EIN: 912135195
UEI: TXE2RGFQWSB4
Audit also covers 4 related EINs: 061381994, 131740104, 141340100, 141347717 · unlinked EINs have no separate FAC filing
Audited by: Grant Thornton LLP
Oversight agency: 97 [Department of Homeland Security]
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Data as of September 2, 2026
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on September 26, 2025. 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 March 26, 2026 (165 days ago).
What is a management decision? →FAC accepted this audit on September 30, 2024 — management decision was due March 30, 2025.
FAC accepted this audit on September 11, 2024 — management decision was due March 11, 2025.
SECTION II - FINANCIAL STATEMENT FINDINGS None noted. SECTION III - FINDINGS AND QUESTIONED COSTS FOR FEDERAL AWARDS Finding 2022-001 – Uniform Guidance Reporting (Significant Deficiency) Criteria: Pursuant to 2 CFR Section 200.512(a) of the Uniform Guidance, the auditee is responsible for submitting its data collection form and reporting package, including the auditor’s reports within the earlier of 30 days after receipt of the auditor’s reports or nine months after the end of the audit period to the Federal Audit Clearinghouse. Condition, Context, Cause and Effect: The Uniform Guidance audit of BSCHS’s federal awards for the year ended December 31, 2022 was not completed within nine months following the period-end and as a result, BSCHS did not submit its Uniform Guidance audit reporting package within the required timeframe. As such, BSCHS did not comply with the aforementioned regulatory requirements. The delay in the issuance of the Uniform Guidance audit report for the year ended December 31, 2022 was due to staff turnover in BSCHS’s finance department. Recommendation: We recommend that BSCHS enhance its closing and reporting process to ensure the Uniform Guidance audit procedures will be completed by the aforementioned deadline. Views of Responsible Officials and Planned Corrective Action: Management refers the reader to the separately provided Corrective Action Plan for its remediation.
Show full finding ▾Hide full finding ▴SECTION II - FINANCIAL STATEMENT FINDINGS None noted. SECTION III - FINDINGS AND QUESTIONED COSTS FOR FEDERAL AWARDS Finding 2022-001 – Uniform Guidance Reporting (Significant Deficiency) Criteria: Pursuant to 2 CFR Section 200.512(a) of the Uniform Guidance, the auditee is responsible for submitting its data collection form and reporting package, including the auditor’s reports within the earlier of 30 days after receipt of the auditor’s reports or nine months after the end of the audit period to the Federal Audit Clearinghouse. Condition, Context, Cause and Effect: The Uniform Guidance audit of BSCHS’s federal awards for the year ended December 31, 2022 was not completed within nine months following the period-end and as a result, BSCHS did not submit its Uniform Guidance audit reporting package within the required timeframe. As such, BSCHS did not comply with the aforementioned regulatory requirements. The delay in the issuance of the Uniform Guidance audit report for the year ended December 31, 2022 was due to staff turnover in BSCHS’s finance department. Recommendation: We recommend that BSCHS enhance its closing and reporting process to ensure the Uniform Guidance audit procedures will be completed by the aforementioned deadline. Views of Responsible Officials and Planned Corrective Action: Management refers the reader to the separately provided Corrective Action Plan for its remediation.
Finding 2022-001: Uniform Guidance Reporting (Significant Deficiency) Condition and Effect: The Uniform Guidance audit of the Corporation’s federal awards for the year ended December 31, 2022 was not completed within nine months following the period-end and as a result, the Corporation did not submit its single audit reporting package within the required timeframe. As such, the Corporation did not comply with the aforementioned regulatory requirements. View of Responsible Officials and Planned Corrective Action: Due to staff turnover in 2022, we did not meet the reporting deadline. We have sufficient staffing during 2023 and are actively working to complete the 2023 Uniform Guidance audit of the Corporation’s federal awards for the year ended December 31, 2023 by the due date of September 30, 2024. Name of Contact Person: Maureen Burke, Director of Finance Maureen.Burke@wmchealth.org 845-368-5448 Proposed Completion Date: September 30, 2024
FAC accepted this audit on September 30, 2024 — management decision was due March 30, 2025.
