Corrective Action Plans

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The Organization has transitioned from QuickBooks to Sage Intacct accounting software, which now requires digital attachments for all transactions to ensure proper documentation. The Organization continues to review and improve processes and procedures as we grow as an organization. We will reinforc...
The Organization has transitioned from QuickBooks to Sage Intacct accounting software, which now requires digital attachments for all transactions to ensure proper documentation. The Organization continues to review and improve processes and procedures as we grow as an organization. We will reinforce adherence to the Organization's policies.
2025-002 – 10.558 – Child and Adult Care Food Program –Eligibility Condition Two providers received an improper amount for their meal reimbursement for the month tested. Recommendation Controls should be reviewed and updated to ensure that complete and accurate meal counts are submitted to the State...
2025-002 – 10.558 – Child and Adult Care Food Program –Eligibility Condition Two providers received an improper amount for their meal reimbursement for the month tested. Recommendation Controls should be reviewed and updated to ensure that complete and accurate meal counts are submitted to the State for reimbursement. Comments on the Finding Given Sunshine Connections, Inc.’s limited staffing structure, full segregation of duties within the meal claims process is not always possible. However, the organization has implemented practical internal controls to reduce the risk of errors and ensure accurate claims are submitted. All meal count and attendance records submitted are reviewed for completeness and accuracy before being entered into the claim system. Meal counts are checked against enrollment, attendance, and licensed capacity to ensure they are reasonable and allowable. Action Taken Whenever possible, someone other than the Director will prepare the monthly claim. The Director will then review the claim for accuracy and compare totals between the Excel spreadsheet and the Little Organizer program before submission to ensure the information is correct.
FINDING 2025-007 Finding Subject: BRIC: Building Resilient Infrastructure and Communities – Internal Controls Contact Person Responsible for Corrective Action: Lana Hamilton Contact Phone Number and Email Address: 812-883-4437, ext. 1005, lhamilton@salemschools.us Views of Responsible Officials: We ...
FINDING 2025-007 Finding Subject: BRIC: Building Resilient Infrastructure and Communities – Internal Controls Contact Person Responsible for Corrective Action: Lana Hamilton Contact Phone Number and Email Address: 812-883-4437, ext. 1005, lhamilton@salemschools.us Views of Responsible Officials: We concur with the finding Description of Corrective Action Plan: This grant was fully expended in 2024. Going forward, the current treasurer will work closely with the grant administrator, whether within corporation or an outside source, when compiling all claims, disbursements and reporting for any given project, including BRIC programs. Internal controls will be incorporated at the Corporation level for future grants that use an outside Grant Administrator. Anticipated Completion Date: 2/16/2026
FINDING 2025-005 Finding Subject: COVID-19 - Education Stabilization Fund - Reporting Contact Person Responsible for Corrective Action: Lana Hamilton Contact Phone Number and Email Address: 812-883-4437, ext. 1005, lhamilton@salemschools.us Views of Responsible Officials: We concur with the finding ...
FINDING 2025-005 Finding Subject: COVID-19 - Education Stabilization Fund - Reporting Contact Person Responsible for Corrective Action: Lana Hamilton Contact Phone Number and Email Address: 812-883-4437, ext. 1005, lhamilton@salemschools.us Views of Responsible Officials: We concur with the finding Description of Corrective Action Plan: Internal controls for reimbursement requests will include necessary documentation of expenditures from the accounting program attached to the reimbursement form for all grants. Each reimbursement request will be checked and approved by two school employees. The treasurer will keep the packet until funds are received and receipted and then the packet, with the receipt, will be filed in two places; the respective grant folder and in the monthly receipt folder. Anticipated Completion Date: 2/16/2026
Finding 2025 – 001: Restatement to Fund Balance/Net Position Condition: During audit fieldwork, our testing resulted in a restatement of fund balance in order to correct retainage payable and capital assets that were improperly recorded in prior years. Plan: The City will implement effective interna...
