EIN: 880198997
UEI: GSA_MIGRATION
Audited by: WIPFLI 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 December 16, 2021. 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 June 16, 2022 (1537 days ago).
What is a management decision? →The Organization did not meet its requirements to use the funds to prevent, prepare for, and respond to coronavirus and that the payment shall reimburse the recipient only for health care related expenses or lost revenues that are attributable to coronavirus. During the audit, it was determined that for 2 of 40 payroll expenditures tested a portion was not an allowable COVID expense under the Department of Health and Human Services guidelines for the use of Provider Relief Funds. The total amount of nonallowable costs was $2,746. Criteria: 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 recipient only for health care related expenses or lost revenues that are attributable to coronavirus. Cause: Management oversight. Effect: The Organization is not in compliance with federal regulations and guidelines surrounding the use of the Provider Relief Funds. Recommendation: We recommend that management review all payroll expenditures for allowability under the criteria provided by the U.S. Department of Health and Human Services. However, it was noted that the Hospital has enough excess lost revenue to cover the disbursements noted above and retain the grant funding. View of Responsible Official: Management will review all payroll expenditures to determine allowability under the specific grant?s rules and regulations.
Show full finding ▾Hide full finding ▴Finding 2021.006 Program Name: Provider Relief Fund Federal Assistance Listing Number: 93.498 Federal Agency: U.S. Department of Health and Human Services Type of Finding: Noncompliance, Significant Deficiency Compliance Requirement: Allowable Costs Condition: The Organization did not meet its requirements to use the funds to prevent, prepare for, and respond to coronavirus and that the payment shall reimburse the recipient only for health care related expenses or lost revenues that are attributable to coronavirus. During the audit, it was determined that for 2 of 40 payroll expenditures tested a portion was not an allowable COVID expense under the Department of Health and Human Services guidelines for the use of Provider Relief Funds. The total amount of nonallowable costs was $2,746. Criteria: 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 recipient only for health care related expenses or lost revenues that are attributable to coronavirus. Cause: Management oversight. Effect: The Organization is not in compliance with federal regulations and guidelines surrounding the use of the Provider Relief Funds. Recommendation: We recommend that management review all payroll expenditures for allowability under the criteria provided by the U.S. Department of Health and Human Services. However, it was noted that the Hospital has enough excess lost revenue to cover the disbursements noted above and retain the grant funding. View of Responsible Official: Management will review all payroll expenditures to determine allowability under the specific grant?s rules and regulations.
Finding # 2021.001 Internal Control Over Preparation of the Financial Statements Response Management believes that committing the resources necessary to perform a review of the footnote disclosures for completeness would be a duplication of expenditures, since this is part of the cost of the audit engagement. In addition, the administrator and controller review the internal financials on a monthly basis and present to the results to the Board of Trustees. Responsible Party Melissa Rowe, Administrator/CEO Estimated Completion June 30, 2022 Finding # 2021.002 Significant Adjustments Response Management relies on Wipfli to prepare the annual cost report and adjust for the annual fiscal year settlement estimates. Management will implement a process to ensure that accounts are reconciled on a monthly basis and all activity is accounted for in the general ledger. Responsible Party Melissa Rowe, Administrator/CEO Estimated Completion June 30, 2022 Finding # 2021.003 Controls Within the Accounting Department Response Considering the size of our facility and financial status, management believes that the current segregation of duties is sufficient to protect the facility from significant errors or fraudulent transactions. Responsible Party Melissa Rowe, Administrator/CEO Estimated Completion June 30, 2022 Finding # 2021.004 Controls Within the Business Office Response Considering the size of our facility and financial status, management believes that the current segregation of duties is sufficient to protect the facility from significant errors or fraudulent transactions. Responsible Party Melissa Rowe, Administrator/CEO Estimated Completion June 30, 2022 Finding # 2021.005 Violation of Statute Response Management will implement procedures to monitor and comply with the NRS to ensure they do not expend operating and nonoperating expenses in excess of budgeted appropriations. Responsible Party Melissa Rowe, Administrator/CEO Estimated Completion June 30, 2022 Finding # 2021.006 Allowable Costs Response Management will review all payroll expenditures to determine allowability under the specific grant rules and regulations. Responsible Party Melissa Rowe, Administrator/CEO Estimated Completion June 30, 2022
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