EIN: 420868216
UEI: NM7YLLHNVBL8
Data as of August 22, 2026
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on March 14, 2024. 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 September 14, 2024 (707 days ago).
What is a management decision? →The Hospital claimed expenses in the HHS special report for Period 4 that were related to services to be performed after the period of availability. Cause: The Hospital did not have an internal control process in place to ensure that all expenditures claimed met the terms and conditions of the federal award. Effect: Without an improved internal control process there is a possibility that ineligible expenditures may be claimed under the program. Questioned Costs: None over the $25,000 threshold. Context: A nonstatistical sample of 65 items ($592,145) from a total population exceeding 250 items ($1,708,935) were tested. Repeat Finding from Prior Years: No Recommendation: We recommend the Hospital enhance internal control policies to ensure that the federal expenditures meet the terms and conditions of the grant. 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 #93.498 COVID‐19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year – Period 4 TIN #420868216 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 Hospital claimed expenses in the HHS special report for Period 4 that were related to services to be performed after the period of availability. Cause: The Hospital did not have an internal control process in place to ensure that all expenditures claimed met the terms and conditions of the federal award. Effect: Without an improved internal control process there is a possibility that ineligible expenditures may be claimed under the program. Questioned Costs: None over the $25,000 threshold. Context: A nonstatistical sample of 65 items ($592,145) from a total population exceeding 250 items ($1,708,935) were tested. Repeat Finding from Prior Years: No Recommendation: We recommend the Hospital enhance internal control policies to ensure that the federal expenditures meet the terms and conditions of the grant. 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 4 TIN #420868216 Federal Financial Assistance Listing #93.498 Compliance Requirement: Activities Allowed or Unallowed and Allowable Costs/Cost Principles Finding Summary: The Hospital claimed expenses in the HHS special report for Period 4 that were related to services to be performed after the period of availability. Responsible Individuals: Craig Carstens, CFO Corrective Action Plan: Management agrees with the findings. Management will ensure that all expenses claimed are properly documented and supported by appropriate documentation, including invoices, receipts, and service agreements. Management will provide training and education to relevant staff members responsible for preparing and submitting expense claims to ensure they understand the period of availability and the importance of accurate reporting. Management will implement controls and procedures to prevent similar errors in the future. This may include implementing a review process for expense claims to ensure compliance with reporting requirements. Management will communicate the importance of accurate reporting and adherence to reporting equirements to all relevant staff members. Emphasize the impact of inaccurate reporting on the hospital's reputation and compliance status. Management will Establish a system for ongoing monitoring and oversight of expense reporting processes to identify and address any issues or discrepancies in a timely manner. Anticipated Completion Date: 2/26/2024.
There was no evidence retained that the Hospital’s special report submitted to the Department of Health and Human Services for Period 4 TIN #420868216 was reviewed or approved by an individual separate from the preparer prior to submission. Cause: The Hospital did not have an internal control process in place to ensure documented review of the report submitted to the Department of Health and Human Services for Period 4. Effect: The lack of adequate policies governing review and approval increases the risk that employees participating in the federal awards administration may not be able to detect and correct noncompliance in a timely manner. Questioned Costs: None reported. Context: Key line items were tested on the Period 4 Department of Health and Human Services special report. Repeat Finding from Prior Years: Yes Recommendation: We recommend the Hospital enhance internal control policies to ensure that formal documentation of review and approval is obtained and retained. 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 #93.498 COVID‐19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year – Period 4 TIN #420868216 Reporting 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: There was no evidence retained that the Hospital’s special report submitted to the Department of Health and Human Services for Period 4 TIN #420868216 was reviewed or approved by an individual separate from the preparer prior to submission. Cause: The Hospital did not have an internal control process in place to ensure documented review of the report submitted to the Department of Health and Human Services for Period 4. Effect: The lack of adequate policies governing review and approval increases the risk that employees participating in the federal awards administration may not be able to detect and correct noncompliance in a timely manner. Questioned Costs: None reported. Context: Key line items were tested on the Period 4 Department of Health and Human Services special report. Repeat Finding from Prior Years: Yes Recommendation: We recommend the Hospital enhance internal control policies to ensure that formal documentation of review and approval is obtained and retained. 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 4 TIN #420868216 Federal Financial Assistance Listing #93.498 Compliance Requirement: Reporting Finding Summary: There was no evidence retained that the Hospital’s special report submitted to the Department of Health and Human Services for Period 4 TIN #420868216 was reviewed or approved by an individual separate from the preparer prior to submission. Responsible Individuals: Craig Carstens, CFO Corrective Action Plan: Management agrees with this finding. Management will designate specific individuals to review HHS special report submissions before submission to HHS. Management will require documentation verifying independent review and approval prior to submission. Management will provide comprehensive training to staff on the importance of independent review processes. Management will set up automated workflow systems and checklists to enforce review procedures. Management will regularly audit the review process, gather feedback, and make necessary adjustments for enhancement. Anticipated Completion Date: 2/26/2024.