Finding 2025 – 001: Restatement to Fund Balance/Net Position Condition: During audit fieldwork, our testing resulted in a restatement of fund balance in order to correct retainage payable and capital assets that were improperly recorded in prior years. Plan: The City will implement effective internal controls in order to provide an accurate assessment of reporting requirements. This implementation of improved controls would result in the appropriate recognition for financial reporting requirements Anticipated Date of Completion: June 30, 2026 Name of Contact Person: Elizabeth Hannan, CFO/HR Director Management Response: Management acknowledges this comment and will work to implement and correct by the anticipated date of completion noted above.
The District acknowledges the finding regarding inaccuracies in meal counts reported for the Child Nutrition Program reimbursement claims. To address this issue, the District will strengthen internal controls over the meal count reporting and claim preparation process. The food service department wi...
The District acknowledges the finding regarding inaccuracies in meal counts reported for the Child Nutrition Program reimbursement claims. To address this issue, the District will strengthen internal controls over the meal count reporting and claim preparation process. The food service department will ensure that daily meal count documentation is properly maintained and reconciled to the monthly claim totals prior to submission. In addition, the Director of Business Operations will implement a formal management review process prior to submission of each monthly claim for reimbursement to the Arizona Department of Education. This review will include verification that reported meal counts agree to supporting documentation and that all reconciliations have been completed and documented. Any discrepancies identified during the review will be investigated and corrected before the claim is submitted. These procedures will provide additional oversight and help ensure the District maintains compliance with federal regulations and the reporting requirements of the Child Nutrition Program. The Director of Business Operations is responsible for implementing and monitoring this correction action, which will be completed at the end of the next fiscal year.
Finding 2025-003 Duplicate expenditures charged to same grant Recommendation: We recommend the District establish and maintain proper review procedures for expenditures charged to grants prior to submission for reimbursement. Management’s View: The District will strengthen internal controls over pay...
Finding 2025-003 Duplicate expenditures charged to same grant Recommendation: We recommend the District establish and maintain proper review procedures for expenditures charged to grants prior to submission for reimbursement. Management’s View: The District will strengthen internal controls over payroll expenditures charged to federal grants by implementing a standard operating procedure that will be conducted by the Payroll Specialist of verifying payroll distribution reports, funding codes, and supporting documentation prior to submission for payment. Before each payroll is finalized, the payroll specialist will run a payroll report that will be generated and sorted by employee to verify that no duplicate charges have been applied to the same grant within the same payroll period. This review will ensure that all costs charged to federal grants during the pay period are accurate, allowable, properly coded, and not duplicated. No payroll adjustments will be keyed until timesheets have been verified against previously submitted timesheets and that they are reviewed to confirm that prior entries have not already been charged to the same grant. Additionally, a secondary review by the accountant will be conducted prior to finalizing grant-related payrolls. Effective March 1, 2026, the Payroll Accountant and Chief Financial Officer will review grant-related payroll transactions to ensure accuracy, proper funding allocation, and compliance with applicable federal requirements. Effective Date: March 1, 2026 Contact Person: Sylvia Garza, Chief Financial Officer, Edcouch-Elsa Independent School District
Management concurs with the finding and will implement corrective actions to improve claim review procedures and staff training to ensure future reimbursement submissions are accurate and compliant.
Management concurs with the finding and will implement corrective actions to improve claim review procedures and staff training to ensure future reimbursement submissions are accurate and compliant.
Recommendation: We recommend that the Department identify the reason for the exclusion of the credit in its query. Additionally, the Department should consider reviewing the query to the general ledger as part of the final review before submitting the reimbursement request. Explanation of disagreeme...
