EIN: 870419324
UEI: GSA_MIGRATION
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 January 26, 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 July 26, 2023 (1132 days ago).
What is a management decision? →Amounts reported on the SEFA did not agree to underlying documentation. Cause: The Hospital does not have an internal control system designed to provide for a complete and accurate SEFA being audited. Effect: Prior to correction, the SEFA was understated by $190,081. Questioned Costs: None reported. Context: Sampling was not used. Repeat Finding from Prior Years: No Recommendation: We recommend that the Hospital enhance internal controls to ensure program expenditures are appropriately reported on the SEFA. 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 (PRF) and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year ? Period 1 TIN #870419324 Preparation of Schedule of Expenditures of Federal Awards Significant Deficiency in Internal Control Over Compliance Criteria: Title 2 Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit requirements for Federal Awards (Uniform Guidance) requires the Hospital to prepare a Schedule of Expenditures of Federal Awards (SEFA). Condition: Amounts reported on the SEFA did not agree to underlying documentation. Cause: The Hospital does not have an internal control system designed to provide for a complete and accurate SEFA being audited. Effect: Prior to correction, the SEFA was understated by $190,081. Questioned Costs: None reported. Context: Sampling was not used. Repeat Finding from Prior Years: No Recommendation: We recommend that the Hospital enhance internal controls to ensure program expenditures are appropriately reported on the SEFA. Views of Responsible Officials: Management agrees with the finding.
Finding 2021-001 Federal Agency Name: Department of Health and Human Services Program Name: Provider Relief Fund (PRF) 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 SEFA being audited. Responsible Individuals: Brent Davis, CFO Corrective Action Plan: Because of a misunderstanding on costs covered by other assistance (the Medicare Cost Report) the SEFA was not accurate. Otherwise, the information on the SEFA was accurate. Guidelines regarding other assistance will be better discovered and followed in the future. Anticipated Completion Date: Completed
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. Cause: The Hospital did not have adequate internal controls policy in place to ensure expenses claimed were being reduced by Medicare's reimbursement. Effect: The Hospital claimed and reported expenses that were reimbursed or obligated to be reimbursed by Medicare. Questioned Costs: $139,133 Context: The Hospital?s estimate of reimbursement from Medicare for costs incurred was based on the Medicare utilization from the 2021 annual cost report. This methodology was applied to the costs included in the Medicare cost report in determining the total amount of $139,133 considered to be reimbursed by another source. 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 Federal Assistance Listing/CFDA #93.498 Provider Relief Fund (PRF) and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year ? Period 1 TIN #870419324 Activities Allowed or Unallowed, Allowable Cost/Cost Principles, and Reporting Material Weakness in Internal Control Over Compliance and Material Noncompliance Criteria: 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. Cause: The Hospital did not have adequate internal controls policy in place to ensure expenses claimed were being reduced by Medicare's reimbursement. Effect: The Hospital claimed and reported expenses that were reimbursed or obligated to be reimbursed by Medicare. Questioned Costs: $139,133 Context: The Hospital?s estimate of reimbursement from Medicare for costs incurred was based on the Medicare utilization from the 2021 annual cost report. This methodology was applied to the costs included in the Medicare cost report in determining the total amount of $139,133 considered to be reimbursed by another source. 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 2021-002 Federal Agency Name: Department of Health and Human Services Program Name: Provider Relief Fund (PRF) and American Rescue Plan (ARP) Rural Distribution CFDA # 93.498 Finding Summary: 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. Responsible Individuals: Brent Davis, CFO Corrective Action Plan: Because of misunderstood guidelines regarding costs covered by other assistance or the Medicare Cost Report, these costs were not removed. These costs will be removed in the future. Anticipated Completion Date: Completed
The Hospital claimed and reported expenditures that were reimbursed by other federal award programs. Cause: The Hospital did not have adequate internal controls policy in place to ensure expenses claimed were not being reimbursed by other sources. Effect: The Hospital claimed and reported expenses that were reimbursed or obligated to be reimbursed by other sources. Questioned Costs: $156,215 Context: The Hospital claimed expenses attributable to coronavirus totaling $1,602,259. The Hospital claimed certain expenditures under other programs resulting in an overstatement of $156,215. 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. 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 (PRF) and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year ? Period 1 TIN #870419324 Activities Allowed or Unallowed, Allowable Cost/Cost Principles, and Reporting Material Weakness in Internal Control Over Compliance and Material Noncompliance Criteria: 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 and reported expenditures that were reimbursed by other federal award programs. Cause: The Hospital did not have adequate internal controls policy in place to ensure expenses claimed were not being reimbursed by other sources. Effect: The Hospital claimed and reported expenses that were reimbursed or obligated to be reimbursed by other sources. Questioned Costs: $156,215 Context: The Hospital claimed expenses attributable to coronavirus totaling $1,602,259. The Hospital claimed certain expenditures under other programs resulting in an overstatement of $156,215. 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. Views of Responsible Officials: Management agrees with the finding.
