EIN: 810515463
UEI: GSA_MIGRATION
Single Audit filed under EINs: 237293874, 932584380
203752312, 273866474, 311703013, 371518772, 462669324, 810231784, 810232406, 810247969, 810286525, 810391600, 810398400, 810406485, 810407289, 810413632, 810420653, 810526541, 810530457, 810540517, 810541707, 854133807, 862327525, 862346458, 862394240, 880538346 · unlinked EINs have no separate FAC filing
Audited by: EIDE BAILLY LLP
Oversight agency: 93 [Department of Health and Human Services]
View federal awards & risk assessment →
Data as of August 31, 2026
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on September 29, 2022. 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 March 29, 2023 (1252 days ago).
What is a management decision? →2021-005 ? Department of Health and Human Services CFDA 93.498 COVID-19 Provider Relief Fund and American Rescue Plan Rural Distribution Applicable Federal Award Number and Year ? Period 1 TIN #810515463 Department of Health and Human Services CFDA 93.301 Small Rural Hospital Improvement Grant Program Department of Treasury CFDA 21.019 COVID-19 Coronavirus Relief Fund Auditor 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 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 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 management be aware of the financial reporting requirements relating to the Hospital?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 ▴2021-005 ? Department of Health and Human Services CFDA 93.498 COVID-19 Provider Relief Fund and American Rescue Plan Rural Distribution Applicable Federal Award Number and Year ? Period 1 TIN #810515463 Department of Health and Human Services CFDA 93.301 Small Rural Hospital Improvement Grant Program Department of Treasury CFDA 21.019 COVID-19 Coronavirus Relief Fund Auditor 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 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 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 management be aware of the financial reporting requirements relating to the Hospital?s schedule of expenditures of federal awards and internal controls that impact financial reporting. Views of Responsible Officials ? Management agrees with the finding.
Finding 2021-005 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 Applicable Federal Award Number and Year ? Period 1 TIN#810515463 Department of Health and Human Services CFDA 93.3.01 Small Rural Hospital Improvement Grant Program Department of Treasury CFDA 21.019 COVID-19 Coronavirus Relief Fund Finding Summary: We requested that our auditors, Eide Bailly LLP, prepare the schedule of expenditures of federal awards as part of their Single Audit. Responsible Individual: Shari Dolan, President / Chief Financial Officer Corrective Action Plan: It is not cost effective to have an internal control system designed to prepare the schedule of expenditures of federal awards. We requested that our auditors, Eide Bailly LLP, to assist with the preparation of the schedule of expenditures of federal awards. We have designated a member of management to review the draft schedule of expenditures of federal awards, and we have reviewed and agree with the final schedule of expenditures of federal awards. Anticipated Completion Date: Ongoing
2021-006 - Department of Health and Human Services CFDA 93.498 COVID-19 Provider Relief Fund and American Rescue Plan Rural Distribution Applicable Federal Award Number and Year ? Period 1 TIN #810515463 Activities Allowed or Unallowed, Allowable Costs/Costs Principles, and 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 claimed expenses that were reimbursed by other funding sources. These expenses were improperly included within the HHS Special Report ? Period 1. Cause ? The Hospital submitted expenses that were to be reimbursed by other funding sources (i.e., Medicare), as unreimbursed expenses attributable to coronavirus. Expenses net of amounts that were to be reimbursed by other funding sources (i.e., Medicare) were errantly reported in the unreimbursed section of the Period 1 Report. The Hospital did not have an adequate internal control policy in place to ensure review expenses claimed in the Report were accurate. Effect ? The lack of adequate policies governing 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. The Hospital submitted expenses over the actual allowable expenses. Questioned Costs ? There are questioned costs of $964,556 (actual in expense population) that were reimbursed or will be reimbursed by other funding sources. Context ? A nonstatistical sample of 60 expenditures were selected for testing, which accounted for $971,042 of $3,226,006 direct program expenditures. Within the $971,042 sample, $366,497 of costs were reimbursed by a different funding source (i.e., Medicare cost reimbursed percentage estimated using the filed cost report for fiscal year 2020). The Report section, Other PRF Expenses, included expenses that were reimbursed or would be reimbursed by other funding sources. Repeat