Recommendation: We recommend that the Department identify the reason for the exclusion of the credit in its query. Additionally, the Department should consider reviewing the query to the general ledger as part of the final review before submitting the reimbursement request. Explanation of disagreement with audit finding: The Department recognizes the audit finding and its responsibility to comply with 2 CFR §200.403(f). Action planned in response to finding: Corrective action will be taken. The Department revised the policies and procedures for cash disbursements within the Administrative Services Division. Effective immediately, upon running the monthly query of federal expenditures for the cash reimbursement for federal grants, the Federal Financial Analyst will submit the query to the Budget Director and the Accountant/Auditor. A reconciliation to the General Ledger will be completed by them prior to the Federal Financial Analyst requesting the cash reimbursement. Name(s) of the contact person(s) responsible for corrective action: Paul Varela, CFO Planned completion date for corrective action plan: July 31, 2026
Maywood-Melrose Park-Broadview School District 89 06-016-0890-02 CORRECTIVE ACTION PLAN FOR CURRENT YEAR AUDIT FINDINGS Year Ending June 30, 2025 Corrective Action Plan Finding No.: 2025- 003 Condition: It was noted during the audit that ineligible expenditures were charged to the food service expen...
Maywood-Melrose Park-Broadview School District 89 06-016-0890-02 CORRECTIVE ACTION PLAN FOR CURRENT YEAR AUDIT FINDINGS Year Ending June 30, 2025 Corrective Action Plan Finding No.: 2025- 003 Condition: It was noted during the audit that ineligible expenditures were charged to the food service expenditure function. These expenditures were for a back-to-school picnic and consisted of backpacks with school supplies that were provided to students, as well as a lunch provided to new teachers and staff. These expenditures should not have been charged to the food service function in the District’s general ledger system. Plan: The district is reviewing all expenditures monthly to ensure all of them are recorded with the proper account code. Any changes needed will get a journal entry through the Proviso Treasurer’s Office. The district has also identified the main vendors from which picnic supplies are purchased and stopped charging expenditures from these vendors to food service account codes. Anticipated Date of Completion: June 30, 2026 Name of Contact Person: Scott Wold, Business Manager
The University acknowledges the audit finding and remains committed to maintaining compliance with the cash management requirements outlined in 2 CFR 200.302 (b)(3), which stipulates that recipients must maintain records that sufficiently identify Federal awards and ensure that drawdowns are properl...
The University acknowledges the audit finding and remains committed to maintaining compliance with the cash management requirements outlined in 2 CFR 200.302 (b)(3), which stipulates that recipients must maintain records that sufficiently identify Federal awards and ensure that drawdowns are properly supported and authorized prior to submission. During the audit period, at least one drawdown was approved, one day retroactively, after submission but prior to receipt of funds. This occurred prior to the remediation period. No exceptions were identified in the remediation period, and the finding is considered remediated. The instance arose during a leadership transition with the Office of Research Administration. Since that time, the entire drawdown process, review and approval has been clarified under new leadership, and additional oversight has been implemented to ensure approvals are documented prior to submission. As part of the drawdown process review, the University developed a standardized drawdown template, which streamlines how the Federal award expense information is gathered, compared to approve budgeted amounts and reviewed for approval. The template documents the preparer, the approver and the dates of both for the respective drawdown. The Office of Research Administration received training on the use of the template in January and February 2026 and implementation is planned for February 2026. Primary responsibility for implementing the correction action plan for this finding rests with Angela Tagliaferri, Assistant Vice President of Post-Award Services and Financial Compliance, 216-368-6269.
Finding: 2025-001 School Food Account - Net Cash Resources (ALN #10.553/10.555/10.559) Corrective Action Plan: The School District has begun taking action to address this issue, as follows: Equipment Improvement - School Food Service Director, Joe Kilmer, Food Service Manager, Ann Overhiser, and the...
