Audit 411239

Federal Award Number and Award Year RW1-17, award year 3/1/2023 – 2/29/2024 for AL No. 93.914 Criteria The 2 CFR section 200.303 requires that non-federal entities receiving federal awards establish and maintain internal control over the federal awards that provides reasonable assurance that the non-federal entity is managing the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal awards. Condition and Context BayCare included expenditures related to 2023 dates of service on the Schedule of Expenditures of Federal Awards (SEFA). An adjustment to the final SEFA of $155,429 was required and resulted in identification of an additional major program. Possible Cause and Effect In preparing the SEFA, BayCare utilized the 2024 claim payments received as the basis of the amount on the SEFA rather than expenditures incurred during 2024. Thus, this resulted in 2023 expenditures being included on the SEFA. Questioned Costs None Statistically Valid Sample Not applicable Repeat of Prior Finding Yes Recommendations Management should enhance its process to include a supervisory review of the SEFA, ensuring its completeness and accuracy. View of Responsible Official Management agrees with the noted finding.

Federal Award Number and Award Year 4486DR-FL and January 1, 2024 to December 31, 2024 Criteria According to 2 CFR 200.510(b), a recipient of federal awards is required to prepare a schedule of expenditures of federal awards for the period covered by the entity’s financial statements which must include the total federal awards expended as determined in accordance with 2 CFR 200.502. Additionally, 2 CFR 200.303 requires non-federal entities receiving federal awards to establish and maintain internal controls designed to reasonably ensure compliance with federal laws, regulations, and program compliance requirements. Effective internal control should include procedures to ensure federal expenditures are accurately and completely reported on the SEFA. Condition and Context The Organization did not have adequate controls in place related to the identification and reporting of federal expenditures for the COVID-19 Disaster Grants - Public Assistance (Presidentially Declared Disasters) program (FEMA) on the SEFA. Specifically, the Organization lacked controls to ensure expenditures incurred for FEMA were recognized on the SEFA when obligated. As a result, $4,644,457 of FEMA expenditures were omitted from the December 31, 2024 SEFA. Possible Cause and Effect Management did not perform appropriate risk assessment procedures related to federal awards that have unique recognition criteria such as FEMA. Specifically, there was not a control in place to ensure FEMA expenditures were recognized on the SEFA based on when the FEMA award was both obligated and expenditures were incurred. Failure to establish effective internal controls over the preparation of the SEFA may prevent the Organization from reporting accurate information and completing an audit in accordance with the Uniform Guidance. Questioned Cost Not applicable Statistically Valid Sample The sample was not intended to be, and was not, a statistically valid sample. Repeat of Prior Finding Not a repeat finding. Recommendation We recommend that the Organization strengthen its processes and internal controls over ensuring that expenditures have been reported completely and accurately on the SEFA. View of Responsible Official Management agrees with the noted finding.

Federal Program AL No. 97.036 - COVID-19 Disaster Grants- Public Assistance (Presidentially Declared Disasters) Federal Agency U.S. Department of Homeland Security- Federal Emergency Management Agency Federal Award Number and Award Year 4486DR-FL and January 1, 2024 to December 31, 2024 Criteria Activities Allowed or Unallowed and Allowable Costs/Cost Principles Per FEMA’s Public Assistance Program and Policy Guide, this criterion applies to all costs claimed. Not all costs incurred as a result of the incident are eligible. To be eligible, costs must be: • Directly tied to the performance of eligible work; • Adequately documented (2 CFR 200.403(g)); • Reduced by all applicable credits, such as insurance proceeds and salvage values (Stafford Act Section 312, 42 USC Section 5155, and 2 CFR 200.406); • Authorized and not prohibited under Federal or SLTT government laws or regulations; • Consistent with the Applicant’s internal policies, regulations, and procedures that apply uniformly to both Federal awards and other activities of the Applicant; and • Necessary and reasonable to accomplish the work properly and efficiently (2 CFR 200.403). Special Tests and Provisions – Project Accounting For large projects, the recipient is required to make an accounting to FEMA of eligible costs. Similarly, the subrecipient must make an accounting to the recipient. In submitting the accounting, the entity is required to certify that reported costs were incurred in performance of eligible work, that the approved work was completed, that the project is in compliance with the provisions of the FEMA-State Agreement, all grant conditions were met, and that payments for that project were made in accordance with the applicable payment provisions. For improved and alternate projects, if the total cost of the projects does not equal or exceed the approved eligible costs, then the auditor should expect to see an adjustment to reduce eligible costs (44 CFR section 206.205). Internal Control Additionally, 2 CFR 200.303 requires non-federal entities receiving federal awards to establish and maintain internal controls designed to reasonably ensure compliance with federal laws, regulations, and program compliance requirements. Condition and Context On December 9, 2024, FEMA obligated Project Worksheet #674964 in the amount of $4,644,457. This amount included $209,763 of duplicate invoices. In July 2025, the Homeland Security Operational Analysis Center (HSOAC) issued an Applicant Review Memorandum indicating that it had evaluated Project Worksheet #674964 and determined that the methodology used by management to calculate a portion of the estimated expenditures was not reasonable, as the population included two duplicate invoices. As a result of these findings, FEMA subsequently deobligated $209,763. The Organization had a control in place over the compilation and review of expenditures submitted to FEMA for reimbursement that was appropriately designed to detect duplicate expenditures. However, the control did not operate effectively, as the review was not performed with sufficient rigor to identify and remove duplicate invoices prior to submission. Consequently, duplicate expenditures were included in the reimbursement request submitted to FEMA. Possible Cause and Effect The Organization had established a review control over expenditures submitted to FEMA for reimbursement that was designed to identify and prevent duplicate expenditures from being included in reimbursement requests. However, the control did not operate effectively, resulting in two duplicate expenditures totaling approximately $209,000 being included in a reimbursement request submitted to FEMA. The duplicate expenditures were subsequently identified during the HSOAC review process and were deobligated. Questioned Costs $209,763 Statistically Valid Sample Not applicable Repeat of Prior Finding Not a repeat finding. Recommendations We recommend that the Organization strengthen controls over the preparation and management review of FEMA reimbursement submissions to ensure duplicate invoices are identified and excluded, unallowable costs are not included, and all relevant supporting documentation is maintained in accordance with Federal requirements. View of Responsible Official Management agrees with the noted finding.