Corrective Action Plans

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Name of auditee: City of Fulton, New York TIN: 15-6000406 Name of Audit Firm: EFPR Group, CPAs, PLLC Period covered by audit: December 31, 2023 CAP prepared by: Misty DeGroat Current Finding on the Schedule of Findings and Questioned Costs and Recommendations (3) Finding 2023-003 (a) Comments on the...
Name of auditee: City of Fulton, New York TIN: 15-6000406 Name of Audit Firm: EFPR Group, CPAs, PLLC Period covered by audit: December 31, 2023 CAP prepared by: Misty DeGroat Current Finding on the Schedule of Findings and Questioned Costs and Recommendations (3) Finding 2023-003 (a) Comments on the finding and recommendations - Management agrees with the finding. Management also agrees with the recommendation. See below for action taken. (b) Action taken - The City acknowledges the finding and will work with a third party specialist to obtain all audit information closer to the end of the year to ensure that all future reporting deadlines can be met.
Management concurs with this finding and acknowledges that this is a repeat finding from the prior year (2022-001). The Alliance takes this matter seriously and recognizes that the prior corrective action plan was insufficient in scope and specificity to prevent recurrence. To fully remediate this d...
Management concurs with this finding and acknowledges that this is a repeat finding from the prior year (2022-001). The Alliance takes this matter seriously and recognizes that the prior corrective action plan was insufficient in scope and specificity to prevent recurrence. To fully remediate this deficiency and ensure timely compliance with the reporting requirements of 2 CFR 200.512, the Alliance has implemented or will implement the following corrective actions 1. Concurrent Single Audits for FY 2023 - 2024 and FY 2024 - 2025. The Alliance will conduct concurrent audits on the currently late years to bring filing status to the current year. 2 Formal Fiscal Policy Adopted. The Alliance will adopt a formal fiscal policy governing the Single Audit process, which establishes a detailed project timeline with clearly defined milestones, responsible parties, and internal deadlines for each phase of the audit cycle — including year-end close, preparation of financial statements, auditor fieldwork, draft review, and submission of the SF-SAC Data Collection Form to the Federal Audit Clearinghouse (FAC). 3. Reverse-Engineered Timeline. The project timeline is structured to work backward from the 9-month federal deadline (March 31 for a June 30 fiscal year-end), building in a minimum 30-day buffer to ensure all deliverables — including management review of draft financial statements, resolution of auditor inquiries, and final submission — are completed well in advance of the statutory due date.4 Designated Responsible Party. The Administrative Services Officer, with regular reviews by the Executive Director, has been designated as the responsible party for monitoring progress against the timeline and escalating delays to the Executive Director and Board of Directors if any milestone is at risk of being missed.5 . Quarterly Progress Reporting. Beginning in the first quarter following fiscal year-end, the Administrative Services Officer will provide quarterly progress updates to the Executive Director on the status of the Single Audit, including any identified risks to the timeline. 6.Auditor Engagement Timeline. The Alliance will execute its audit engagement letter no later than 60 days after fiscal year-end and will provide all requested schedules and supporting documentation to the auditors within 90 days of fiscal year-end to ensure adequate time for fieldwork and report issuance. 7. Internal Controls Over Reporting. The Alliance will implement a closing checklist and internal review process to ensure that all reconciliations, adjusting entries, and supporting schedules are completed and reviewed prior to the commencement of auditor fieldwork. Estimated Completion Date: Fully implemented for the fiscal year ending June 30, 2024 audit cycle.Responsible Party: Taylor Swain, Administrative Services Officer
2023-003 SCDA Special Tests Significant Deficiency and Non-Material Noncompliance Corrective Action: We've hired competent staff that understand how to reconcile inventory to the general ledger. Person Responsible: Stephano Blake Email: S8lake@harvesthope.org Phone: 803-636-6635
2023-003 SCDA Special Tests Significant Deficiency and Non-Material Noncompliance Corrective Action: We've hired competent staff that understand how to reconcile inventory to the general ledger. Person Responsible: Stephano Blake Email: S8lake@harvesthope.org Phone: 803-636-6635
Condition The reporting package and data collection form for the fiscal year ended September 30, 2023 were not submitted to the Federal Audit Clearinghouse by the June 30, 2024 deadline required under 2 CFR §200.512(a). This represents a repeat finding from the prior audit period. Corrective Action ...
