EIN: 410694689
UEI: U6UDLQKMFJF7
Audited by: EIDE BAILLY LLP
Oversight agency: 93 [Department of Health and Human Services]
View federal awards & risk assessment →
Data as of September 2, 2026
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on June 26, 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 December 26, 2023 (983 days ago).
What is a management decision? →The Hospital District does not have an internal control system designed to provide for a complete and accurate schedule of expenditures of federal awards being audited. As auditors, we were requested to assist with the preparation of the schedule. Cause: Auditor assistance with preparation of the schedule is not unusual as the schedule has unique and specialized requirements and preparation is only required when the Hospital District meets a specified threshold of federal expenditures. Effect: There is a reasonable possibility that the Hospital District would not be able to draft a complete and accurate schedule. Questioned Costs: None reported. Context: Sampling was not used. Repeat Finding from Prior Years: Yes Recommendation: While we recognize that this condition is not unusual for an organization with limited staffing, it is important that the Hospital District is aware of this condition for financial reporting requirements relating to the Hospital District?s schedule of expenditures of federal awards and the internal controls that impact financial reporting. 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 and Period 3 TIN #410694689 Department of Health and Human Services Federal Financial Assistance Listing #93.697 COVID-19 Testing and Mitigation for Rural Health Clinics Preparation of the Schedule of Expenditures of Federal Awards Material Weakness in Internal Control over Compliance - Other Criteria: Proper controls over financial reporting include a system designed to prepare the schedule of expenditures of federal awards (the schedule) and the accompanying notes to the schedule. Condition: The Hospital District does not have an internal control system designed to provide for a complete and accurate schedule of expenditures of federal awards being audited. As auditors, we were requested to assist with the preparation of the schedule. Cause: Auditor assistance with preparation of the schedule is not unusual as the schedule has unique and specialized requirements and preparation is only required when the Hospital District meets a specified threshold of federal expenditures. Effect: There is a reasonable possibility that the Hospital District would not be able to draft a complete and accurate schedule. Questioned Costs: None reported. Context: Sampling was not used. Repeat Finding from Prior Years: Yes Recommendation: While we recognize that this condition is not unusual for an organization with limited staffing, it is important that the Hospital District is aware of this condition for financial reporting requirements relating to the Hospital District?s schedule of expenditures of federal awards and the internal controls that impact financial reporting. Views of Responsible Officials: Management agrees with the finding.
Finding 2022-003 Finding Summary: The Hospital District does not have an internal control system designed to provide for a complete and accurate schedule of expenditures of federal awards being audited. As auditors, we were requested to assist with the preparation of the schedule. Responsible Individuals: Crystal Bothun, Chief Financial Officer Corrective Action Plan: We recognize that we have limited number of staff that can properly prepare and complete the schedule of expenditures of federal awards to ensure completeness and accuracy. We have hired a Grant/Foundation Manager that is responsible for the grant process but are still training our staff on reporting requirements around the schedule of expenditures of federal awards; therefore, we have requested Eide Bailly LLP to assist with the preparation of the schedule. Anticipated Completion Date: Ongoing
2021-002
The Hospital District?s lost revenue reported within the special reports submitted to the Department of Health and Human Services for Period 2 and Period 3 TIN#410694689 is overstated. Cause: The Hospital District did not reduce the lost revenue by the amount of questioned costs identified under Period 1 TIN#410694689 which totaled $307,910. The Period 2 and Period 3 lost revenue reported was not adjusted due to management?s understanding that lost revenue was not available to be utilized on the nursing home infection control distributions. In addition, the Period 2 report was filed with the Department of Health and Human Services during March 2022 which was prior to the completion of the single audit testing relating to Period 1 completed in June 2022. Effect: The lost revenue reported within the special reports submitted to the Department of Health and Human Services for Period 2 and Period 3 TIN#410694689 is overstated. Questioned Costs: None reported. The lost revenue was not available to be utilized under the nursing home infection control distributions received in Period 2 and Period 3. Context/Sampling: Key line items including expenditures and lost revenue were tested on the Period 2 and Period 3 Department of Health and Human Services special reports. Repeat Finding from Prior Years: Yes Recommendation: All required reports have been filed to the federal agency as of the date of this report. We recommend the Hospital District retain documentation of the revised lost revenue calculation which includes the adjustment for the Period 1 identified questioned costs in their internal records. Views of Responsible Officials: Management agrees with the finding.
