EIN: 953154530
UEI: LJ24CFL2PTT9
Data as of August 27, 2026
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on September 10, 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 March 10, 2024 (901 days ago).
What is a management decision? →The District?s lost revenue calculation claimed under the Provider Relief Fund program and the HHS reported submitted to the Department of Health and Human Services were not reviewed and approved by a separate individual outside of the preparer. Cause: The District did not have an internal control process in place to ensure review and approval of the lost revenue calculation claimed under the federal program and the report submitted to the Department of Health and Human Services for Period 2 was documented. Effect: The lack of adequate policies governing review and approval increases the risk that employees participating in the federal award administration may not be able to detect and correct noncompliance in a timely manner. Questioned Costs: None reported. Context/Sampling: All key line items related to lost revenue were tested on the Period 2 Department of Health and Human Services special report. Repeat Finding from Prior Year: Yes, finding 2021-002 Recommendation: We recommend the District implement a control process which includes a secondary review and documented approval of the lost revenue calculation under the federal program. Views of Responsible Officials: Management agrees with the finding.
Show full finding ▾Hide full finding ▴2022-002 Department of Health and Human Services Federal Financial Assistance Listing #93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year ? Period 2 TIN #953154530 Activities Allowed or Unallowed and Allowable Costs/Cost Principles Significant Deficiency in Internal Control over Compliance Criteria: 2 CFR 200.303(a) establishes that the auditee must establish and maintain effective internal control over the federal award that provides assurance that the entity is managing the federal award in compliance with federal statutes, regulations, and conditions of the federal award. Condition: The District?s lost revenue calculation claimed under the Provider Relief Fund program and the HHS reported submitted to the Department of Health and Human Services were not reviewed and approved by a separate individual outside of the preparer. Cause: The District did not have an internal control process in place to ensure review and approval of the lost revenue calculation claimed under the federal program and the report submitted to the Department of Health and Human Services for Period 2 was documented. Effect: The lack of adequate policies governing review and approval increases the risk that employees participating in the federal award administration may not be able to detect and correct noncompliance in a timely manner. Questioned Costs: None reported. Context/Sampling: All key line items related to lost revenue were tested on the Period 2 Department of Health and Human Services special report. Repeat Finding from Prior Year: Yes, finding 2021-002 Recommendation: We recommend the District implement a control process which includes a secondary review and documented approval of the lost revenue calculation under the federal program. Views of Responsible Officials: Management agrees with the finding.
Finding 2022-002 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year ? Period 2 TIN #953154530 Federal Financial Assistance Listing #: #93.498 Finding Summary: The District?s lost revenue calculation claimed under the Provider Relief Fund program and the HHS reported submitted to the Department of Health and Human Services were not reviewed and approved by a separate individual outside of the preparer. Responsible Individuals: Melanie Van Winkle, CFO Corrective Action Plan: A policy was developed on October 14, 2022, outlining the controls to be followed for filing reports with Federal Agencies. This policy reflects the procedures needed for proper internal controls to provide assurance that the District is managing the federal award in compliance with federal statutes, regulations, and conditions of the federal award. All reporting after the creation of the policy has followed the policy. Unfortunately, this finding and policy were after the Provider Relief Fund reporting #2 was submitted. Anticipated Completion Date: Completed October 14, 2022 2
2021-002
The District incorrectly selected Option i as the reporting method when they submitted their report as the client had calculated the amount reported based on Option iii. Cause: The District did not have an internal control process in place to ensure the reporting portal input fields for the lost revenue option was incorrectly chosen as Option i rather than Option iii. Effect: Option i was incorrectly selected as the reporting method. Questioned Costs: None reported. The District had sufficient lost revenue had they correctly indicated the method they intended to use in reporting. Had the District reported the amounts under the Option i method, the lost revenue on the HHS reporting would have decreased by approximately $188,000. In addition, total unused lost revenues remaining would be approximately $11,500,000. Context/Sampling: Key line items were tested on the Period 2 Department of Health and Human Services special report. Repeat Finding from Prior Year: Yes, finding 2021-003 Recommendation: We recommend the District update future reporting to Option iii. Views of Responsible Officials: Management agrees with the finding.