Condition The reporting package and data collection form for the fiscal year ended September 30, 2023 were not submitted to the Federal Audit Clearinghouse by the June 30, 2024 deadline required under 2 CFR §200.512(a). This represents a repeat finding from the prior audit period. Corrective Action Plan RJI acknowledges the delayed completion and submission of the Single Audit and has implemented corrective actions designed to strengthen financial oversight, improve audit readiness, and ensure timely completion of future federal and state reporting requirements. To address the root causes identified, RJI has implemented the following corrective measures. Strengthened Financial and Grants Infrastructure RJI has expanded organizational financial capacity through dedicated finance and grants management staffing with responsibility for grant tracking, financial reconciliation, audit preparation, and compliance monitoring. Formalized Audit Preparation and Annual Compliance Calendar RJI has established a documented year-end financial close and audit readiness calendar that includes internal deadlines for monthly reconciliations, grant closeout procedures, preparation of supporting schedules, auditor request tracking, draft review periods, and Federal Audit Clearinghouse submission timelines. Enhanced Fiscal Sponsor Coordination and Governance Procedures RJI has refined communication and workflow processes with its fiscal sponsor and external financial partners by implementing recurring financial review meetings, defined responsibility matrices, and standardized documentation requirements to ensure timely access to financial records and audit support. Established Audit Continuity and Vendor Management Procedures Recognizing prior disruptions caused by auditor transitions and capacity limitations, RJI has implemented procedures to maintain continuity of audit services including earlier auditor engagement, documented deliverables and timelines, periodic status meetings, and contingency planning for audit completion. Ongoing Monitoring and Board Oversight Financial compliance status, audit progress, and reporting deadlines will be reviewed regularly by executive leadership and reported to the Board of Directors (or Finance/Audit Committee, if applicable) until all required filings are completed and sustained. Documentation and Internal Controls Enhancement RJI has strengthened record retention, reconciliation procedures, and grant documentation practices to improve the completeness and availability of records required for annual audit testing and federal reporting Anticipated Completion Date Corrective actions began implementation in November 2025 and are expected to be fully operational and incorporated into all future annual audit and federal reporting cycles beginning with FY2026 reporting requirements. Status In Progress / Partially Implemented RJI has completed staffing and process improvements and is actively implementing monitoring procedures to ensure sustained compliance with 2 CFR §200.512(a) and timely submission of future Single Audit reporting packages. Management Statement Management believes the corrective actions implemented will ensure full compliance with federal and state reporting requirements and prevent recurrence of late audit submissions. Responsible Individual Dr. Liza Chowdhury Executive Director Date: 5/26/2026
2023-003 Federal Clearinghouse Late Filing Name of Contact Person: Beth Chumley, CEO Corrective Action: The Organization will complete the audit process within the time period allowed and submit the audit to the clearinghouse in that time frame. Proposed Completion Date: June 30, 2026
2023-003 Federal Clearinghouse Late Filing Name of Contact Person: Beth Chumley, CEO Corrective Action: The Organization will complete the audit process within the time period allowed and submit the audit to the clearinghouse in that time frame. Proposed Completion Date: June 30, 2026
Response: Management concurs with the finding. Corrective Action Plan: NewSpace Nexus will ensure all required financial and programmatic reports are prepared and submitted on time in accordance with grant requirements. A centralized reporting calendar will track deadlines, and responsibilities for ...
