EIN: 450226472
UEI: GT6BQCALMK18
Data as of August 22, 2026
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on October 1, 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 April 1, 2024 (874 days ago).
What is a management decision? →The Health Center does not have an internal control system designed to allow for a complete and accurate Schedule. We were requested to draft 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 Health Center meets a specified threshold of federal expenditures. Effect: There is a reasonable possibility the Health Center would not be able to draft a Schedule that is correct without assistance of the auditors. 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, we recommend that management be aware of the financial reporting requirements relating to the Health Center?s schedule of expenditures of federal awards and 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 Agriculture Federal Financial Assistance Listing #10.766 Community Facilities Loans and Grants Cluster Department of Health and Human Services Federal Financial Assistance Listing #93.155 Rural Health Research Centers Preparation of Schedule of Expenditures of Federal Awards Material Weakness 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 Health Center does not have an internal control system designed to allow for a complete and accurate Schedule. We were requested to draft 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 Health Center meets a specified threshold of federal expenditures. Effect: There is a reasonable possibility the Health Center would not be able to draft a Schedule that is correct without assistance of the auditors. 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, we recommend that management be aware of the financial reporting requirements relating to the Health Center?s schedule of expenditures of federal awards and internal controls that impact financial reporting. Views of Responsible Officials: Management agrees with the finding.
Finding 2022-003 Federal Agency Name: Department of Agriculture Department of Health and Human Services Program Name: Community Facilities Loans and Grants Cluster Federal Financial Assistance Listing #10.766 Rural Health Research Centers Federal Financial Assistance Listing #93.155 Finding Summary: Eide Bailly LLP prepared our schedule of expenditures of federal awards (Schedule) and accompanying notes to the Schedule. Responsible Individuals: Pete Antonson, CFO Corrective Action Plan: Having auditors assist with preparing the schedule of expenditures of federal awards (SEFA) is not unusual. We will continue to be aware of the financial reporting requirements relating to the Health Center?s schedule of expenditures of federal awards and internal control that impact financial reporting. Anticipated Completion Date: Ongoing
2021-003
During our testing, there was no formal documented review over the reserve fund reconciliation for the federal program. Cause: The Health Center did not have an adequate internal control policy in place to ensure review and approval over the reserve fund was maintained. Effect: The lack of adequate policies governing the review and approval of the reserve fund 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 was not used. The Health Center has one reserve account that was tested. Repeat Finding From Prior Years: No Recommendation: We recommend that the Health Center enhance internal control policies to ensure that formal documentation of reviews are present. Views of Responsible Officials: Management agrees with the finding.
Show full finding ▾Hide full finding ▴2022-004 Department of Agriculture Federal Financial Assistance Listing #10.766 Community Facilities Loans and Grants Cluster Special Tests and Provisions 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: During our testing, there was no formal documented review over the reserve fund reconciliation for the federal program. Cause: The Health Center did not have an adequate internal control policy in place to ensure review and approval over the reserve fund was maintained. Effect: The lack of adequate policies governing the review and approval of the reserve fund 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 was not used. The Health Center has one reserve account that was tested. Repeat Finding From Prior Years: No Recommendation: We recommend that the Health Center enhance internal control policies to ensure that formal documentation of reviews are present. Views of Responsible Officials: Management agrees with the finding.
Finding 2022-004 Federal Agency Name: Community Facilities Loans and Grants Cluster Federal Financial Assistance Listing #10.766 Finding Summary: There was no informal documented review over the reserve fund reconciliation for the federal program. Responsible Individuals: Pete Antonson, CFO Corrective Action Plan: We have adopted a policy to enhance internal control to ensure the reserve fund reconciliation has a secondary review and approval that is documented. Anticipated Completion Date: October 30, 2023
FAC accepted this audit on September 29, 2022 — management decision was due March 29, 2023.
The Health Center does not have an internal control system designed to allow for a complete and accurate Schedule being audited. We were requested to draft 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 Health Center meets a specified threshold of federal expenditures. Effect: There is a reasonable possibility the Health Center would not be able to draft a Schedule that is correct without 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 that management be aware of the financial reporting requirements relating to the Health Center?s schedule of expenditures of federal awards and internal controls that impact financial reporting. Views of Responsible Officials: Management agrees with the finding.
