financial statements.
Show full finding ▾Hide full finding ▴Finding 2023-005: Restricted Net Assets Restatement - Condition and Criteria: The Organization must maintain accurate records and internal controls to ensure that financial statements are free of material misstatement, including the proper classification of net assets. During the audit, material adjustments were required to correct restricted net assets for prior years. The adjustments were necessary due to contributions and/or grant funds that had been incorrectly classified as unrestricted rather than donor-restricted. This misstatement resulted in a material errors in previously issued financial statements.
Finding 2023-005: Restricted Net Assets Restatement - Recommendation: We recommend implementing enhanced controls to ensure all donor and grant agreements are reviewed for restrictions upon receipt and at year-end. Restricted net asset balances should be reconciled regularly to ensure accurate financial reporting. Management’s Response: We agree with the recommendation. Management will implement enhanced controls to ensure all donor and grant agreements are reviewed for restrictions both upon receipt and as part of the year-end close process. In addition, restricted net asset balances will be reviewed and reconciled on a regular basis to ensure accurate classification and financial reporting in accordance with donor intent and applicable accounting standards.
FAC accepted this audit on January 10, 2024 — management decision was due July 10, 2024.
Finding 2021-001: Year-End Close and Review Condition and Criteria: During the prior year audit, we discovered deficiencies in the internal controls over the year-end close and review process that accumulated to a material weakness. Year-end balances for accrued wages, compensated absences, accrued property taxes, and unallocated deposits required adjustments due to a number of reasons including year-end entries were entered incorrectly, balances were incorrectly calculated, or simply no year-end entry was made. In addition, cash balances contained numerous outstanding reconciling items that were required to be removed as they related to duplicative checks and deposits. Lastly, there were capital expenditures not appropriately capitalized per the Organization's policy. Recommendation: We recommend the Organization perform a thorough year-end close and review by reviewing current balances compared to the prior year, reviewing bank reconciliations for any largely outstanding items, and reviewing details of account balances, as necessary, prior to providing the trial balance for audit. errors related to the year-end close. First, beginning net assets were overstated by $61,479 related to un-posted adjustments from the prior year audit. Second, accounts payable and fixed assets were understated by $101,650 related to a construction bill that was not accrued at year-end. Third, accrued compensated absences was overstated by $62,919 related to errors in the Organization's calculation. We continue to recommend the Organization perform a thorough year-end close and review by reviewing current balances compared to the prior year, reviewing bank reconciliations for any largely outstanding items, and reviewing details of account balances, as necessary, prior to providing the trial balance for audit.
Show full finding ▾Hide full finding ▴Finding 2021-001: Year-End Close and Review Condition and Criteria: During the prior year audit, we discovered deficiencies in the internal controls over the year-end close and review process that accumulated to a material weakness. Year-end balances for accrued wages, compensated absences, accrued property taxes, and unallocated deposits required adjustments due to a number of reasons including year-end entries were entered incorrectly, balances were incorrectly calculated, or simply no year-end entry was made. In addition, cash balances contained numerous outstanding reconciling items that were required to be removed as they related to duplicative checks and deposits. Lastly, there were capital expenditures not appropriately capitalized per the Organization's policy. Recommendation: We recommend the Organization perform a thorough year-end close and review by reviewing current balances compared to the prior year, reviewing bank reconciliations for any largely outstanding items, and reviewing details of account balances, as necessary, prior to providing the trial balance for audit. errors related to the year-end close. First, beginning net assets were overstated by $61,479 related to un-posted adjustments from the prior year audit. Second, accounts payable and fixed assets were understated by $101,650 related to a construction bill that was not accrued at year-end. Third, accrued compensated absences was overstated by $62,919 related to errors in the Organization's calculation. We continue to recommend the Organization perform a thorough year-end close and review by reviewing current balances compared to the prior year, reviewing bank reconciliations for any largely outstanding items, and reviewing details of account balances, as necessary, prior to providing the trial balance for audit.
2021-001 Year-End Close and Review Recommendation: We recommend the Organization perform a thorough year-end close and review by reviewing current balances compared to the prior year, reviewing bank reconciliations for any largely outstanding items, and reviewing details of account balances, as necessary, prior to providing the trial balance for audit. Management's Response: We concur with the recommendation, and the thorough year-end close and review process will be implemented in November 2023.
2021-001
FAC accepted this audit on June 6, 2022 — management decision was due December 6, 2022.
