EIN: 730929722
UEI: XST3FQVSC7B6
Audited by: Eide Bailly LLP
Oversight agency: 93 [Department of Health and Human Services]
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Data as of September 2, 2026
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on March 18, 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 18, 2024 (717 days ago).
What is a management decision? →The total lost revenues included on the report submitted to the Health Resources and Services Administration (HRSA) for Period 1 (Period 1 Report) utilizing Option 1, as defined by HRSA, contained errors. Accordingly, the exclusion of clinic revenue and the exclusion of the cost report estimate adjustment in the lost revenue calculation spreadsheet were not identified by management. Cause: The Hospital did not have an internal control process in place to ensure the calculation of lost revenues was reviewed and approved. Accordingly, the errors in the lost revenue calculation spreadsheet were not identified by management. In addition, the Hospital did not have an internal control process in place to ensure a review and approval of the Period 1 Report was performed by someone other than the preparer of the report. Effect: The lost revenue reported to HRSA for Period 1 was understated. Questioned Costs: None. The Hospital’s lost revenues for Period 1 were understated. Context: All 10 line items associated with the Option 1 lost revenue calculation were tested. There were errors noted in all line items tested. The lost revenues included on the Period 1 Report totaled $2,917,668 but should have been $3,377,089 for a difference of $459,421. Repeat Finding from Prior Years: No Recommendation: We recommend the Hospital implement a control process which includes a documented secondary review and approval of required reports to be submitted to the federal agency prior to submission. The Hospital’s processes should also be amended to ensure the lost revenue calculation not only agrees with system generated reports but is accurately calculated and has a documented secondary review and approval. Views of Responsible Officials: Management agrees with the finding
Show full finding ▾Hide full finding ▴Department of Health and Human Services Federal Assistance Listing/CFDA #93.498 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year – Period 1 TIN #730929722 Activities Allowed or Unallowed, Allowable Costs/Cost Principles, and Reporting Material Weakness in Internal Control Over Compliance and 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 total lost revenues included on the report submitted to the Health Resources and Services Administration (HRSA) for Period 1 (Period 1 Report) utilizing Option 1, as defined by HRSA, contained errors. Accordingly, the exclusion of clinic revenue and the exclusion of the cost report estimate adjustment in the lost revenue calculation spreadsheet were not identified by management. Cause: The Hospital did not have an internal control process in place to ensure the calculation of lost revenues was reviewed and approved. Accordingly, the errors in the lost revenue calculation spreadsheet were not identified by management. In addition, the Hospital did not have an internal control process in place to ensure a review and approval of the Period 1 Report was performed by someone other than the preparer of the report. Effect: The lost revenue reported to HRSA for Period 1 was understated. Questioned Costs: None. The Hospital’s lost revenues for Period 1 were understated. Context: All 10 line items associated with the Option 1 lost revenue calculation were tested. There were errors noted in all line items tested. The lost revenues included on the Period 1 Report totaled $2,917,668 but should have been $3,377,089 for a difference of $459,421. Repeat Finding from Prior Years: No Recommendation: We recommend the Hospital implement a control process which includes a documented secondary review and approval of required reports to be submitted to the federal agency prior to submission. The Hospital’s processes should also be amended to ensure the lost revenue calculation not only agrees with system generated reports but is accurately calculated and has a documented secondary review and approval. Views of Responsible Officials: Management agrees with the finding
Finding 2021-005 Federal Agency Name: Department of Health and Human Services Program Name: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution CFDA # 93.498 Finding Summary: The Hospital did not have an internal control process in place to ensure the calculation of lost revenues was reviewed and approved. Accordingly, the errors in the lost revenue calculation spreadsheet were not identified by management. In addition, the Hospital did not have an internal control process in place to ensure a review and approval of the Period 1 Report was performed by someone other than the preparer of the report. Responsible Individuals: Scott Callender Corrective Action Plan : The Hospital will implement a control process which includes a documented secondary review and approval of required reports to be submitted to the federal agency prior to submission. Anticipated Completion Date: Ongoing
The Hospital claimed expenditures that were not incurred during the reporting period. These expenditures were identified as unallowed on the Hospital’s schedule of expenditures, but inadvertently included in the amounts ultimately reported on the Period 1 report to HHS. Cause: The Hospital did not have an adequate internal control process in place to ensure expenditures claimed were being in the proper period. The Hospital also did not have a control to ensure the reporting was reviewed and approved by someone other than the preparer. Effect: The Hospital claimed and reported expenditures in the incorrect reporting period. Questioned Costs: None. While there were $240,637 of expenditures considered to be reported in the incorrect reporting period, the Hospital had excess lost revenues of $268,046 and additional underreported lost revenues of $459,421, which covers the error. Context: We sampled 60 of 382 expenditure transactions. We noted five selections resulting in a specific error totaling $240,637. Upon discovery of the error, we reviewed all purchase dates of expenditures to ensure no additional expenditures were outside the reporting period. Repeat Finding from Prior Years: No Recommendation: We recommend the Hospital create an internal control policy to ensure expenditures are reported in the correct period. Views of Responsible Officials: Management agrees with the finding.