The Provider Relief Fund General and Targeted Distribution Post-Payment Notice of Reporting Requirements dated June 11, 2021 (?HHS Reporting Guidance?), provides guidance on the applicability of other general and administrative expenses attributable to Coronavirus charged to the Provider Relief Fund. Context: BSCHS prepared a calculation of general and administrative expenses to charge to the Provider Relief Fund, based on management?s understanding of the Provider Relief Fund reporting at the time of submission, that did not include all the pertinent expenditure categories for allocation. Management of BSCHS prepared a revised calculation for which we noted no exceptions through our testing. Cause and Effect: The initial general and administrative cost allocation calculation was not prepared by management utilizing the latest HHS Reporting Guidance which caused an understatement of the expenditures reported in BSCHS?s Period 1 submission. Questioned Costs BSCHS?s revised general and administrative expense calculation based on the latest HHS Reporting Guidance supported the amount reported to through the Department of Health and Human Services PRF Reporting Portal. Therefore, there are no questioned costs identified.
Show full finding ▾Hide full finding ▴Criteria and Condition: The Provider Relief Fund General and Targeted Distribution Post-Payment Notice of Reporting Requirements dated June 11, 2021 (?HHS Reporting Guidance?), provides guidance on the applicability of other general and administrative expenses attributable to Coronavirus charged to the Provider Relief Fund. Context: BSCHS prepared a calculation of general and administrative expenses to charge to the Provider Relief Fund, based on management?s understanding of the Provider Relief Fund reporting at the time of submission, that did not include all the pertinent expenditure categories for allocation. Management of BSCHS prepared a revised calculation for which we noted no exceptions through our testing. Cause and Effect: The initial general and administrative cost allocation calculation was not prepared by management utilizing the latest HHS Reporting Guidance which caused an understatement of the expenditures reported in BSCHS?s Period 1 submission. Questioned Costs BSCHS?s revised general and administrative expense calculation based on the latest HHS Reporting Guidance supported the amount reported to through the Department of Health and Human Services PRF Reporting Portal. Therefore, there are no questioned costs identified.
Views of Responsible Officials and Planned Corrective Action Plan: BSCHS prepared the initial calculation of general and administrative expenses based on its understanding of the guidance in effect at the time of preparation. Management will check for updates to guidance and make necessary changes as appropriate.
The Provider Relief Fund General and Targeted Distribution Post-Payment Notice of Reporting Requirements dated June 11, 2021 ("HHS Reporting Guidance"), provides guidance on the applicability of other general and administrative expenses attributable to Coronavirus charged to the Provider Relief Fund. Context: BSCHS prepared a calculation of general and administrative expenses to charge to the Provider Relief Fund, based on management's understanding of the Provider Relief Fund reporting at the time of submission, that did not include all the pertinent expenditure categories for allocation. Management of BSCHS prepared a revised calculation for which we noted no exceptions through our testing. Cause and Effect: The initial general and administrative cost allocation calculation was not prepared by management utilizing the latest HHS Reporting Guidance which caused an understatement of the expenditures reported in BSCHS's Period 1 submission. Questioned Costs BSCHS's revised general and administrative expense calculation based on the latest HHS Reporting Guidance supported the amount reported to through the Department of Health and Human Services PRF Reporting Portal. Therefore, there are no questioned costs identified.
Show full finding ▾Hide full finding ▴Criteria and Condition: The Provider Relief Fund General and Targeted Distribution Post-Payment Notice of Reporting Requirements dated June 11, 2021 ("HHS Reporting Guidance"), provides guidance on the applicability of other general and administrative expenses attributable to Coronavirus charged to the Provider Relief Fund. Context: BSCHS prepared a calculation of general and administrative expenses to charge to the Provider Relief Fund, based on management's understanding of the Provider Relief Fund reporting at the time of submission, that did not include all the pertinent expenditure categories for allocation. Management of BSCHS prepared a revised calculation for which we noted no exceptions through our testing. Cause and Effect: The initial general and administrative cost allocation calculation was not prepared by management utilizing the latest HHS Reporting Guidance which caused an understatement of the expenditures reported in BSCHS's Period 1 submission. Questioned Costs BSCHS's revised general and administrative expense calculation based on the latest HHS Reporting Guidance supported the amount reported to through the Department of Health and Human Services PRF Reporting Portal. Therefore, there are no questioned costs identified.
Views of Responsible Officials and Planned Corrective Action Plan: BSCHS prepared the initial calculation of general and administrative expenses based on its understanding of the guidance in effect at the time of preparation. Management will check for updates to guidance and make necessary changes as appropriate.
FAC accepted this audit on September 29, 2022 — management decision was due March 29, 2023.