Finding: 2025-001 School Food Account - Net Cash Resources (ALN #10.553/10.555/10.559) Corrective Action Plan: The School District has begun taking action to address this issue, as follows: Equipment Improvement - School Food Service Director, Joe Kilmer, Food Service Manager, Ann Overhiser, and the School Business Administrator have plans to improve and replace cafeteria equipment. The replacement plan will be completed in conjunction with the School District’s upcoming Capital Project. This work was originally expected to be included in a prior project but due to scheduling issues, is now included in the upcoming project which is expected to be completed byAugust 31, 2026. Retained Balance for Pending Settlements - Wages will increase into 2026 and beyond. The minimum wage in New York State is expected to continue to rise according to legislation. The rate will rise to $16.00 per hour by the end of 2025 and to $16.50 per hour by the end of 2026. Annual increases will be published by the Commissioner of Labor and based on a number of economic factors. Due to the critical labor shortage, the School District recently increased hourly wages for food service helpers and cooks in order to attract additional workers to maintain operations. Enhanced Meals - The Food Service Director and Food Service Manager continue to take steps to improve food options. They include making improvements to center of the plate options and improving local food options as well. In addition, the School District plans to spend a portion of the School Lunch excess cash on cafeteria equipment as a part of its upcoming Capital Project which is expected to be completed by August 31, 2026. Anticipated Correction Date: August 31, 2026 Contact Information: Kyle Bower Interim School Business Administrator Odessa - Montour Central School District 300 College Avenue Odessa, New York 14869
Responsible Person(s): Darin Moore, Deputy Director of Administration and Outreach; Sarah Boggs, Accounting Manager for Planning and Finance; Suzanne Robinson; Tim Springer, Budget Manager for Planning and Finance Corrective Action Planned: Review the current DWR process and determine whether DWR sh...
Responsible Person(s): Darin Moore, Deputy Director of Administration and Outreach; Sarah Boggs, Accounting Manager for Planning and Finance; Suzanne Robinson; Tim Springer, Budget Manager for Planning and Finance Corrective Action Planned: Review the current DWR process and determine whether DWR should petition the Comptroller for an exception to CAPP Topic 20605 or modify the DWR process to the “split coding” method instead. This will include: 1.) Evaluation of grant program guidance to ensure no obstacles exist from the Federal Awarding Agency to changing DWR's current methodology; 2.) Meeting and discussing with other (like) state agencies for policy, procedure, and training examples for split coding grant eligible expenditures; 3.) Scheduling meetings with Department of Accounts and the previous APA Audit Team to discuss DWR's evaluation, decision, and next steps; 4.) Developing and implementing new DWR policies and training to ensure compliance with the approved methodology. (Estimated completion date: July 1, 2026) Update current policies and procedures to conform with CAPP Manual Topic 20405 and to enhance the agency's current supporting documentation for all journal entries. At a minimum, these new policies and procedures will require that Voucher ID/Expense Report IDs that are moved within a journal entry are documented in the journal reference line in the system to improve transparency, will add more detailed explanations to justify coding changes, will upload applicable documents into the system to assist in manager approval, and will maintain all documentation centrally in one location for easier access and review. (Estimated completion date: July 1, 2026) Publish and maintain a sustainable federal drawdown schedule, by: 1.) Evaluating DWR's current federal drawdown schedule in accordance with current policies, procedures, employee workload, cashflow, and Federal Awarding Agency's guidance; 2.) Developing specific controls, and revised job descriptions as needed to ensure the drawdown schedule can be consistently maintained; and 3.) Incorporating both the new schedule and controls into appropriate policies and procedures to ensure accountability. (Estimated completion date: June 1, 2026) Evaluate current policies, procedures, and practices pertaining to how DWR manages and records Program Income. Develop and update policies and procedures to ensure compliance with CAPP 20205. Provide training on new policies and procedures to employees within the Planning and Finance Division. (Estimated completion date: June 1, 2026) Review current internal procedures for reporting federal expenses on the SEFA and Attachment 15 and identify training gaps. Enlist training support from Department of Accounts and/or other state agencies to address training gaps. Develop new written policies and procedures, along with new supporting documentation requirements, to conform to SEFA and Attachment 15 guidelines and expectations. Provide training on new policies and procedures to employees within the Planning and Finance Division. (Estimated completion date: July 1, 2026) Review all other written policies and procedures for administering federal grants and contracts, and develop and update as necessary to address insufficient guidance and noncompliance. (Estimated completion date: August 31, 2025) Estimated Completion Date: 7/1/2026
Condition: One (1) of the monthly claims for reimbursement reported meal counts in excess of those supported by records of the District. The November 2024 claim amounts were consistent with participation levels and reimbursement amounts in other months tested. No anomalies or fluctuations were ident...
