EIN: 420921296
UEI: F1YSTY2N15F4
Audited by: Eide Bailly 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 February 8, 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 August 8, 2024 (753 days ago).
What is a management decision? →FAC accepted this audit on May 19, 2022 — management decision was due November 19, 2022.
During the process of testing claimed pandemic related healthcare expenses, it was noted that employee benefits were incorrectly assigned to contract labor and utility expenses were claimed outside the performance period. Cause: Due to the amount of detailed information that was required to be compiled by management in order to enter data into the PRF reporting portal, management had a formula error in its employee benefit calculation. The inclusion of December 2019 utilities was an oversite. Effect: Management included amounts in the PRF reporting portal which were not eligible based on the terms and conditions of the PRF distributions and subsequent HRSA guidance. Questioned Costs: Total questioned costs related to CFDA #93.498 amounted to $125,229 ($118,523 related to employee benefits assigned to contract labor and $6,777 in December 2019 utilities claimed). Context: Contract labor was claimed by the Hospital in five of the six eligible quarters. Employee benefits were erroneously calculated on all five of the reported contract labor quarters. The calculated questioned costs of $118,523 are based on all five reported contract labor quarterly amounts. The PRF and HRSA guidance states that costs incurred prior to January 1, 2020 are not eligible costs for the PRF distributions. Only one of the sampled items included in the PRF reporting portal was incurred outside the noted period. Recommendation: We recommend that management continue to monitor and enhance its internal controls over federal award compliance to ensure that only eligible costs are included in amounts expended. Views of Responsible Officials and Planned Corrective Action: Management agrees with the finding summarized above. However, management notes that additional eligible expenses were claimed during the reporting period in excess of the questioned costs identified above. As a result, had the questioned costs noted above not been included in the PRF submission, there would be no change in the amount of PRF expended by the Hospital during the reporting period.
Show full finding ▾Hide full finding ▴Finding No. 2021-001 Federal Program: CFDA #93.498 US Department of Health and Human Services COVID-19 - Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Criteria: The terms and conditions of the CARES Act Provider Relief Fund (PRF) distributions state that funds are to only be used to prevent, prepare for and respond to coronavirus, and that funds may only be used for healthcare related expenses or lost revenue that is attributable to the coronavirus. Subsequent guidance issued by the Health Resources and Services Administration (HRSA) states that recipients may use payments for eligible expenses incurred prior to the receipt of PRF distributions dating back to January 1, 2020, so long as they are to prevent, prepare for, and respond to coronavirus. Condition: During the process of testing claimed pandemic related healthcare expenses, it was noted that employee benefits were incorrectly assigned to contract labor and utility expenses were claimed outside the performance period. Cause: Due to the amount of detailed information that was required to be compiled by management in order to enter data into the PRF reporting portal, management had a formula error in its employee benefit calculation. The inclusion of December 2019 utilities was an oversite. Effect: Management included amounts in the PRF reporting portal which were not eligible based on the terms and conditions of the PRF distributions and subsequent HRSA guidance. Questioned Costs: Total questioned costs related to CFDA #93.498 amounted to $125,229 ($118,523 related to employee benefits assigned to contract labor and $6,777 in December 2019 utilities claimed). Context: Contract labor was claimed by the Hospital in five of the six eligible quarters. Employee benefits were erroneously calculated on all five of the reported contract labor quarters. The calculated questioned costs of $118,523 are based on all five reported contract labor quarterly amounts. The PRF and HRSA guidance states that costs incurred prior to January 1, 2020 are not eligible costs for the PRF distributions. Only one of the sampled items included in the PRF reporting portal was incurred outside the noted period. Recommendation: We recommend that management continue to monitor and enhance its internal controls over federal award compliance to ensure that only eligible costs are included in amounts expended. Views of Responsible Officials and Planned Corrective Action: Management agrees with the finding summarized above. However, management notes that additional eligible expenses were claimed during the reporting period in excess of the questioned costs identified above. As a result, had the questioned costs noted above not been included in the PRF submission, there would be no change in the amount of PRF expended by the Hospital during the reporting period.
Finding No. 2021-001 Criteria: The terms and conditions of the CARES Act Provider Relief Fund (PRF) distributions state that funds are to only be used to prevent, prepare for and respond to coronavirus, and that funds may only be used for healthcare related expenses or lost revenue that is attributable to the coronavirus. Subsequent guidance issued by the Health Resources and Services Administration (HRSA) states that recipients may use payments for eligible expenses incurred prior to the receipt of PRF distributions dating back to January 1, 2020, so long as they are to prevent, prepare for, and respond to coronavirus. Condition: During the process of testing claimed pandemic related healthcare expenses, it was noted that employee benefits were incorrectly assigned to contract labor and utility expenses were claimed outside the performance period. Planned Corrective Action: Management will continue to refine processes to more diligently review expenses to ensure employee benefit allocation formulas are correct and only those costs incurred during the eligibility period are included in future reporting. However, management notes that additional eligible expenses were claimed during the reporting period in excess of the questioned costs identified above. As a result, had the questioned costs noted above not been included in the PRF submission, there would be no change in the amount of PRF expended by the Hospital during the reporting period. Planned Completion Date: Ongoing Person Responsible: Abbey Stangl, CFO
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