The Provider Relief Fund General and Targeted Distribution Post-Payment Notice of Reporting Requirements dated June 11, 2021 (?HHS Reporting Guidance?), provides guidance on the applicability of other general and administrative expenses attributable to Coronavirus charged to the Provider Relief Fund. Context: BSCHS prepared a calculation of general and administrative expenses to charge to the Provider Relief Fund, based on management?s understanding of the Provider Relief Fund reporting at the time of submission, that did not include all the pertinent expenditure categories for allocation. Management of BSCHS prepared a revised calculation for which we noted no exceptions through our testing. Cause and Effect: The initial general and administrative cost allocation calculation was not prepared by management utilizing the latest HHS Reporting Guidance which caused an understatement of the expenditures reported in BSCHS?s Period 1 submission. Questioned Costs BSCHS?s revised general and administrative expense calculation based on the latest HHS Reporting Guidance supported the amount reported to through the Department of Health and Human Services PRF Reporting Portal. Therefore, there are no questioned costs identified.
Show full finding ▾Hide full finding ▴Criteria and Condition: The Provider Relief Fund General and Targeted Distribution Post-Payment Notice of Reporting Requirements dated June 11, 2021 (?HHS Reporting Guidance?), provides guidance on the applicability of other general and administrative expenses attributable to Coronavirus charged to the Provider Relief Fund. Context: BSCHS prepared a calculation of general and administrative expenses to charge to the Provider Relief Fund, based on management?s understanding of the Provider Relief Fund reporting at the time of submission, that did not include all the pertinent expenditure categories for allocation. Management of BSCHS prepared a revised calculation for which we noted no exceptions through our testing. Cause and Effect: The initial general and administrative cost allocation calculation was not prepared by management utilizing the latest HHS Reporting Guidance which caused an understatement of the expenditures reported in BSCHS?s Period 1 submission. Questioned Costs BSCHS?s revised general and administrative expense calculation based on the latest HHS Reporting Guidance supported the amount reported to through the Department of Health and Human Services PRF Reporting Portal. Therefore, there are no questioned costs identified.
Views of Responsible Officials and Planned Corrective Action Plan: BSCHS prepared the initial calculation of general and administrative expenses based on its understanding of the guidance in effect at the time of preparation. Management will check for updates to guidance and make necessary changes as appropriate.
The Provider Relief Fund General and Targeted Distribution Post-Payment Notice of Reporting Requirements dated June 11, 2021 ("HHS Reporting Guidance"), provides guidance on the applicability of other general and administrative expenses attributable to Coronavirus charged to the Provider Relief Fund. Context: BSCHS prepared a calculation of general and administrative expenses to charge to the Provider Relief Fund, based on management's understanding of the Provider Relief Fund reporting at the time of submission, that did not include all the pertinent expenditure categories for allocation. Management of BSCHS prepared a revised calculation for which we noted no exceptions through our testing. Cause and Effect: The initial general and administrative cost allocation calculation was not prepared by management utilizing the latest HHS Reporting Guidance which caused an understatement of the expenditures reported in BSCHS's Period 1 submission. Questioned Costs BSCHS's revised general and administrative expense calculation based on the latest HHS Reporting Guidance supported the amount reported to through the Department of Health and Human Services PRF Reporting Portal. Therefore, there are no questioned costs identified.
Show full finding ▾Hide full finding ▴Criteria and Condition: The Provider Relief Fund General and Targeted Distribution Post-Payment Notice of Reporting Requirements dated June 11, 2021 ("HHS Reporting Guidance"), provides guidance on the applicability of other general and administrative expenses attributable to Coronavirus charged to the Provider Relief Fund. Context: BSCHS prepared a calculation of general and administrative expenses to charge to the Provider Relief Fund, based on management's understanding of the Provider Relief Fund reporting at the time of submission, that did not include all the pertinent expenditure categories for allocation. Management of BSCHS prepared a revised calculation for which we noted no exceptions through our testing. Cause and Effect: The initial general and administrative cost allocation calculation was not prepared by management utilizing the latest HHS Reporting Guidance which caused an understatement of the expenditures reported in BSCHS's Period 1 submission. Questioned Costs BSCHS's revised general and administrative expense calculation based on the latest HHS Reporting Guidance supported the amount reported to through the Department of Health and Human Services PRF Reporting Portal. Therefore, there are no questioned costs identified.
Views of Responsible Officials and Planned Corrective Action Plan: BSCHS prepared the initial calculation of general and administrative expenses based on its understanding of the guidance in effect at the time of preparation. Management will check for updates to guidance and make necessary changes as appropriate.
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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