Finding from Prior Years ? No. Recommendation ? We recommend that the Hospital 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 CFDA 93.498 COVID-19 Provider Relief Fund and American Rescue Plan Rural Distribution Applicable Federal Award Number and Year ? Period 1 TIN #810515463 Activities Allowed or Unallowed, Allowable Costs/Costs Principles, and 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 claimed expenses that were reimbursed by other funding sources. These expenses were improperly included within the HHS Special Report ? Period 1. Cause ? The Hospital submitted expenses that were to be reimbursed by other funding sources (i.e., Medicare), as unreimbursed expenses attributable to coronavirus. Expenses net of amounts that were to be reimbursed by other funding sources (i.e., Medicare) were errantly reported in the unreimbursed section of the Period 1 Report. The Hospital did not have an adequate internal control policy in place to ensure review expenses claimed in the Report were accurate. Effect ? The lack of adequate policies governing 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. The Hospital submitted expenses over the actual allowable expenses. Questioned Costs ? There are questioned costs of $964,556 (actual in expense population) that were reimbursed or will be reimbursed by other funding sources. Context ? A nonstatistical sample of 60 expenditures were selected for testing, which accounted for $971,042 of $3,226,006 direct program expenditures. Within the $971,042 sample, $366,497 of costs were reimbursed by a different funding source (i.e., Medicare cost reimbursed percentage estimated using the filed cost report for fiscal year 2020). The Report section, Other PRF Expenses, included expenses that were reimbursed or would be reimbursed by other funding sources. Repeat Finding from Prior Years ? No. Recommendation ? We recommend that the Hospital 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 Applicable Federal Award Number and Year ? Period 1 TIN#810515463 Finding Summary: The Hospital claimed expenses that were reimbursed by other funding sources. These expenses were improperly included withing the HHS Special Report ? Period 1 (Report) which caused the Report to be inaccurate. The Hospital submitted expenses that were reimbursed by other funding sources (i.e. Medicare) incorrectly as unreimbursed expenses in the Period 1 Report. Responsible Individual: Shari Dolan, President / Chief Financial Officer Corrective Action Plan: The Hospital will enhance internal control policies to ensure all amounts reimbursed by other funding sources are adequately documented and reduced from all eligible expenditure listing are properly recorded in the reports required to be submitted to the federal agency. The Hospital will 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. Had the expenses been recorded properly we could have claimed $665,779 of lost revenues under Option 1 in the Period 1 Report. The Hospital did not have additional internal management personnel that had the knowledge/ability to review the report prior to submission. Preparer spoke to the Hospital?s Management Company and it was stated that the scope of the Management Agreement did not provide for guidance, discussion and/or review of Provider Relief Funding reporting. Identification of the above noted reporting errors occurred after the portal closed for the Phase 1 report period. The Preparer contacted HRSA, in January 2022, and made a request for a re-opening of the HRSA account to make corrections. The preparer was told that the account could be re-opened to make these corrections. The Preparer was provided with Case #00025789. When the preparer attempted to login again, the account had not been unlocked. The preparer contacted HRSA once again and spoke to a different individual who stated that the account could not be unlocked for corrections. The case number (identified above) did have the information from the previous call where the Preparer was told that the account could be re-opened. The second individual stated that she would speak to a Case Manager and see what could be done, as the Preparer was told in the initial call that the account could be re-opened. Several days later the Preparer received an email, which stated: ?Thank you for contacting the Provider Relief Fund (PRF) Program. The Health Resources and Services Administration is not currently accepting requests to revise Phase 1 reports. However, providers are able to view and make changes to their report's contact information at any time. Please continue to monitor the PRF website for future communications regarding requests to revise reports. Effective July 1, 2022 the Hospital will have increased internal controls due to new affiliation with Logan Health System in Kalispell, MT. Additional oversite will be able to be provided by a Regional Director of Finance. Anticipated Completion Date: October 2022
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