Response: Management concurs with the finding. Corrective Action Plan: NewSpace Nexus will ensure all required financial and programmatic reports are prepared and submitted on time in accordance with grant requirements. A centralized reporting calendar will track deadlines, and responsibilities for preparation, review, and submission will be clearly assigned. Program reports will be prepared by the VP Programs Manager, reviewed by the Executive Director, and documentation of submission will be retained. Financial reports will be prepared by the Financial Analyst, reviewed by the Executive Director, and documentation of submission will be retained. Periodic checks will be performed to ensure compliance, and any issues will be addressed promptly. Designation of Employee Position Responsible for Meeting Deadline: Financial Analyst, by March 31st, 2024
Response: Management concurs with the finding. Corrective Action Plan: NewSpace Nexus will maintain written financial and grants management policies to support consistent operations and compliance with Uniform Guidance (2 CFR Part 200). These policies will cover key areas including allowable costs, ...
Response: Management concurs with the finding. Corrective Action Plan: NewSpace Nexus will maintain written financial and grants management policies to support consistent operations and compliance with Uniform Guidance (2 CFR Part 200). These policies will cover key areas including allowable costs, procurement, cash management, subrecipient monitoring, reporting, record retention, and internal controls. The Financial Analyst will be responsible for maintaining and updating these policies, with oversight from the Executive Director, and policies will be reviewed at least annually and updated as needed. Designation of Employee Position Responsible for Meeting Deadline: Financial Analyst, by March 31st, 2024
Response: Management concurs with the finding. Corrective Action Plan: NewSpace Nexus will comply with federal employment eligibility requirements by ensuring a Form I-9 is completed for every employee within three business days of their start date. Employees must provide acceptable documentation as...
Response: Management concurs with the finding. Corrective Action Plan: NewSpace Nexus will comply with federal employment eligibility requirements by ensuring a Form I-9 is completed for every employee within three business days of their start date. Employees must provide acceptable documentation as required, and completed forms will be securely maintained and retained for the required period. The Financial Analyst will periodically review personnel files to confirm compliance, and any missing or incomplete forms will be addressed promptly with documentation of corrective actions retained. Designation of Employee Position Responsible for Meeting Deadline: Financial Analyst by: January 31st, 2024
Finding: 2023-011 Agency: Children & Youth Contact Person/Title: Erin Moyer. Administrator of Children & Youth Services Finding Title/Corrective Action: Special Tests and Provisions (DHS Special Tests - FSP) The Agency has a Timeframes Policy which outlines when ISP’s (FSP’s) are to be completed in ...
Finding: 2023-011 Agency: Children & Youth Contact Person/Title: Erin Moyer. Administrator of Children & Youth Services Finding Title/Corrective Action: Special Tests and Provisions (DHS Special Tests - FSP) The Agency has a Timeframes Policy which outlines when ISP’s (FSP’s) are to be completed in accordance with state regulations. This late ISP (FSP) was an exception and is not a systemic Agency issue. Anticipated Completion Date: April 2026
Finding: 2023-009 Agency: Children & Youth Contact Person/Title: Erin Moyer. Administrator of Children & Youth Services Finding Title/Corrective Action: Special Tests and Provisions (DHS Special Tests - ISP) The Agency has a Timeframes Policy which outlines when ISP’s (FSP’s) are to be completed in ...
Finding: 2023-009 Agency: Children & Youth Contact Person/Title: Erin Moyer. Administrator of Children & Youth Services Finding Title/Corrective Action: Special Tests and Provisions (DHS Special Tests - ISP) The Agency has a Timeframes Policy which outlines when ISP’s (FSP’s) are to be completed in accordance with state regulations. This late ISP (FSP) was an exception and is not a systemic Agency issue. Anticipated Completion Date: April 2026
Finding: 2023-008 Agency: Children & Youth Contact Person/Title: Erin Moyer. Administrator of Children & Youth Services Finding Title/Corrective Action: Special Tests and Provisions (DHS Special Tests - Licensure/Approval) We are now monitoring all clearances, licenses, background checks, and COC’s ...