Show full finding ▾Hide full finding ▴2022-003 Department of Health and Human Services Federal Financial Assistance Listing #93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year ? Period 2 TIN #953154530 Reporting Material Weakness in Internal Control over Compliance and Material Noncompliance Criteria: 2 CFR 200.303(a) establishes that the auditee must establish and maintain effective internal control over the federal award that provides assurance that the entity is managing the federal award in compliance with federal statutes, regulations, and conditions of the federal award. The District selected Option i to report lost revenue which consists of a comparison of actual results during the period of availability to the prior fiscal year. Condition: The District incorrectly selected Option i as the reporting method when they submitted their report as the client had calculated the amount reported based on Option iii. Cause: The District did not have an internal control process in place to ensure the reporting portal input fields for the lost revenue option was incorrectly chosen as Option i rather than Option iii. Effect: Option i was incorrectly selected as the reporting method. Questioned Costs: None reported. The District had sufficient lost revenue had they correctly indicated the method they intended to use in reporting. Had the District reported the amounts under the Option i method, the lost revenue on the HHS reporting would have decreased by approximately $188,000. In addition, total unused lost revenues remaining would be approximately $11,500,000. Context/Sampling: Key line items were tested on the Period 2 Department of Health and Human Services special report. Repeat Finding from Prior Year: Yes, finding 2021-003 Recommendation: We recommend the District update future reporting to Option iii. Views of Responsible Officials: Management agrees with the finding.
Finding 2022-003 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year ? Period 2 TIN #953154530 Federal Financial Assistance Listing #: #93.498 Finding Summary: The District incorrectly selected Option i as the reporting method when they submitted their report as the client had calculated the amount reported based on Option iii. Responsible Individuals: Melanie Van Winkle, CFO Corrective Action Plan: As mentioned above in Finding 2022-002 a policy was developed on October 14, 2022, and has been followed since that date. For the Provider Relief Fund reporting #4 Option iii was chosen in March 2023. Unfortunately, this finding and policy were after the Provider Relief Fund reporting #2 was submitted in March 2022. Anticipated Completion Date: The new policy was created in October 2022 and the correct selection of Option iii for PRF reporting #4 was completed in March 2023.
2021-003
FAC accepted this audit on September 29, 2022 — management decision was due March 29, 2023.
The District?s final expenditure listing identified as eligible and lost revenue calculation claimed under the Provider Relief Fund program was not reviewed and approved by a separate individual outside of the preparer. Cause: The District had multiple individuals identifying and compiling eligible costs; however, the District did not have an internal control process in place to ensure a secondary review and approval of eligible expenditures that were summarized from the underlying supporting spreadsheets to the final expenditure listing was formally documented. The summary spreadsheet was used to claim allowable costs under the federal program. The District did not have an adequate internal control policy to ensure review and approval of the lost revenue calculation claimed under the federal program was documented and done in accordance with guidance. Effect: The lack of adequate policies governing review and approval increases the risk that employees participating in the federal award administration may not be able to detect and correct noncompliance in a timely manner. Questioned Costs: None reported. Context/Sampling: A nonstatistical sample of 16 expenditures was selected for testing, which accounted for $382,992 of $1,230,591 of direct program expenditures. Repeat Finding from Prior Year: No Recommendation: We recommend the District implement a control process which includes a secondary review and documented approval of the summarized final expenditure listing used to claim the allowable costs and lost revenue calculation under the federal program. Views of Responsible Officials: Management agrees with the finding.
Show full finding ▾Hide full finding ▴Department of Health and Human Services Federal Financial Assistance Listing/CFDA #93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year ? Period 1 TIN #953154530 Activities Allowed or Unallowed and Allowable Costs/Cost Principles Significant Deficiency in Internal Control over Compliance Criteria: 2 CFR 200.303(a) establishes that the auditee must establish and maintain effective internal control over the federal award that provides assurance that the entity is managing the federal award in compliance with federal statutes, regulations, and conditions of the federal award. Condition: The District?s final expenditure listing identified as eligible and lost revenue calculation claimed under the Provider Relief Fund program was not reviewed and approved by a separate individual outside of the preparer. Cause: The District had multiple individuals identifying and compiling eligible costs; however, the District did not have an internal control process in place to ensure a secondary review and approval of eligible expenditures that were summarized from the underlying supporting spreadsheets to the final expenditure listing was formally documented. The summary spreadsheet was used to claim allowable costs under the federal program. The District did not have an adequate internal control policy to ensure review and approval of the lost revenue calculation claimed under the federal program was documented and done in accordance with guidance. Effect: The lack of adequate policies governing review and approval increases the risk that employees participating in the federal award administration may not be able to detect and correct noncompliance in a timely manner. Questioned Costs: None reported. Context/Sampling: A nonstatistical sample of 16 expenditures was selected for testing, which accounted for $382,992 of $1,230,591 of direct program expenditures. Repeat Finding from Prior Year: No Recommendation: We recommend the District implement a control process which includes a secondary review and documented approval of the summarized final expenditure listing used to claim the allowable costs and lost revenue calculation under the federal program. Views of Responsible Officials: Management agrees with the finding.
Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year ? Period 1 TIN #953154530 Federal Financial Assistance Listing #: CFDA #93.498 Finding Summary: The District?s final expenditure listing identified as eligible and lost revenue calculation claimed under the Provider Relief Fund program was not reviewed and approved by a separate individual outside of the preparer. Responsible Individuals: Melanie Van Winkle, CFO Corrective Action Plan: A policy will be developed outlining the controls to be followed for filing reports with Federal Agencies. This policy will reflect the procedures needed for proper internal controls to provide assurance that the District is managing the federal award in compliance with federal statutes, regulations, and conditions of the federal award. Anticipated Completion Date: January 31, 2023
The District incorrectly selected Option i as the reporting method when they submitted their report as the client had calculated the amount reported based on Option iii. In addition, the District?s special report submitted to the Department of Health and Human Services (HHS) for Period 1 TIN #953154530 was not reviewed and approved by a separate individual outside of the preparer. Cause: The District did not have an internal control process in place to ensure review and approval of the report submitted to the Department of Health and Human Services for Period 1 was documented. The reporting portal input fields for the lost revenue option was incorrectly chosen as Option i rather than Option iii. Effect: The lack of adequate policies governing review and approval increases the risk that employees participating in the federal award administration may not be able to detect and correct noncompliance in a timely manner. Questioned Costs: None reported. The District had sufficient lost revenue had they correctly indicated the method they intended to use in reporting. Alternatively, had the District reported the amounts under the Option i method, the lost revenue on the HHS reporting would have increased by approximately $4,000,000. Context/Sampling: Key line items were tested on the Period 1 Department of Health and Human Services special report. Repeat Finding from Prior Year: No Recommendation: We recommend the District implement a control process which includes a secondary review and documented approval of the required reports to be submitted to the federal agency. Views of Responsible Officials: Management agrees with the finding.
Show full finding ▾Hide full finding ▴Department of Health and Human Services Federal Financial Assistance Listing/CFDA #93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year ? Period 1 TIN #953154530 Reporting Material Weakness in Internal Control over Compliance and Material Noncompliance Criteria: 2 CFR 200.303(a) establishes that the auditee must establish and maintain effective internal control over the federal award that provides assurance that the entity is managing the federal award in compliance with federal statutes, regulations, and conditions of the federal award. The District selected Option i to calculate lost revenue which consists of a comparison of actual results during the period of availability to the prior fiscal year. Condition: The District incorrectly selected Option i as the reporting method when they submitted their report as the client had calculated the amount reported based on Option iii. In addition, the District?s special report submitted to the Department of Health and Human Services (HHS) for Period 1 TIN #953154530 was not reviewed and approved by a separate individual outside of the preparer. Cause: The District did not have an internal control process in place to ensure review and approval of the report submitted to the Department of Health and Human Services for Period 1 was documented. The reporting portal input fields for the lost revenue option was incorrectly chosen as Option i rather than Option iii. Effect: The lack of adequate policies governing review and approval increases the risk that employees participating in the federal award administration may not be able to detect and correct noncompliance in a timely manner. Questioned Costs: None reported. The District had sufficient lost revenue had they correctly indicated the method they intended to use in reporting. Alternatively, had the District reported the amounts under the Option i method, the lost revenue on the HHS reporting would have increased by approximately $4,000,000. Context/Sampling: Key line items were tested on the Period 1 Department of Health and Human Services special report. Repeat Finding from Prior Year: No Recommendation: We recommend the District implement a control process which includes a secondary review and documented approval of the required reports to be submitted to the federal agency. Views of Responsible Officials: Management agrees with the finding.
Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year ? Period 1 TIN #953154530 Federal Financial Assistance Listing #: CFDA #93.498 Finding Summary: The District incorrectly selected Option i as the reporting method when they submitted their report as the client had calculated the amount reported based on Option iii. In addition, the District?s special report submitted to the Department of Health and Human Services (HHS) for Period 1 TIN #953154530 was not reviewed and approved by a separate individual outside of the preparer. Responsible Individuals: Melanie Van Winkle, CFO Corrective Action Plan: Future filings for COVID-19 distributions will be changed to Option iii. In addition, A policy will be developed outlining the controls to be followed for filing reports with Federal Agencies. This policy will reflect the procedures needed for proper internal controls to provide assurance that the District is managing the federal award in compliance with federal statutes, regulations, and conditions of the federal award. Anticipated Completion Date: January 31, 2023
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