Show full finding ▾Hide full finding ▴2021-003 Department of Health and Human Services Federal Financial Assistance Listing/CFDA #93.498 COVID-19 Provider Relief Fund (PRF) and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year - Period 1 and 2 - TIN #450226472 Preparation of Schedule of Expenditures of Federal Awards Material Weakness 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 Health Center does not have an internal control system designed to allow for a complete and accurate Schedule being audited. We were requested to draft 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 Health Center meets a specified threshold of federal expenditures. Effect: There is a reasonable possibility the Health Center would not be able to draft a Schedule that is correct without 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 that management be aware of the financial reporting requirements relating to the Health Center?s schedule of expenditures of federal awards and internal controls that impact financial reporting. Views of Responsible Officials: Management agrees with the finding.
Finding 2021-003 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Rural Distribution Federal Assistance Listing/CFDA #93.498 Finding Summary: Eide Bailly LLP prepared our schedule of expenditures of federal awards (Schedule) and accompanying notes to the Schedule. Responsible Individuals: Pete Antonson, CEO Corrective Action Plan: Having auditors assist with preparing the schedule of expenditures of federal awards (SEFA) is not unusual. We will continue to be aware of the financial reporting requirements relating to the Health Center?s schedule of expenditures of federal awards and internal control that impact financial reporting. Anticipated Completion Date: Ongoing
The Health Center had several invoices identified as eligible under the Provider Relief Funds that were not reviewed and approved. In addition, the Health Center did not have a control policy in place to obtain formal documentation of the secondary review and approval for the final expenditure listing, lost revenue calculation identified as eligible and claimed under the Provider Relief Fund program, and special report submitted to the Department of Health and Human Services for Periods 1 and 2. Cause: The Health Center did not have an adequate internal control policy in place to ensure review and approval over specifically identified invoices, the final expenditure listing, the lost revenue calculation, or preparation of HHS Periods 1 and 2 reporting were documented. Effect: The lack of adequate policies governing the review and approval of invoices, expenditure listing, lost revenue calculation, and the HHS Period 1 and 2 reports increases the risk that employees participating in the federal award administration may not be able to detect and correct noncompliance in a timely manner. Without a secondary review and approval, there is a possibility that ineligible expenditures may be claimed under the program. Questioned Costs: None reported. Context: Detail testing was completed over $497,357 of the expenses and summary level testing was completed over $109,156 of the expenses along with the calculation for lost revenue for activities allowed and unallowable cost/cost principles. A nonstatistical sample of 11 expenditures were selected for detailed testing, 8 of the expenditures did not have evidence of being reviewed and approved. The overall expense worksheet and lost revenue worksheet did not have evidence of a review by someone other than the preparer (i.e. population of two). The Reports submitted to HHS also did not have a documented secondary review and approval (i.e., population of two). Repeat Finding From Prior Years: No Recommendation: We recommend that the Health Center enhance internal control policies to ensure all invoices are reviewed and approved to ensure all expenses claimed under the federal program are necessary, correct, and meet the requirements of the federal program. We also recommend the Health Center implement a control process which includes a secondary review and approval of the final expenditure listing and lost revenue calculation used to claim the allowable costs under the federal program and that there is documented evidence of the review and approval. In addition, the Reports submitted to HHS should have a secondary review and approval that is documented. 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 (PRF) and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year - Period 1 and 2 - TIN #450226472 Activities Allowed or Unallowed, Allowable Costs/Costs 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 Health Center had several invoices identified as eligible under the Provider Relief Funds that were not reviewed and approved. In addition, the Health Center did not have a control policy in place to obtain formal documentation of the secondary review and approval for the final expenditure listing, lost revenue calculation identified as eligible and claimed under the Provider Relief Fund program, and special report submitted to the Department of Health and Human Services for Periods 1 and 2. Cause: The Health Center did not have an adequate internal control policy in place to ensure review and approval over specifically identified invoices, the final expenditure listing, the lost revenue calculation, or preparation of HHS Periods 1 and 2 reporting were documented. Effect: The lack of adequate policies governing the review and approval of invoices, expenditure listing, lost revenue calculation, and the HHS Period 1 and 2 reports increases the risk that employees participating in the federal award administration may not be able to detect and correct noncompliance in a timely manner. Without a secondary review and approval, there is a possibility that ineligible expenditures may be claimed under the