Finding: 2023-008 Agency: Children & Youth Contact Person/Title: Erin Moyer. Administrator of Children & Youth Services Finding Title/Corrective Action: Special Tests and Provisions (DHS Special Tests - Licensure/Approval) We are now monitoring all clearances, licenses, background checks, and COC’s are checked regularly. Anticipated Completion Date: January 2025
Finding: 2023-007 Agency: Children & Youth Contact Person/Title: Erin Moyer. Administrator of Children & Youth Services Finding Title/Corrective Action: Special Tests and Provisions (DHS Common Requirements - Drug-Free Workplace Act) Our fiscal department will begin putting language in our contracts...
Finding: 2023-007 Agency: Children & Youth Contact Person/Title: Erin Moyer. Administrator of Children & Youth Services Finding Title/Corrective Action: Special Tests and Provisions (DHS Common Requirements - Drug-Free Workplace Act) Our fiscal department will begin putting language in our contracts beginning in the FY 25-26. For those contracts already signed, an addendum will be sent to providers to add this language. Anticipated Completion Date: August 2025
Finding: 2023-006 Agency: Children & Youth Contact Person/Title: Erin Moyer. Administrator of Children & Youth Services Finding Title/Corrective Action: Special Tests and Provisions (DHS Common Requirements – Subrecipient Monitoring) We are now monitoring in-home providers to make sure all time is a...
Finding: 2023-006 Agency: Children & Youth Contact Person/Title: Erin Moyer. Administrator of Children & Youth Services Finding Title/Corrective Action: Special Tests and Provisions (DHS Common Requirements – Subrecipient Monitoring) We are now monitoring in-home providers to make sure all time is accounted for as well as clearances, background checks and COC’s for both in-home and placement providers. Anticipated Completion Date: January 2025
Finding: 2023-005 Agency: Children & Youth Contact Person/Title: Erin Moyer. Administrator of Children & Youth Services Finding Title/Corrective Action: Eligibility – Missing Documentation Documentation for eligibility will be reviewed with staff and files will be reviewed by a supervisor. A supervi...
Finding: 2023-005 Agency: Children & Youth Contact Person/Title: Erin Moyer. Administrator of Children & Youth Services Finding Title/Corrective Action: Eligibility – Missing Documentation Documentation for eligibility will be reviewed with staff and files will be reviewed by a supervisor. A supervisor checklist will be used to make sure documents are reviewed. Our IV-E files are also reviewed twice a year by a state IV-E QA team. Anticipated Completion Date: January 2026
Finding: 2023-003 Agency: Children & Youth Contact Person/Title: Erin Moyer. Administrator of Children & Youth Services Finding Title/Corrective Action: Reporting Consistent with our response to 2023-001, our fiscal department will begin implementing a monthly balancing of bank accounts with the gene...
Finding: 2023-003 Agency: Children & Youth Contact Person/Title: Erin Moyer. Administrator of Children & Youth Services Finding Title/Corrective Action: Reporting Consistent with our response to 2023-001, our fiscal department will begin implementing a monthly balancing of bank accounts with the general ledger and accounts receivable. We will also be doing quarterly balancing, which will help keep us on a more timely schedule. Anticipated Completion Date: August 2025
The County has implemented a process of internal controls where expenditures are tracked in a manner that will coincide with reporting requirements for state expenditures for SEFA reporting.
The County has implemented a process of internal controls where expenditures are tracked in a manner that will coincide with reporting requirements for state expenditures for SEFA reporting.
Finding 2023-004 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Housing Voucher Cluster, Public and Indian Housing Program, Public Housing Capital Fund Program, and Coronavirus Relief Fund Assistance Listing Numbers: 14.871, 14.879, 14.850, 14.872, and 21.01...