Condition: One (1) of the monthly claims for reimbursement reported meal counts in excess of those supported by records of the District. The November 2024 claim amounts were consistent with participation levels and reimbursement amounts in other months tested. No anomalies or fluctuations were identified through analytical procedures; however, required supporting documentation was not maintained. Corrective Action Plan: Management will review its policies and procedures and implement changes to strengthen internal control over compliance. Responsible Person: Dr. Cynthia Levy, Superintendent. Anticipated Completion Date: June 30, 2026
Name of auditee: Town of Plattsburgh Housing Development Fund Company, Inc. TIN: 014-EE068 Name of Audit Firm: EFPR Group, CPAs, PLLC Period covered by audit: December 31, 2025 CAP prepared by: David Kimmel President Two Plus Four Property Management Co,. Inc. (315) 437-2178 Current Finding on the S...
Name of auditee: Town of Plattsburgh Housing Development Fund Company, Inc. TIN: 014-EE068 Name of Audit Firm: EFPR Group, CPAs, PLLC Period covered by audit: December 31, 2025 CAP prepared by: David Kimmel President Two Plus Four Property Management Co,. Inc. (315) 437-2178 Current Finding on the Schedule of Findings and Questioned Costs and Recommendations Finding 2025-001 (a) Comments on the finding and recommendation: Management agrees with the finding. Management also agrees with the recommendation, please see below for action taken. (b) Action taken: Management has deposited the underfunded amount of $21,250 into the residual account on February 19, 2026.
Finding Reference Number: 2025-003 Corrective Action: APC is enhancing its compliance approach for loan-related obligations, including reserve reviews and tenant documentation. Oversight of required monitoring activities will be reinforced under the direction of Renee Wright, Director of Property Ma...
Finding Reference Number: 2025-003 Corrective Action: APC is enhancing its compliance approach for loan-related obligations, including reserve reviews and tenant documentation. Oversight of required monitoring activities will be reinforced under the direction of Renee Wright, Director of Property Management. Responsible Person(s): Brett A. Mlinarich, Director of Finance; Renee Wright, Director of Property Management Anticipated Completion Date: March 31, 2026
Section III – Federal Award Finding and Questioned Costs Finding 2025-002 – Eligibility Federal Program: Child and Adult Care Food Program (ALN 10.558) Views of Responsible Officials: NDS management met with CACFP staff to review procedures intended to enhance oversight of student eligibility determ...
Section III – Federal Award Finding and Questioned Costs Finding 2025-002 – Eligibility Federal Program: Child and Adult Care Food Program (ALN 10.558) Views of Responsible Officials: NDS management met with CACFP staff to review procedures intended to enhance oversight of student eligibility determinations on February 10, 2026. The Assistant Administrator for the Child and Adult Care Food Program, Ms. Dawn McCoy, (dmccoy@ndsarch.org) will be responsible for ensuring adherence to these updated procedures.
Corrective Action Plan: Catholic Charities Program Manager conducted the CACFP annual staff training on 12/17/2025 with all CACFP staff present. The annual audit was discussed. Each staff member will review all claims for accuracy before entering the claim into the State's online website for reimbur...