program. Questioned Costs: None reported. Context: Detail testing was completed over $497,357 of the expenses and summary level testing was completed over $109,156 of the expenses along with the calculation for lost revenue for activities allowed and unallowable cost/cost principles. A nonstatistical sample of 11 expenditures were selected for detailed testing, 8 of the expenditures did not have evidence of being reviewed and approved. The overall expense worksheet and lost revenue worksheet did not have evidence of a review by someone other than the preparer (i.e. population of two). The Reports submitted to HHS also did not have a documented secondary review and approval (i.e., population of two). Repeat Finding From Prior Years: No Recommendation: We recommend that the Health Center enhance internal control policies to ensure all invoices are reviewed and approved to ensure all expenses claimed under the federal program are necessary, correct, and meet the requirements of the federal program. We also recommend the Health Center implement a control process which includes a secondary review and approval of the final expenditure listing and lost revenue calculation used to claim the allowable costs under the federal program and that there is documented evidence of the review and approval. In addition, the Reports submitted to HHS should have a secondary review and approval that is documented. 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 Rural Distribution Federal Assistance Listing/CFDA #93.498 Finding Summary: There were several invoices identified as eligible that were not reviewed and approved. In addition, the Health Center's final expenditure listing, lost revenue calculation identified as eligible and claimed under the Provider Relief fund program, and special report submitted to the Department of Health and Human Services for Period 1 and 2 did not have evidence of being reviewed and approved by a separate individual outside of the preparer. Responsible Individuals: Pete Antonson, CEO Corrective Action Plan: An internal control policy will be adopted to mandate all invoices are reviewed and approved to ensure all expenses claimed under the federal program are necessary, correct, and meet the requirements of the federal program. Furthermore, we will also implement a documented control process which includes a secondary review and approval of the final expenditure listing and lost revenue calculation, if applicable, used to claim the allowable costs under the federal program. In addition, any special Reports submitted to HHS will have a secondary review and approval that is documented. Anticipated Completion Date: 11/30/2022
The Health Center selected lost revenue calculation option ii which is budget to actual methodology of calculating lost revenue attributable to coronavirus. Cause: The Health Center did not incorporate the contractual adjustments and bad debt expense into the actual revenue amounts reported within the HHS special reports for the fiscal year 2020 and 2021. Effect: The contractual adjustments and bad debt expenses would have reduced patient service revenue by $125,239 for fiscal year 2020 and by $1,392,307 for fiscal year 2021. Overall, the effect on lost revenue after applying these quarterly to the applicable quarters resulting in the Health Center under reporting their lost revenue. These errors noted indicate there is lack of adequate policies governing the review and approval of the lost revenue calculation and the HHS Period 1 and 2 reports. Without a secondary review and approval, there is a possibility that these errors occur. Questioned Costs: None reported. Context: The lost revenue calculation did not incorporate the contractual adjustments and bad debt expense for the fiscal years 2020 and 2021. After incorporating these adjustments over the applicable quarters, the Health Center ultimately had under reported net patient service revenue by $1,517,546. Repeat Finding From Prior Years: No Recommendation: We recommend that the Health Center enhance internal control policies to ensure the lost revenue calculation is supported by internal financials. This would include implementing a secondary review and approval over the final lost revenue calculation. 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 (PRF) and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year - Period 1 and 2 - TIN #450226472 Activities Allowed or Unallowed and Allowable Costs/Costs Principles 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 Health Center selected lost revenue calculation option ii which is budget to actual methodology of calculating lost revenue attributable to coronavirus. Cause: The Health Center did not incorporate the contractual adjustments and bad debt expense into the actual revenue amounts reported within the HHS special reports for the fiscal year 2020 and 2021. Effect: The contractual adjustments and bad debt expenses would have reduced patient service revenue by $125,239 for fiscal year 2020 and by $1,392,307 for fiscal year 2021. Overall, the effect on lost revenue after applying these quarterly to the applicable quarters resulting in the Health Center under reporting their lost revenue. These errors noted indicate there is lack of adequate policies governing the review and approval of the lost revenue calculation and the HHS Period 1 and 2 reports. Without a secondary review and approval, there is a possibility that these errors occur. Questioned Costs: None reported. Context: The lost revenue calculation did not incorporate the contractual adjustments and bad debt expense for the fiscal years 2020 and 2021. After incorporating these adjustments over the applicable quarters, the Health Center ultimately had under reported net patient service revenue by $1,517,546. Repeat Finding From Prior Years: No Recommendation: We recommend that the Health Center enhance internal control policies to ensure the lost revenue calculation is supported by internal financials. This would include implementing a secondary review and approval over the final lost revenue calculation. 