Finding 2023-004 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Housing Voucher Cluster, Public and Indian Housing Program, Public Housing Capital Fund Program, and Coronavirus Relief Fund Assistance Listing Numbers: 14.871, 14.879, 14.850, 14.872, and 21.019 Material Noncompliance Non Compliance Material to the Financial Statements: Yes Material Weakness in Internal Control over Compliance Criteria: The Authority must maintain complete and accurate accounts and other records for the program in accordance with HUD compliance requirements. Condition: The Authority did not maintain complete and accurate accounts and other records in accordance with HUD compliance requirements regarding Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Eligibility, Reporting, and Special Tests and Provisions. Context: The Authority was unable to provide requested documentation at the time of audit to properly test the HUD compliance requirements. Known Questioned Costs: Unknown Cause: There is a material weakness in internal controls over compliance related to the maintenance of tenant files, wait lists, inspection reports and other records. The Authority has not properly considered, designed, implemented, maintained and monitored a system of internal controls that reasonably assures the program is in compliance. Effect: The Housing Voucher Cluster is in material non- compliance with the compliance requirements of the program. Recommendation: We recommend that the Authority implement a process whereby Authority documents are stored and safeguarded to ensure compliance with the Uniform Guidance and the compliance supplement. View of Responsible Officials and Corrective Actions: The Authority experienced significant turnover in employees during the year and as a result certain source documents were misplaced or destroyed. Management agrees with the Auditors' finding and has hired a new Executive Director who will implement the required safeguards and ensure that the Authority follows its internal control over compliance processes and procedures related to the Housing Voucher Cluster, Public and Indian Housing Program and Public Housing Capital fund Program to remedy the aforementioned deficiencies. Byran McClellan, CFO, will be responsible to implement this corrective action by December 31, 2023.
Finding Reference Number: 2023-011 Description of Finding: The data collection form was not submitted by the September 30, 2024 due date. Response/Corrective Action: Due to fiscal staffing concerns and contracted auditor scheduling and subsequent change in auditors, preparation of all supporting doc...
Finding Reference Number: 2023-011 Description of Finding: The data collection form was not submitted by the September 30, 2024 due date. Response/Corrective Action: Due to fiscal staffing concerns and contracted auditor scheduling and subsequent change in auditors, preparation of all supporting documentation and draft financial statements were significantly delayed as was physical fieldwork, forcing the noncompliance. Upon completion of the 2023 audit, the County will be reliant on the scheduling availability of the County’s appointed auditors to coordinate and complete fieldwork timely to meet the filing for the 2025 audit. The 2024 data collection form was not submitted by the September 30, 2025 due date, and will be completed and filed as timely as the County’s appointed auditors can schedule, coordinate, and complete fieldwork.
FINDING 2023-004- Late Submission of Single Audit and FAC Data Collection Form SIGNIFICANT DEFICIENCY; NONCOMPLIANCE Identification of the Federal Program: U.S. Department of Health and Human Services; direct awards ALN: 93 .011, 93.224/93.527, 93.526, and 93.918 Compliance Requirement: Reporting Cr...