2021-005
The Hospital does not have an internal control system designed to provide for a complete and accurate Schedule being audited. We were requested to draft the Schedule and notes to 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 meets a specified threshold of federal expenditures. Effect: There is a reasonable possibility that the Hospital would not be able to draft the Schedule that is correct without the assistance of the auditors. Questioned Costs: None reported. Context: Sampling was not used. Repeat Finding from Prior Years: No Recommendation: While we recognize that this condition is not unusual for an organization with limited staffing, we recommend management be aware of the financial reporting requirements relating to the Hospital’s Schedule 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 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 4 TIN #420868216 Preparation of Schedule of Expenditures of Federal Awards Significant Deficiency in Internal Control Over Compliance – Other Criteria: Proper controls over financial reporting include the ability to prepare the Schedule of Expenditures of Federal Awards (Schedule) and accompanying notes to the Schedule. Condition: The Hospital does not have an internal control system designed to provide for a complete and accurate Schedule being audited. We were requested to draft the Schedule and notes to 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 meets a specified threshold of federal expenditures. Effect: There is a reasonable possibility that the Hospital would not be able to draft the Schedule that is correct without the assistance of the auditors. Questioned Costs: None reported. Context: Sampling was not used. Repeat Finding from Prior Years: No Recommendation: While we recognize that this condition is not unusual for an organization with limited staffing, we recommend management be aware of the financial reporting requirements relating to the Hospital’s Schedule 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 Distribution Applicable Federal Award Number and Year – Period 4 TIN #420868216 Federal Financial Assistance Listing #93.498 Compliance Requirement: Preparation of Schedule of Expenditures of Federal Awards ‐ Other Finding Summary: The Hospital does not have an internal control system designed to provide for a complete and accurate Schedule being audited. Eide Bailly, LLP, the auditors, were requested to draft the Schedule and notes to the Schedule. Responsible Individuals: Craig Carstens, CFO Corrective Action Plan: Management agrees with this finding. Management will develop and implement an internal control system tailored to ensure completeness and accuracy in auditing the Schedule. Management will clearly define the objectives of the internal control system to address gaps in auditing procedures. Management will set clear standards and protocols for auditing processes, ensuring adherence to regulatory requirements. Management will provide comprehensive training to staff involved in auditing processes to ensure they understand their roles and responsibilities. Management will conduct regular assessments and reviews of the internal control system's effectiveness and make adjustments as needed to improve accuracy and completeness. Anticipated Completion Date: 2/26/2024.
FAC accepted this audit on April 2, 2023 — management decision was due October 2, 2023.
The Hospital included expenses in the HHS special report for Period 1 that were incurred prior to when the Hospital began to prevent, prepare for, and respond to the coronavirus which caused the HHS special report to be inaccurate. Cause: The lack of adequate policies governing the determination of which costs meet the terms and conditions of the federal grant caused the report to be filed incorrectly. Effect: There were $398,755 of expenses that were reported incorrectly in the HHS special report Period 1 submitted. Questioned Costs: None reported for activities allowed or unallowed and allowable costs/cost principles as expenses that were originally reported in the Unreimbursed Expenses Attributable to Coronavirus section of the Department of Health and Human Services for Period 1 TIN #420868216 report were tested to cover the amount of unallowed expenses. Context: A nonstatistical sample of 60 items ($260,977) from a total population exceeding 250 items ($4,393,788) were tested for activities allowed or unallowed and allowable costs/cost principles. Key line items were tested on the Period 1 Department of Health and Human Services special report. Repeat Finding from Prior Years: No Recommendation: We recommend the Hospital enhance internal control policies to ensure that the support of the HHS special report meet the terms and conditions of the grant and are properly included in the reports required to be submitted to the federal agency. Views of Responsible Officials: Management agrees with the finding.
Show full finding ▾Hide full finding ▴2021-004 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 #420868216 Activities Allowed or Unallowed and Allowable Costs/Cost Principles and Reporting Material Weakness in Internal Control Over Compliance and Material Noncompliance for Reporting 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 included expenses in the HHS special report for Period 1 that were incurred prior to when the Hospital began to prevent, prepare for, and respond to the coronavirus which caused the HHS special report to be inaccurate. Cause: The lack of adequate policies governing the determination of which costs meet the terms and conditions of the federal grant caused the report to be filed incorrectly. Effect: There were $398,755 of expenses that were reported incorrectly in the HHS special report Period 1 submitted. Questioned Costs: None reported for activities allowed or unallowed and allowable costs/cost principles as expenses that were originally reported in the Unreimbursed Expenses Attributable to Coronavirus section of the Department of Health and Human Services for Period 1 TIN #420868216 report were tested to cover the amount of unallowed expenses. Context: A nonstatistical sample of 60 items ($260,977) from a total population exceeding 250 items ($4,393,788) were tested for activities allowed or unallowed and allowable costs/cost principles. Key line items were tested on the Period 1 Department of Health and Human Services special report. Repeat Finding from Prior Years: No Recommendation: We recommend the Hospital enhance internal control policies to ensure that the support of the HHS special report meet the terms and conditions of the grant and are properly included in the reports required to be submitted to the federal agency. Views of Responsible Officials: Management agrees with the finding.