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 Rural Distribution Federal Assistance Listing/CFDA #93.498 Finding Summary: The Health Center selected lost revenue calculation option ii which is budget to actual methodology of calculating lost revenue attributable to coronavirus. Responsible Individuals: Pete Antonson, CEO Corrective Action Plan: We will be implementing an internal control policy (referenced in Corrective Action Plan for Finding 2021-004) that will ensure a second check and approval to catch incorrect calculations. Furthermore, the incorrect gross patient revenues from Ql 2020 to Q2 2021 have been updated with net the correct net patient revenues for Reporting Period 3. Q3 2021 to Q2 2022 actual figures are net patient revenues. All figures are supported by approved budgets and audited financial statements that were uploaded as supporting documents with Report 3. By correcting the gross patient revenue to net patient revenue figures in reporting Period 3, we feel this finding has been corrected since the lost revenue was understated. Anticipated Completion Date: 09/30/2022
The Health Center claimed lost revenues that were incorrectly supported. These were improperly included within the Reports and caused the Reports to be inaccurate. Cause: The Health Center claimed lost revenue under Option ii and did have an approved budget prior to March 27, 2020 for fiscal year 2020, but the approved budget did not cover the entire period of availability. Effect: The lack of adequate policies over the Report preparation and submission increases the risk that employees participating in the federal award administration may not be able to detect and correct noncompliance in a timely manner. This resulted in $511,562 of lost revenue that was reported in periods which did not have an approved budget prior to March 27, 2020. Questioned Costs: None reported. Context: The Report section, Lost Revenues, included lost revenue calculations that were not supported by an approved budget for the entire period of availability. Repeat Finding From Prior Years: No Recommendation: We recommend that the Health Center enhance internal control policies to ensure the appropriate lost revenue methodology is utilized. We also recommend that the Health Center enhance internal control policies to ensure that the required reports are properly reviewed prior to submission to ensure all key line items are necessary, correct, meet the requirements of the federal program and are properly recorded 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 ▴2021-006 Department of Health and Human Services Federal Financial Assistance Listing/CFDA #93.498 COVID-19 Provider Relief Fund (PRF) and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year - Period 1 and 2 - TIN #450226472 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 Health Center claimed lost revenues that were incorrectly supported. These were improperly included within the Reports and caused the Reports to be inaccurate. Cause: The Health Center claimed lost revenue under Option ii and did have an approved budget prior to March 27, 2020 for fiscal year 2020, but the approved budget did not cover the entire period of availability. Effect: The lack of adequate policies over the Report preparation and submission increases the risk that employees participating in the federal award administration may not be able to detect and correct noncompliance in a timely manner. This resulted in $511,562 of lost revenue that was reported in periods which did not have an approved budget prior to March 27, 2020. Questioned Costs: None reported. Context: The Report section, Lost Revenues, included lost revenue calculations that were not supported by an approved budget for the entire period of availability. Repeat Finding From Prior Years: No Recommendation: We recommend that the Health Center enhance internal control policies to ensure the appropriate lost revenue methodology is utilized. We also recommend that the Health Center enhance internal control policies to ensure that the required reports are properly reviewed prior to submission to ensure all key line items are necessary, correct, meet the requirements of the federal program and are properly recorded in the Reports required to be submitted to the federal agency. Views of Responsible Officials: Management agrees with the finding.
Finding 2021-006 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Rural Distribution Federal Assistance Listing/CFDA #93.498 Finding Summary: The Health Center claimed lost revenues that were incorrectly supported in the amount of $511,562. These were improperly included within the Report and caused the Report to be inaccurate. Responsible Individuals: Pete Antonson, CEO Corrective Action Plan: We will be implementing an internal control policy (referenced in Corrective Action Plan for Finding 2021-004) that will ensure a second check and approval to catch incorrect calculations. Furthermore, the lost revenue has been changed to option iii for Reporting Period 3. A memo has been uploaded with Reporting Period 3 explaining the error in lost revenue calculation in prior reports. By changing to the correct option iii, lost revenue figures are supported by comparing 2020/21/22 approved budgets to 2020/21/22 actual net patient revenue. Reporting Period 3 contains the correct lost revenue figures from Q1 2020 to Q2 2022. By filing the correct figures in Reporting Period 3 and justifying the previously unsupported amount of $511,562 we feel this finding has been corrected. Anticipated Completion Date: 09/30/2022
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