FINDING 2023-004- Late Submission of Single Audit and FAC Data Collection Form SIGNIFICANT DEFICIENCY; NONCOMPLIANCE Identification of the Federal Program: U.S. Department of Health and Human Services; direct awards ALN: 93 .011, 93.224/93.527, 93.526, and 93.918 Compliance Requirement: Reporting Criteria: Uniform Guidance requires nonfederal entities to submit the reporting entity's Uniform Guidance reporting package, including the audit report and completed Federal Audit Clearinghouse (F AC) Data Collection Form, to the F AC within the earlier of 30 calendar days after receipt of the auditor's rep01ts or nine months after fiscal year-end (2 CFR 200. 512( a)). Timely submission of the reporting package is required to facilitate federal oversight of award compliance. Context: The condition was identified during Single Audit testing of reporting requirements applicable to the Health Center Cluster. Sampling was not utilized. Condition: The Center did not submit its required Uniform Guidance reporting package, including the reporting entity's audit report and the FAC Data Collection Form, within the required submission timeframe. Specifically, the Uniform Guidance audit and related FAC Data Collection Form were submitted after the earlier of (1) 3 0 calendar days after receipt of the auditor's reports or (2) nine months after the end of the reporting entity's fiscal year. Cause: Due to a delay in the compiling of records related to the audit, the Center was not in compliance with the reporting requirements. Effect or Potential Effect: Failure to submit the Uniform Guidance audit and F AC Data Collection Form timely increases the risk of noncompliance with Uniform Guidance reporting requirements and may result in delayed federal oversight, increased monitoring by the awarding agency, or the imposition of additional administrative conditions. Questioned Costs: No questioned costs were identified as a result of this finding. Repeat Finding: This is a repeat finding. Recommendation: The Center should strengthen internal controls over Uniform Guidance audit reporting by ·implementing procedures to track submission deadlines, assigning responsibility for timely filing of the audit report and FAC Data Collection Form, and establishing management review processes to ensure compliance with Uniform Guidance reporting requirements. View of Responsible Officials: Neighborhood's prior auditor indicated just before time to begin the audit for FY2022; they would not be able to complete the audit because of staff sho1tages. Two RFPs were issued, and it took the center a year and a half to secure a new auditor. The 2022 and 2023 audits have been completed. Engagement contract has been issued for the 2024 audit.
Corrective action is in process. In March 2026, the Organization contracted with a public accounting firm to function as the CFO and provide other accounting and finance support. These individuals are working to reestablish timely internal and external reporting. It is expected that 2026 year end re...
Corrective action is in process. In March 2026, the Organization contracted with a public accounting firm to function as the CFO and provide other accounting and finance support. These individuals are working to reestablish timely internal and external reporting. It is expected that 2026 year end reporting will be timely. Management agrees with the finding. The Single Audit report was not submitted to the Federal Audit Clearinghouse within the required nine-month timeframe due to delays in completing year-end financial reporting and audit fieldwork. We recognize the importance of timely submission to ensure compliance with Uniform Guidance requirements. The Organization has contracted with a public accounting firm to implement measures to strengthen its year-end close process, improve coordination with the external auditors, and establish internal deadlines that ensure all reporting components are completed well in advance of the federal due date.
Finding No.: 2023-006 Area: Reporting Views of responsible official and planned corrective actions: The Trust has updated its due diligence checklist to include specific steps to ensure compliance with Federal Funding Accountability and Transparency Act (FFATA) requirements. This includes identifying...
Finding No.: 2023-006 Area: Reporting Views of responsible official and planned corrective actions: The Trust has updated its due diligence checklist to include specific steps to ensure compliance with Federal Funding Accountability and Transparency Act (FFATA) requirements. This includes identifying qualifying subawards, collecting required reporting data, and ensuring timely submission of reports. These procedures have been integrated into the Trust’s grant management processes to strengthen internal controls and support full compliance with applicable federal regulations and grantor expectations. Contact Person: Melanie Lawrence Aiseam, Chief Financial Officer Expected Completion Date: The Trust started working on the checklist last year and finalized it in Q4 2025.
Finding No.: 2023-004 Area: Reporting Views of responsible official and planned corrective actions: The Trust has updated its due diligence checklist to include specific steps to ensure compliance with Federal Funding Accountability and Transparency Act (FFATA) requirements. This includes identifying...
Finding No.: 2023-004 Area: Reporting Views of responsible official and planned corrective actions: The Trust has updated its due diligence checklist to include specific steps to ensure compliance with Federal Funding Accountability and Transparency Act (FFATA) requirements. This includes identifying qualifying subawards, collecting required reporting data, and ensuring timely submission of reports. These procedures have been integrated into the Trust’s grant management processes to strengthen internal controls and support full compliance with applicable federal regulations and grantor expectations. Contact Person: Melanie Lawrence Aiseam, Chief Financial Officer Expected Completion Date: The Trust started working on the checklist last year and finalized it in Q4 2025.