Finding 2021-001: Year-End Close and Review Condition and Criteria: During the current year audit, we discovered deficiencies in the internal controls over the year-end close and review process that accumulated to a material weakness. Year-end balances for accrued wages, compensated absences, accrued property taxes, and unallocated deposits required adjustments due to a number of reasons including year-end entries were entered incorrectly, balances were incorrectly calculated, or simply no year-end entry was made. In addition, cash balances contained numerous outstanding reconciling items that were required to be removed as they related to duplicative checks and deposits. Lastly, there were capital expenditures not appropriately capitalized per the Organization's policy. Cause: The Organization did not perform a thorough year-end close and review of balances and corresponding account details, as necessary, prior to providing the trial balance for the audit. Effect: The effect of these deficiencies in internal controls was the net understatement of assets in the amount of $73,723, net understatement of liabilities in the amount of $51,271, and the net understatement of net assets in the amount of $22,452. The potential effect of these deficiencies is the misstatement of month-end and year-end asset, liability, and net asset balances due to an erroneous closing process. Recommendation: We recommend the Organization perform a thorough year-end close and review by reviewing current balances compared to the prior year, reviewing bank reconciliations for any largely outstanding items, and reviewing details of account balances, as necessary, prior to providing the trial balance for audit.
Show full finding ▾Hide full finding ▴Finding 2021-001: Year-End Close and Review Condition and Criteria: During the current year audit, we discovered deficiencies in the internal controls over the year-end close and review process that accumulated to a material weakness. Year-end balances for accrued wages, compensated absences, accrued property taxes, and unallocated deposits required adjustments due to a number of reasons including year-end entries were entered incorrectly, balances were incorrectly calculated, or simply no year-end entry was made. In addition, cash balances contained numerous outstanding reconciling items that were required to be removed as they related to duplicative checks and deposits. Lastly, there were capital expenditures not appropriately capitalized per the Organization's policy. Cause: The Organization did not perform a thorough year-end close and review of balances and corresponding account details, as necessary, prior to providing the trial balance for the audit. Effect: The effect of these deficiencies in internal controls was the net understatement of assets in the amount of $73,723, net understatement of liabilities in the amount of $51,271, and the net understatement of net assets in the amount of $22,452. The potential effect of these deficiencies is the misstatement of month-end and year-end asset, liability, and net asset balances due to an erroneous closing process. Recommendation: We recommend the Organization perform a thorough year-end close and review by reviewing current balances compared to the prior year, reviewing bank reconciliations for any largely outstanding items, and reviewing details of account balances, as necessary, prior to providing the trial balance for audit.
2021-001 Year-End Close and Review Recommendation: We recommend the Organization perform a thorough year-end close and review by reviewing current balances compared to the prior year, reviewing bank reconciliations for any largely outstanding items, and reviewing details of account balances, as necessary, prior to providing the trial balance for audit. Management?s Response: We concur with the recommendation, and the thorough year-end close and review process will be implemented for the year ending September 30, 2022.
Finding 2021-002: Indirect Cost Allocation Condition and Criteria: During the current year audit, we noted the allocation methodology established for shared costs and payroll costs were inconsistently followed. Indirect costs should be allocated to each federal program based on the benefit provided to that program. Cause: The Organization is not consistently applying the established methodology for shared costs and payroll costs. Effect: There is no dollar impact on the current year audit. However, the potential effect of this deficiency is increased risk that disallowed costs could be allocated to federal grants in the future. Recommendation: We recommend the Organization establish, document, and maintain an allocation methodology for indirect costs including payroll costs. Indirect costs should be allocated to each federal program based on the benefit provided.
Show full finding ▾Hide full finding ▴Finding 2021-002: Indirect Cost Allocation Condition and Criteria: During the current year audit, we noted the allocation methodology established for shared costs and payroll costs were inconsistently followed. Indirect costs should be allocated to each federal program based on the benefit provided to that program. Cause: The Organization is not consistently applying the established methodology for shared costs and payroll costs. Effect: There is no dollar impact on the current year audit. However, the potential effect of this deficiency is increased risk that disallowed costs could be allocated to federal grants in the future. Recommendation: We recommend the Organization establish, document, and maintain an allocation methodology for indirect costs including payroll costs. Indirect costs should be allocated to each federal program based on the benefit provided.
2021-002 Indirect Cost Allocation Recommendation: We recommend the Organization establish, document, and maintain an allocation methodology for indirect costs including payroll costs. Indirect costs should be allocated to each federal program based on the benefit provided. Management?s Response: We concur with the recommendation, and the methodology for indirect costs has been established, documented, and maintained during the year ended September 30, 2022.
FAC accepted this audit on June 10, 2021 — management decision was due December 10, 2021.
FAC accepted this audit on July 19, 2020 — management decision was due January 19, 2021.
FAC accepted this audit on March 17, 2019 — management decision was due September 17, 2019.
FAC accepted this audit on March 20, 2018 — management decision was due September 20, 2018.
FAC accepted this audit on March 2, 2017 — management decision was due September 2, 2017.
Data source: This information comes from the Federal Audit Clearinghouse, the official repository of Single Audit data. All data is public domain. Verify this organization's audit history at fac.gov.
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