Show full finding ▾Hide full finding ▴Department of Health and Human Services Federal Assistance Listing/CFDA #93.498 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year – Period 1 TIN #730929722 Activities Allowed or Unallowed, Allowable Costs/Cost Principles, and Reporting Material Weakness in Internal Control Over Compliance and 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 claimed expenditures that were not incurred during the reporting period. These expenditures were identified as unallowed on the Hospital’s schedule of expenditures, but inadvertently included in the amounts ultimately reported on the Period 1 report to HHS. Cause: The Hospital did not have an adequate internal control process in place to ensure expenditures claimed were being in the proper period. The Hospital also did not have a control to ensure the reporting was reviewed and approved by someone other than the preparer. Effect: The Hospital claimed and reported expenditures in the incorrect reporting period. Questioned Costs: None. While there were $240,637 of expenditures considered to be reported in the incorrect reporting period, the Hospital had excess lost revenues of $268,046 and additional underreported lost revenues of $459,421, which covers the error. Context: We sampled 60 of 382 expenditure transactions. We noted five selections resulting in a specific error totaling $240,637. Upon discovery of the error, we reviewed all purchase dates of expenditures to ensure no additional expenditures were outside the reporting period. Repeat Finding from Prior Years: No Recommendation: We recommend the Hospital create an internal control policy to ensure expenditures are reported in the correct period. Views of Responsible Officials: Management agrees with the finding.
Finding 2021-006 Federal Agency Name: Department of Health and Human Services Program Name: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution CFDA# 93.498 Finding Summary: The Hospital did not have an adequate internal control process in place to ensure expenditures claimed were being in the proper period. The Hospital also did not have a control to ensure the reporting was reviewed and approved by someone other than the preparer. Responsible Individuals: Scott Callender Corrective Action Plan: The Hospital will implement a control process which includes a documented secondary review and approval of required reports to be submitted to the federal agency prior to submission. Anticipated Completion Date: Ongoing
The Hospital is a critical access hospital and reimbursed from Medicare based on the expenses incurred to treat Medicare beneficiaries for the majority of operating activities. The Hospital claimed expenses attributable to coronavirus but did not reduce such expense by the amounts Medicare reimburses or is obligated to reimburse the Hospital or amounts reimbursed by other grants. Cause: The Hospital did not have an adequate internal control policy in place to ensure expenses claimed were being reduced by Medicare's reimbursement or claimed on other grants. The Hospital also did not have a control to ensure the reporting was reviewed and approved by someone other than the preparer. Effect: The Center claimed and reported expenses that were reimbursed or obligated to be reimbursed by Medicare or other grants. Questioned Costs: None. While there were $308,355 of expenses considered to be reimbursed by other sources, the Hospital had excess lost revenues of $268,046 and additional underreported lost revenues of $459,421, which covers the error. Context: We sampled 60 of 382 expenditure transactions. Excluding the five transactions noted in Finding 2021-006, errors were identified in all other selections. The Hospital estimated that Medicare reimburses approximately 28.92% of expenses reported on annual cost reports based on its 2021 filed cost report. The reimbursement percentage was then applied to the entire population of allowable expenses. In addition, one transaction was identified that was also reimbursed by another federal grant. Repeat Finding from Prior Years: No Recommendation: We recommend the Hospital modify internal control policies to ensure amounts claimed for this program are reduced by amounts reimbursed or obligated to be reimbursed by another source, including Medicare cost-based reimbursement. Views of Responsible Officials: Management agrees with the finding.
Show full finding ▾Hide full finding ▴Department of Health and Human Services Views of Responsible Officials: Management agrees with the finding. Federal Assistance Listing/CFDA #93.498 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year – Period 1 TIN #730929722 Activities Allowed or Unallowed, Allowable Costs/Cost Principles, and Reporting Material Weakness in Internal Control Over Compliance and 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 is a critical access hospital and reimbursed from Medicare based on the expenses incurred to treat Medicare beneficiaries for the majority of operating activities. The Hospital claimed expenses attributable to coronavirus but did not reduce such expense by the amounts Medicare reimburses or is obligated to reimburse the Hospital or amounts reimbursed by other grants. Cause: The Hospital did not have an adequate internal control policy in place to ensure expenses claimed were being reduced by Medicare's reimbursement or claimed on other grants. The Hospital also did not have a control to ensure the reporting was reviewed and approved by someone other than the preparer. Effect: The Center claimed and reported expenses that were reimbursed or obligated to be reimbursed by Medicare or other grants. Questioned Costs: None. While there were $308,355 of expenses considered to be reimbursed by other sources, the Hospital had excess lost revenues of $268,046 and additional underreported lost revenues of $459,421, which covers the error. Context: We sampled 60 of 382 expenditure transactions. Excluding the five transactions noted in Finding 2021-006, errors were identified in all other selections. The Hospital estimated that Medicare reimburses approximately 28.92% of expenses reported on annual cost reports based on its 2021 filed cost report. The reimbursement percentage was then applied to the entire population of allowable expenses. In addition, one transaction was identified that was also reimbursed by another federal grant. Repeat Finding from Prior Years: No Recommendation: We recommend the Hospital modify internal control policies to ensure amounts claimed for this program are reduced by amounts reimbursed or obligated to be reimbursed by another source, including Medicare cost-based reimbursement. Views of Responsible Officials: Management agrees with the finding.