Show full finding ▾Hide full finding ▴2022-004 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 and 3 TIN #410694689 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. Condition: The Hospital District?s lost revenue reported within the special reports submitted to the Department of Health and Human Services for Period 2 and Period 3 TIN#410694689 is overstated. Cause: The Hospital District did not reduce the lost revenue by the amount of questioned costs identified under Period 1 TIN#410694689 which totaled $307,910. The Period 2 and Period 3 lost revenue reported was not adjusted due to management?s understanding that lost revenue was not available to be utilized on the nursing home infection control distributions. In addition, the Period 2 report was filed with the Department of Health and Human Services during March 2022 which was prior to the completion of the single audit testing relating to Period 1 completed in June 2022. Effect: The lost revenue reported within the special reports submitted to the Department of Health and Human Services for Period 2 and Period 3 TIN#410694689 is overstated. Questioned Costs: None reported. The lost revenue was not available to be utilized under the nursing home infection control distributions received in Period 2 and Period 3. Context/Sampling: Key line items including expenditures and lost revenue were tested on the Period 2 and Period 3 Department of Health and Human Services special reports. Repeat Finding from Prior Years: Yes Recommendation: All required reports have been filed to the federal agency as of the date of this report. We recommend the Hospital District retain documentation of the revised lost revenue calculation which includes the adjustment for the Period 1 identified questioned costs in their internal records. Views of Responsible Officials: Management agrees with the finding.
Finding 2022-004 Finding Summary: The Hospital District?s lost revenue reported within the special report submitted to the Department of Health and Human Services for Period 2 and Period 3 TIN#410694689 is overstated. Responsible Individuals: Crystal Bothun, Chief Financial Officer Corrective Action Plan: We did not adjust or add any additional loss revenue to Period 2 or 3 as lost revenue was not available to be utilized under the nursing home infection control distributions received during these two periods. We will retain documentation of the adjustment to lost revenue. If any additional funding is received, we will ensure reports are properly updated to notify the Department of Health and Human Services of the Period 1 adjustment. Anticipated Completion Date: Pending. No funds have been received since Period 4 (July 1, 2021 ? December 31, 2021).
2021-003
FAC accepted this audit on June 26, 2022 — management decision was due December 26, 2022.
The Johnson Memorial Health Services (the Hospital District) does not have an internal control system designed to provide for a complete and accurate schedule of federal expenditures of federal awards being audited. As auditors, we were requested to assist with the preparation of the schedule.Cause: Auditor assistance with preparation of the schedule is not unusual as the schedule has unique and specialized requirement and preparation is only required when the Hospital District meets a specified threshold of federal expenditures.Effect: There is a reasonable possibility that the Hospital District would not be able to draft a complete and accurate schedule.Questioned Costs: None reported.Context: Sampling was not used.Repeat Finding from Prior Years: NoRecommendation: While we recognize that this condition is not unusual for an organization with limited staffing, it is important that the Hospital District is aware of this condition for financial reporting requirements relating to the Hospital District?s schedule of expenditures of federal awards and the internal controls that impact financial reporting. Views of Responsible Officials: Management agrees with the finding.