Finding 2021-003 Federal Agency Name: Department of Health and Human Services Program Name: Provider Relief Fund (PRF) and American Rescue Plan (ARP) Rural Distribution CFDA # 93.498 Finding Summary: The Hospital claimed and reported expenditures that were reimbursed by other federal award programs. Responsible Individuals: Brent Davis, CFO Corrective Action Plan: Because of misunderstood guidelines regarding costs covered by other assistance or the Medicare Cost Report, these costs were not removed. These costs will be removed in the future. Anticipated Completion Date: Completed
The Hospital claimed and reported expenditures that contained errors based upon the underlying documentation. Cause: The Hospital did not have adequate internal controls policy in place to ensure expenditures claimed were accurate based upon the underlying records. Effect: The Hospital claimed and reported expenditures that contained errors based upon the underlying documentation. Questioned Costs: None reported. Context: A nonstatistical sample of 60 supplies and services transactions out of a population of approximately 969 was selected for testing, and a sample of 60 co-pay write off transactions out of a population of 1,745 was selected for testing. The total sample of supplies and services tested was $25,086 from a population of $1,070,571. The total sample of co-pay write offs tested was $11,208 from a population of $375,473. The supplies and services sample contained errors in three transactions in which the amounts claimed on the Period 1 report were less than the supporting documentation. The co-pay write offs contained an error in one transaction in which amounts claimed were greater than the supporting documentation. Repeat Finding from Prior Years: No Recommendation: We recommend the Hospital modify internal control policies to ensure amounts claimed for this program agree to underlying 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 (PRF) and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year ? Period 1 TIN #870419324 Activities Allowed or Unallowed, Allowable Cost/Cost Principles, and Reporting Significant Deficiency in Internal Control Over Compliance and Noncompliance Not Considered Material Criteria: 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 and reported expenditures that contained errors based upon the underlying documentation. Cause: The Hospital did not have adequate internal controls policy in place to ensure expenditures claimed were accurate based upon the underlying records. Effect: The Hospital claimed and reported expenditures that contained errors based upon the underlying documentation. Questioned Costs: None reported. Context: A nonstatistical sample of 60 supplies and services transactions out of a population of approximately 969 was selected for testing, and a sample of 60 co-pay write off transactions out of a population of 1,745 was selected for testing. The total sample of supplies and services tested was $25,086 from a population of $1,070,571. The total sample of co-pay write offs tested was $11,208 from a population of $375,473. The supplies and services sample contained errors in three transactions in which the amounts claimed on the Period 1 report were less than the supporting documentation. The co-pay write offs contained an error in one transaction in which amounts claimed were greater than the supporting documentation. Repeat Finding from Prior Years: No Recommendation: We recommend the Hospital modify internal control policies to ensure amounts claimed for this program agree to underlying documentation. Views of Responsible Officials: Management agrees with the finding.
Finding 2021-004 Federal Agency Name: Department of Health and Human Services Program Name: Provider Relief Fund (PRF) and American Rescue Plan (ARP) Rural Distribution CFDA # 93.498 Finding Summary: The Hospital claimed and reported expenditures that contained errors based upon the underlying documentation. Responsible Individuals: Brent Davis, CFO Corrective Action Plan: Identified expenditures will be more thoroughly reviewed for accuracy in the future. Anticipated Completion Date: Completed
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