Corrective Action Plan: Catholic Charities Program Manager conducted the CACFP annual staff training on 12/17/2025 with all CACFP staff present. The annual audit was discussed. Each staff member will review all claims for accuracy before entering the claim into the State's online website for reimbursement. Program Manager, Joanne Varnes, will conduct case record reviews of the providers’ files/claims to ensure participants are reimbursed at the correct rate, days, and number of meals served. Contact Person Responsible for Corrective Action: Joanne Varnes, CACFP Program Manager Anticipated Completion Date of Corrective Action: December 17, 2025
The City acknowledges the internal control deficiencies related to the tracking, recording, and monitoring of grant receivables, related revenue and deferred revenue, and the timely preparation of reimbursement requests for federal and state grants. Management recognizes that the current process, wh...
The City acknowledges the internal control deficiencies related to the tracking, recording, and monitoring of grant receivables, related revenue and deferred revenue, and the timely preparation of reimbursement requests for federal and state grants. Management recognizes that the current process, which relies heavily on individual departments to initiate reimbursement activity, has resulted in delays and incomplete financial reporting. To address the issue, the City will implement the following corrective actions: 1. Centralized Grant Monitoring Process: The Accounting Department will assume responsibility for proactively identifying and recording grant receivables and associated revenue and deferred revenue at the time expenditures are incurred. This process will no longer be dependent solely on departmental requests for reimbursement. 2. Quarterly Review and Reconciliation: A new quarterly grant monitoring schedule will be established. As part of this process, the Accounting Department will review expenditure reports for all active grants, estimate receivable amounts, and ensure timely recognition of revenue in accordance with applicable accounting standards. 3. Formal Documentation and Workflow Procedures: The City will develop written procedures detailing the steps for monitoring grant expenditures, estimating receivables, reconciling recorded amounts to actual reimbursement submissions, and communicating with grant managing departments. 4. Departmental Training: The City will provide training to staff involved in grant management to ensure all departments understand the updated process and the importance of timely expenditure reporting. These corrective actions will strengthen internal controls, improve accuracy in financial reporting, and ensure compliance with federal grant reimbursement requirements. Anticipated Completion Date: Procedures will be drafted and implemented by June 30, 2026, with quarterly monitoring beginning immediately thereafter. Views of Responsible Officials: The City concurs with the auditors’ findings and recommendations.
Estacada School District submits this Corrective Action Plan in response to audit finding SA-2025-02, included in the District’s audit report for the fiscal year ended June 30, 2025, related to the Child Nutrition Cluster federal programs. Finding SA-2025-02 – Significant Deficiency Federal Program:...
Estacada School District submits this Corrective Action Plan in response to audit finding SA-2025-02, included in the District’s audit report for the fiscal year ended June 30, 2025, related to the Child Nutrition Cluster federal programs. Finding SA-2025-02 – Significant Deficiency Federal Program: 10.553, 10.555, 10.559 Child Nutrition Cluster Condition: NSLP reimbursement claims were submitted without consistent evidence of independent review and documentation prior to submission. Cause: Staffing turnover and workload demands contributed to inconsistent review practices. Recommendation: Assign an individual other than the preparer to review NSLP reimbursement claims prior to submission and retain documentation of the review. Corrective Action Plan The District has implemented procedures requiring all NSLP reimbursement claims to be reviewed and approved by an individual independent of the preparer prior to submission. A standardized review and documentation process has been implemented to ensure review is consistently completed and retained with claim submission records. Written procedures and cross-training will continue to support consistency and continuity. Implementation Date Corrective actions were implemented during in July 2025 and are currently in place as of February 2026.
The Department agrees with the recommendation. The Center for Accounting (CFA) and the Office of Transportation Safety (OTS) have coordinated to implement updated reviews and controls. This implementation involves reviewing current processes to ensure supporting documentation is vetted and grant com...