Finding 2021-004 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 #420868216 Federal Financial Assistance Listing #93.498 Compliance Requirement: Activities Allowed or Unallowed and Allowable Costs/Cost Principles and Reporting Finding Summary: The Hospital included expenses in the HHS special report for Period 1 that were incurred prior to when the Hospital began to prevent, prepare for, and respond to the coronavirus which caused the HHS special report to be inaccurate. Responsible Individuals: Craig Carstens, CFO Corrective Action Plan: FCMC misunderstood the communication from HRSA on when the timeline of expenses were allowed and we mistakenly submitted for expenses starting in January. I do not believe we can amend the submission, but we have been assured we have more expenses we did not claim that would make up for this deficit. We will provide any supporting documents needed for the expenses we did not claim and moving forward we will ensure to correctly enter the appropriate data and timelines. Anticipated Completion Date: 3/31/2023
The client did not have an expenditure listing that showed all claimed expenses and how they reconciled to the report. The client did have various listings that were used to support the amounts claimed, but they were not consolidated or structured for effective review. As such, there was no evidence of formal review and approval over tracking of expenditures that were claimed for the program. In addition, there was no evidence retained that the Hospital?s special report submitted to the Department of Health and Human Services for Period 1 TIN #420868216 was reviewed or approved by an individual separate from the preparer prior to submission. Cause: The Hospital did not have an internal control process in place to ensure tracking of expenditures was done in way to allow for the documentation of review and approval of the expenditures claimed under the federal program and the report submitted to the Department of Health and Human Services for Period 1. Effect: The lack of adequate policies governing review and approval increases the risk that employees participating in the federal awards administration may not be able to detect and correct noncompliance in a timely manner. Questioned Costs: None reported. Context: A nonstatistical sample of 60 items ($260,977) from a total population exceeding 250 items ($4,393,788) were tested for activities allowed or unallowed and allowable costs/cost principles. Key line items were tested on the Period 1 Department of Health and Human Services special report. Repeat Finding from Prior Years: No Recommendation: We recommend the Hospital enhance internal control policies to ensure that formal documentation of review and approval is obtained and retained. Views of Responsible Officials: Management agrees with the finding.
Show full finding ▾Hide full finding ▴2021-005 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 #420868216 Activities Allowed or Unallowed and Allowable Costs/Cost Principles and Reporting Material Weakness 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 client did not have an expenditure listing that showed all claimed expenses and how they reconciled to the report. The client did have various listings that were used to support the amounts claimed, but they were not consolidated or structured for effective review. As such, there was no evidence of formal review and approval over tracking of expenditures that were claimed for the program. In addition, there was no evidence retained that the Hospital?s special report submitted to the Department of Health and Human Services for Period 1 TIN #420868216 was reviewed or approved by an individual separate from the preparer prior to submission. Cause: The Hospital did not have an internal control process in place to ensure tracking of expenditures was done in way to allow for the documentation of review and approval of the expenditures claimed under the federal program and the report submitted to the Department of Health and Human Services for Period 1. Effect: The lack of adequate policies governing review and approval increases the risk that employees participating in the federal awards administration may not be able to detect and correct noncompliance in a timely manner. Questioned Costs: None reported. Context: A nonstatistical sample of 60 items ($260,977) from a total population exceeding 250 items ($4,393,788) were tested for activities allowed or unallowed and allowable costs/cost principles. Key line items were tested on the Period 1 Department of Health and Human Services special report. Repeat Finding from Prior Years: No Recommendation: We recommend the Hospital enhance internal control policies to ensure that formal documentation of review and approval is obtained and retained. Views of Responsible Officials: Management agrees with the finding.
Finding 2021-005 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 #420868216 Federal Financial Assistance Listing #93.498 Compliance Requirement: Activities Allowed or Unallowed and Allowable Costs/Cost Principles and Reporting Finding Summary: The Hospital did not have an expenditure listing that showed all claimed expenses and how they reconciled to the report. The Hospital did have various listings that were used to support the amounts claimed, but they were not consolidated or structured for effective review. As such, there was no evidence of formal review and approval over tracking of expenditures that were claimed for the program. In addition, there was no evidence retained that the Hospital?s special report submitted to the Department of Health and Human Services for Period 1 TIN #420868216 was reviewed or approved by an individual separate from the preparer prior to submission. Responsible Individuals: Craig Carstens, CFO Corrective Action Plan: Going forward there will be an organized review process set in place for any other federal rewards FCMC may receive. The process will start with the accounting team putting together any expenses we may claim in a data base built in excel using tables and a review session will take place with the CFO to ensure the expenses are reasonable and have supporting documentation to support. Anticipated Completion Date: 3/31/2023
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