Finding 2021-007 Federal Agency Name: Department of Health and Human Services Program Name: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution CFDA # 93.498 Finding Summary: The Hospital did not have an adequate internal control policy in place to ensure expenses claimed were being reduced by Medicare's reimbursement or claimed on other grants. The Hospital also did not have a control to ensure the reporting was reviewed and approved by someone other than the preparer. Responsible Individuals: Scott Callender Corrective Action Plan: The Hospital will implement a control process to ensure amounts claimed for this program are reduced by amounts reimbursed or obligated by another source and include a documented secondary review and approval of required reports to be submitted to the federal agency prior to submission Anticipated Completion Date: Ongoing
The total eligible expenses included on the Period 1 Report did not agree with the underlying supporting schedules. In addition, there were errors identified in the underlying supporting schedules. Cause: The Hospital did not have an adequate internal control policy in place to ensure a review and approval of the Period 1 Report was performed by someone other than the preparer of the report. Effect: The Hospital claimed eligible expenditures that were not supportable. Questioned Costs: None. While there was an overstatement of allowable expenses of $19,356, the Hospital had excess lost revenues of $268,046 and additional underreported lost revenues of $459,421, which covers the error. Context: Sampling was not used. We tested the key line item related to Other PRF Expenditures in identifying the error. Repeat Finding from Prior Years: No Recommendation: We recommend the Hospital implement a control process which includes a documented secondary review and approval of required reports to be submitted to the federal agency prior to submission. In addition, we recommend the report be based upon supporting schedules that also includes a documented secondary review and approval. Any expenses claimed for the federal program should be calculated correctly and have adequate supporting documentation. Views of Responsible Officials: Management agrees with the finding.
Show full finding ▾Hide full finding ▴Department of Health and Human Services Federal Assistance Listing/CFDA #93.498 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year – Period 1 TIN #730929722 Activities Allowed or Unallowed, Allowable Costs/Cost Principles, and Reporting Material Weakness in Internal Control Over Compliance and Noncompliance Not Considered Material 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 total eligible expenses included on the Period 1 Report did not agree with the underlying supporting schedules. In addition, there were errors identified in the underlying supporting schedules. Cause: The Hospital did not have an adequate internal control policy in place to ensure a review and approval of the Period 1 Report was performed by someone other than the preparer of the report. Effect: The Hospital claimed eligible expenditures that were not supportable. Questioned Costs: None. While there was an overstatement of allowable expenses of $19,356, the Hospital had excess lost revenues of $268,046 and additional underreported lost revenues of $459,421, which covers the error. Context: Sampling was not used. We tested the key line item related to Other PRF Expenditures in identifying the error. Repeat Finding from Prior Years: No Recommendation: We recommend the Hospital implement a control process which includes a documented secondary review and approval of required reports to be submitted to the federal agency prior to submission. In addition, we recommend the report be based upon supporting schedules that also includes a documented secondary review and approval. Any expenses claimed for the federal program should be calculated correctly and have adequate supporting documentation. Views of Responsible Officials: Management agrees with the finding.
Finding 2021-008 Federal Agency Name: Department of Health and Human Services Program Name: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution CFDA # 93.498 Finding Summary: The Hospital did not have an adequate internal control policy to ensure reported amounts agreed with underlying supporting documentation. In addition the underlying supporting documentation contained errors. Responsible Individuals: Scott Callender Corrective Action Plan: The Hospital will implement a control process to a ensure the report agrees with the under lying supporting documentation. Anticipated Completion Date: Ongoing
The Hospital does not have an internal control system designed to provide for a complete and accurate schedule of expenditures of federal awards 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 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 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 Services Federal Assistance Listing/CFDA #93.498 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year – Period 1 TIN #730929722 Other - Preparation of Schedule of Expenditures of Federal Awards Material Weakness in internal Control Over Compliance 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 of expenditures of federal awards 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 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 of expenditures of federal awards and the internal controls that impact financial reporting. Views of Responsible Officials: Management agrees with the finding.
Finding 2021-009 Federal Agency Name: Department of Health and Human Services Program Name: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution CFDA # 93.498 Finding Summary: The Hospital does not have an internal control system designed to provide for a complete and accurate schedule of expenditures of federal awards being audited. Responsible Individuals: Scott Callender Corrective Action Plan : Due to the small accounting staff there was little internal review of the schedule of federal expenditures resulting in errors. The Hospital will adopt a policy where the schedule of expenditures will be reviewed by a qualified individual. Anticipated Completion Date: Ongoing
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.
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