The Department agrees with the recommendation. The Center for Accounting (CFA) and the Office of Transportation Safety (OTS) have coordinated to implement updated reviews and controls. This implementation involves reviewing current processes to ensure supporting documentation is vetted and grant compliance is verified prior to payment. It also includes assessing the need for increased monitoring to ensure initial program reviews are complete and accurate. This remediation effort was finalized on June 30, 2025, following the September 2024 transaction in question. Additionally, the Department plans to review the remediation plan with all relevant staff again this season. This will ensure that all supporting documentation is thoroughly vetted and that expenditures comply with the applicable award period of performance.
The Colorado Department of Transportation (CDOT) agrees with the recommendation. The Center for Accounting (CFA) and the Office of Transportation Safety (OTS) have coordinated on its implementation. The Department has assessed and updated training for staff responsible for reviewing and approving in...
The Colorado Department of Transportation (CDOT) agrees with the recommendation. The Center for Accounting (CFA) and the Office of Transportation Safety (OTS) have coordinated on its implementation. The Department has assessed and updated training for staff responsible for reviewing and approving invoices for Highway Safety Cluster grants, with a specific focus on the period of performance. This training plan will be revisited and reviewed with all staff involved by April 2026.
The Department agrees with the recommendation and will strengthen internal controls over Children’s Basic Health Plan eligibility determinations to ensure compliance with federal and state regulations. The Department will issue formal Management Decision Letters to the identified counties requiring ...
The Department agrees with the recommendation and will strengthen internal controls over Children’s Basic Health Plan eligibility determinations to ensure compliance with federal and state regulations. The Department will issue formal Management Decision Letters to the identified counties requiring Department-approved Corrective Action Plans. These plans will be required to address root causes related to income documentation, application of correct income thresholds, and compliance with CBHP eligibility requirements, including any necessary training or guidance for county and Medical Assistance site caseworkers. The Department will review, approve, and monitor corrective actions to ensure deficiencies are addressed.
The Council is award of the requirements concerning advances from the Payment Management System and plan to establish internal controls concerning such advances in the future.
The Council is award of the requirements concerning advances from the Payment Management System and plan to establish internal controls concerning such advances in the future.
Re: Finding 2025 001 – Significant Deficiency in Internal Control Over Financial Reporting – Preparation of the Schedule of Expenditures of Federal Awards (SEFA) The Corporation agrees with the recommendation. Management acknowledges that certain federal expenditures were not initially reported on t...
Re: Finding 2025 001 – Significant Deficiency in Internal Control Over Financial Reporting – Preparation of the Schedule of Expenditures of Federal Awards (SEFA) The Corporation agrees with the recommendation. Management acknowledges that certain federal expenditures were not initially reported on the Schedule of Expenditures of Federal Awards (SEFA) in the appropriate fiscal periods due to a misunderstanding of applicable Uniform Guidance requirements and reliance on prior audit treatment. Specifically, expenditures related to Federal Emergency Management Agency (FEMA) programs were not included on the SEFA until reimbursement was received, and certain per patient payments associated with federally funded research were not initially identified as SEFA reportable. To address this matter and strengthen internal controls over the preparation and review of the SEFA, management will implement the following corrective actions: • Future FEMA expenditures will be reported on the SEFA in the fiscal year in which the projects are obligated and eligible expenditures are incurred, regardless of the timing of reimbursement. • Per patient payments received in connection with federally funded research programs will be evaluated for SEFA reporting and included as required. • A formal Standard Operating Procedures related to the preparation of the SEFA will be developed and implemented to clarify reporting requirements for obligated expenditures, per patient grant activity, and other federal awards. • Review procedures will be enhanced to include confirmation by entity and corporate leadership that all federal awards and related expenditures have been identified, evaluated, and appropriately reported on the SEFA. • Management will evaluate opportunities to complete SEFA preparation and preliminary review earlier in the audit cycle to allow for timely identification and resolution of potential reporting issues. Management believes these actions will improve the accuracy and completeness of the SEFA and reduce the risk of similar issues in future reporting periods.
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