2023-001 REPORTING Recommendation: Reports prepared by the Executive Director should be reviewed by an independent person to ensure completeness and accuracy. Additionally, the Organization should design a control to ensure reports are submitted in a timely manner in accordance with compliance requi...
2023-001 REPORTING Recommendation: Reports prepared by the Executive Director should be reviewed by an independent person to ensure completeness and accuracy. Additionally, the Organization should design a control to ensure reports are submitted in a timely manner in accordance with compliance requirements. Corrective Action: Community of Hope recognizes that our expansion and growth have made it difficult to maintain full and timely compliance with some reporting criter+B11 ia. As such, we have created a compliance calendar that will alert staff to impending deadlines and requirements. In addition, we recently hired a staff member with compliance being a primary function. She is reviewing grant and policy compliance, making recommendations, and instituting changes to enhance compliance. Responsible party: Drew Warren, Executive Director Date Expected to be Corrected: March 1, 2026
Finding 2023-012 - Single Audit Reporting Auditee's Response and Planned Corrective Action The Town will work with the accounting department, fee accountant, and audit fmn to file the required reports timely. Planned Implementation Date of Corrective Action: January 2026 Person Responsible for Corre...
Finding 2023-012 - Single Audit Reporting Auditee's Response and Planned Corrective Action The Town will work with the accounting department, fee accountant, and audit fmn to file the required reports timely. Planned Implementation Date of Corrective Action: January 2026 Person Responsible for Corrective Action: Fred Costello, T own Supervisor
Finding No: 2023 001 Federal Agency: U.S. Department of Homeland Security Federal Emergency Management Agency Assistance Listing Number: 97.036 Program: COVID 19 – Disaster Grants Public Assistance (Presidentially Declared Disasters) Award Year: July 1, 2022 to June 30, 2023 Compliance Requirement: ...
Finding No: 2023 001 Federal Agency: U.S. Department of Homeland Security Federal Emergency Management Agency Assistance Listing Number: 97.036 Program: COVID 19 – Disaster Grants Public Assistance (Presidentially Declared Disasters) Award Year: July 1, 2022 to June 30, 2023 Compliance Requirement: Other – Inaccurate reporting of the Schedule of Expenditures of Federal Awards Criteria According to 2 CFR 200.510(b), a recipient of federal awards is required to prepare a schedule of expenditures of federal awards (SEFA) 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. Conditions Found The System did not have adequate controls related to the identification and reporting of federal expenditures for the COVID 19 – Disaster Grants Public Assistance (Presidentially Declared Disasters) program on the SEFA. Specifically, the System lacked controls to ensure expenditures incurred for COVID 19 Disaster Grants Public Assistance (Presidentially Declared Disasters) program were recognized on the SEFA when obligated. As a result, $16,310,090 of FEMA expenditures were omitted from the June 30, 2023 SEFA. Cause 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. Effect Failure to establish effective internal controls over the preparation of the SEFA may prevent the System from reporting accurate program information and completing an audit in accordance with the Uniform Guidance. Questioned Cost Not applicable Statistical Sample The sample was not intended to be, and was not, a statistically valid sample. Repeat Finding in the Prior Year Not a repeat finding. Recommendation We recommend that the System strengthen its processes and internal controls over ensuring that proper recognition of expenditures have been reported completely and accurately on SEFA. View of Responsible Official Wellstar Health System, Inc. has implemented a control and process to ensure that expenditures are properly reflected on the SEFA. Corrective Action Plan Wellstar Health System, Inc. has implemented a control and process to ensure that expenditures are properly reflected on the SEFA at time of obligation. Anticipated Completion Date: Wellstar Health System, Inc has already implemented the corrective action. Name of Contact Person for Corrective Action: Beth Loudermilk, VP Financial Planning & Analysis
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