Show full finding ▾Hide full finding ▴Department of Health and Human ServicesFederal Financial Assistance Listing/CFDA #93.498COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural DistributionApplicable Federal Award Number and Year ? Period 1 TIN #410694689Preparation of the Schedule of Expenditures of Federal AwardsMaterial Weakness in Internal Control over Compliance - OtherCriteria: Proper controls over financial reporting include a system designed to prepare the schedule of expenditures of federal awards (the schedule) and the accompanying notes to the schedule.Condition: The Johnson Memorial Health Services (the Hospital District) does not have an internal control system designed to provide for a complete and accurate schedule of federal expenditures of federal awards being audited. As auditors, we were requested to assist with the preparation of the schedule.Cause: Auditor assistance with preparation of the schedule is not unusual as the schedule has unique and specialized requirement and preparation is only required when the Hospital District meets a specified threshold of federal expenditures.Effect: There is a reasonable possibility that the Hospital District would not be able to draft a complete and accurate schedule.Questioned Costs: None reported.Context: Sampling was not used.Repeat Finding from Prior Years: NoRecommendation: While we recognize that this condition is not unusual for an organization with limited staffing, it is important that the Hospital District is aware of this condition for financial reporting requirements relating to the Hospital District?s schedule of expenditures of federal awards and the internal controls that impact financial reporting. 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 DistributionApplicable Federal Award Number and Year ? Period 1 TIN#410694689Federal Financial Assistance Listing # 93.498Compliance Requirement: Preparation of the Schedule of Expenditures of Federal Awards Material Weakness in Internal Control over Compliance - OtherFinding Summary: Eide Bailly LLP prepared and completed the schedule of federal expenditures of federal awards being audited to ensure completeness and accuracy of the schedule.Responsible Individuals: Crystal Bothun, Chief Financial OfficerCorrective Action Plan: Develop a Grant Award Policy and Procedure Manual around tracking and reporting of awards to ensure accurate and up-to-date communication of award requirements. This communication will include implementing additional processes to improve our internal controls over identifying and reporting of expenditures in compliance with the Schedule of Expenditures of Federal Awards (SEFA) if applicable. Train staff annually for any updates or adjustments to Federal required communications and reporting of awards. Anticipated Completion Date: 9/30/2022
The Hospital District?s lost revenue calculation and final expenditure listing identified as eligible and claimed under the Provider Relief Fund and American Rescue Plan Rural Distribution program (the program) were not reviewed and approved by a separate individual outside of the preparer. There was no documentation relating to mortgage principal and interest payments, insurance, and information technology expenses from January 2020 that supported the costs were necessary to prevent, prepare for, or respond to the coronavirus. In addition, the Hospital District claimed insurance expenses in excess of the amounts actually incurred under the program, which were included within the report submitted to the Department of Health and Human Services for Period 1.Cause: The Hospital District had multiple individuals identifying and compiling eligible costs including the calculation of lost revenue; however, the Hospital District did not have an internal control process in place to ensure a secondary review and approval of the lost revenue calculation and approval of eligible expenditures that were summarized from the underlying supporting spreadsheets to the final expenditure listing was documented. The guidance relating to allowable costs was unclear relating to general and administrative incurred in quarter 1 of 2020 prior to the start of when the Hospital District first started preparing for coronavirus. In addition, Hospital District did not document their consideration of allowability of the January 2020 expenses claimed. The Hospital District over claimed insurance expenses due to a formula error within thefinal expenditure listing. The Hospital District?s secondary review of the special report submitted to the Department of Health and Human Services for Period 1 TIN#390832914 did not identify the overclaimed expenses.Effect: Without a secondary review and approval and documentation in place to support the Hospital District?s decisions, there is a possibility that lost revenue may be miscalculated or ineligible expenditures claimed under the program and included within the special report.Questioned Costs: The Hospital District has additional lost revenue that exceeds the January 2020 expenses claimed and insurance expenses claimed incorrectly due to a clerical error. As a result, there are no questioned costs for activities allowed or unallowed and allowable costs/cost principles. Expenses included within the special report were overstated by $307,910.Context/Sampling: Summary level testing was performed over mortgage and insurance expenses. In addition, a nonstatistical sample of 60 ($444,130) out of a population greater than 250 transactions relating to general and administrative and healthcare related expenses, including personnel, fringe benefits, lease payments, supplies, equipment, information technology, and facilities ($2,190,605) were tested. Key line items were tested on the Period 1 Department of Health and Human Services special report.Repeat Finding from Prior Years: NoRecommendation: We recommend the Hospital District implement a control process which includes a secondary review and approval of the lost revenue calculation and final expenditure listing used to claim the allowable costs under the program. We recommend reducing the excess lost revenue in future reports by the expenses claimed as a result of clerical error or oversight. Views of Responsible Officials: Management agrees with the finding.
