EIN: 826001208
UEI: GSA_MIGRATION
Audited by: EIDE BAILLY LLP
Oversight agency: 93 [Department of Health and Human Services]
View federal awards & risk assessment →
Data as of August 28, 2026
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on July 25, 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 January 25, 2023 (1313 days ago).
What is a management decision? →There was no evidence retained that the Hospital?s Schedule was reviewed and approved by a separate individual outside of the preparer. Cause: There was turnover of key financial positions during 2021. Due to the turnover, the Hospital did not have an internal control process in place to ensure review and approval of the Schedule. Effect: Without documentation of a secondary review and approval, demonstrating internal controls over compliance is difficult Questioned Costs: None reported. Context: Sampling was not used. Repeat Finding from Prior Years: No Recommendation: We recommend that management implement a control process which includes 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 CFDA 93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) 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) along with a review by a separate individual outside of the preparer. Condition: There was no evidence retained that the Hospital?s Schedule was reviewed and approved by a separate individual outside of the preparer. Cause: There was turnover of key financial positions during 2021. Due to the turnover, the Hospital did not have an internal control process in place to ensure review and approval of the Schedule. Effect: Without documentation of a secondary review and approval, demonstrating internal controls over compliance is difficult Questioned Costs: None reported. Context: Sampling was not used. Repeat Finding from Prior Years: No Recommendation: We recommend that management implement a control process which includes a documented secondary review and approval. Views of Responsible Officials: Management agrees with the finding.
Finding 2021-003 Department of Health and Human Services COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Federal Financial Assistance Listing/Federal CFDA #: 93.498 Finding Summary: Eide Bailly LLP noted there was no evidence of review for the schedule of expenditures by a separate individual outside the preparer. The main factor around this was turnover of accounting personnel near year end. Responsible Individuals: Ryan Larson, Interim CFO Corrective Action Plan: Due to turnover of accounting staff close to year end, we had minimal accounting staff. Our plan is to hire new team members to have proper staffing levels that would allow for sufficient reviews of entries, schedules, and supporting documentation. In the meantime, we accept the associated risk. Anticipated Completion Date: Ongoing
There was no evidence retained that the Hospital?s special report submitted to the Department of Health and Human Services for Period 1 was reviewed and approved by a separate individual outside of the preparer. In addition there was no evidence of review and approval of the allowability of activities and costs that were applied to the program. Cause: There was turnover of key financial positions during 2021. Due to the turnover, the Hospital did not have an internal control process in place to ensure review and approval of expenditures, the lost revenue calculation claimed under the federal program and the report submitted to the Department of Health and Human Services for Period 1 was documented. Effect: Without documentation of a secondary review and approval, demonstrating internal controls over compliance is difficult Questioned Costs: None reported. Context: Key line were tested on the Period 1 Department of Health and Human Services special report. Repeat Finding from Prior Years: No Recommendation: We recommend that management implement a control process which includes 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 CFDA 93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) 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: There was no evidence retained that the Hospital?s special report submitted to the Department of Health and Human Services for Period 1 was reviewed and approved by a separate individual outside of the preparer. In addition there was no evidence of review and approval of the allowability of activities and costs that were applied to the program. Cause: There was turnover of key financial positions during 2021. Due to the turnover, the Hospital did not have an internal control process in place to ensure review and approval of expenditures, the lost revenue calculation claimed under the federal program and the report submitted to the Department of Health and Human Services for Period 1 was documented. Effect: Without documentation of a secondary review and approval, demonstrating internal controls over compliance is difficult Questioned Costs: None reported. Context: Key line were tested on the Period 1 Department of Health and Human Services special report. Repeat Finding from Prior Years: No Recommendation: We recommend that management implement a control process which includes a documented secondary review and approval. Views of Responsible Officials: Management agrees with the finding.
Finding 2021-004 Department of Health and Human Services COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Federal Financial Assistance Listing/Federal CFDA #: 93.498 Finding Summary: Eide Bailly LLP noted there was no evidence retained that the Hospital?s special report submitted to the Health and human Services for Period 1 was reviewed and approved by a separate individual outside the preparer. In addition there was no evidence of review and approval of activities and costs that were applied to the program. The main factor around this was turnover of accounting personnel near year end. Responsible Individuals: Ryan Larson, Interim CFO Corrective Action Plan: Due to turnover of accounting staff close to year end, we had minimal accounting staff. Our plan is to hire new team members to have proper staffing levels that would allow for sufficient reviews of entries, schedules, and supporting documentation. In the meantime, we accept the associated risk. 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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