Show full finding ▾Hide full finding ▴Department of Health and Human ServicesFederal Financial Assistance Listing/CFDA #93.498COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural DistributionApplicable Federal Award Number and Year ? Period 1 TIN #410694689Activities Allowed or Unallowed and Allowable Costs/Cost PrinciplesMaterial Weakness in Internal Control over Compliance and NoncomplianceReportingMaterial Weakness in Internal Control over Compliance and Material NoncomplianceCriteria: 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 Hospital District?s lost revenue calculation and final expenditure listing identified as eligible and claimed under the Provider Relief Fund and American Rescue Plan Rural Distribution program (the program) were not reviewed and approved by a separate individual outside of the preparer. There was no documentation relating to mortgage principal and interest payments, insurance, and information technology expenses from January 2020 that supported the costs were necessary to prevent, prepare for, or respond to the coronavirus. In addition, the Hospital District claimed insurance expenses in excess of the amounts actually incurred under the program, which were included within the report submitted to the Department of Health and Human Services for Period 1.Cause: The Hospital District had multiple individuals identifying and compiling eligible costs including the calculation of lost revenue; however, the Hospital District did not have an internal control process in place to ensure a secondary review and approval of the lost revenue calculation and approval of eligible expenditures that were summarized from the underlying supporting spreadsheets to the final expenditure listing was documented. The guidance relating to allowable costs was unclear relating to general and administrative incurred in quarter 1 of 2020 prior to the start of when the Hospital District first started preparing for coronavirus. In addition, Hospital District did not document their consideration of allowability of the January 2020 expenses claimed. The Hospital District over claimed insurance expenses due to a formula error within thefinal expenditure listing. The Hospital District?s secondary review of the special report submitted to the Department of Health and Human Services for Period 1 TIN#390832914 did not identify the overclaimed expenses.Effect: Without a secondary review and approval and documentation in place to support the Hospital District?s decisions, there is a possibility that lost revenue may be miscalculated or ineligible expenditures claimed under the program and included within the special report.Questioned Costs: The Hospital District has additional lost revenue that exceeds the January 2020 expenses claimed and insurance expenses claimed incorrectly due to a clerical error. As a result, there are no questioned costs for activities allowed or unallowed and allowable costs/cost principles. Expenses included within the special report were overstated by $307,910.Context/Sampling: Summary level testing was performed over mortgage and insurance expenses. In addition, a nonstatistical sample of 60 ($444,130) out of a population greater than 250 transactions relating to general and administrative and healthcare related expenses, including personnel, fringe benefits, lease payments, supplies, equipment, information technology, and facilities ($2,190,605) were tested. Key line items were tested on the Period 1 Department of Health and Human Services special report.Repeat Finding from Prior Years: NoRecommendation: We recommend the Hospital District implement a control process which includes a secondary review and approval of the lost revenue calculation and final expenditure listing used to claim the allowable costs under the program. We recommend reducing the excess lost revenue in future reports by the expenses claimed as a result of clerical error or oversight. 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 DistributionApplicable Federal Award Number and Year ? Period 1 TIN#410694689Federal Financial Assistance Listing # 93.498Compliance Requirement: Activities Allowed or Unallowed and Allowable Costs/Cost Principles; ReportingFinding Summary: The Hospital District?s lost revenue calculation and final expenditure listing identified as eligible and claimed under the Provider Relief Fund and American Rescue Plan Rural Distribution program (the program) were not reviewed and approved by a separate individual outside of the preparer. There was no documentation relating to mortgage principal and interest payments, insurance, and information technology expenses from January 2020 that supported the costs were necessary to prevent, prepare for, or respond to the coronavirus. In addition, the Hospital District claimed insurance expenses in excess of the amounts actually incurred under the program, which were included within the report submitted to the Department of Healthand Human Services for Period 1.Responsible Individuals: Crystal Bothun, Chief Financial OfficerCorrective Action Plan: On September 24, 2021, JMHS called the Health Resources & Services Administration Provider Support hotline and inquired about eligible expenses in which JMHS received the response that any eligible expenses related to our ability to response, prepare, and plan for COVID incurred during quarter 1 of 2020 would be eligible to be claimed under the program. In addition, we will develop develop a Grant Award Policy and Procedure Manual which includes (but not limited to) outlined internal controls around the review, approval, and tracking of grant/award allowable expenses. Train staff annually for any updates or adjustments to the policy. Anticipated Completion Date: 09/30/2022
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.
Browse other Single Audit organizations in Minnesota →
Track your findings and corrective action plans across audit cycles.
Start tracking findings →Add it to a monitored group and get alerted when a new audit, finding, repeat finding, or management-decision deadline shows up — instead of checking back.
Checking several at once? Portfolio view →
© 2026 Single Audit Intelligence. All data is public domain.
