Corrective Action Plans

Finding 1158080 (2023-007)

Material Weakness 2023

AK

Allowable Costs / Cost Principles Material Weakness Reporting

Finding 2023-007 Lack of Internal Control over Activities Allowed or Unallowed and Allowable Costs/Cost Principles Type of Finding: Material weakness in internal control over compliance and material Noncompliance. Name of Contact: Adela Lane, Executive Director Corrective Action Plan: 1. Update and ...

Finding 2023-007 Lack of Internal Control over Activities Allowed or Unallowed and Allowable Costs/Cost Principles Type of Finding: Material weakness in internal control over compliance and material Noncompliance. Name of Contact: Adela Lane, Executive Director Corrective Action Plan: 1. Update and Disseminate Financial Management Policies: • Action: Formally update and reissue Chapter III (Financial Management) of the Administrative Manual to specifically include the following requirements for all payroll-related actions. o Mandatory use of the payment authorization form for all employee pays rate changes, bonuses, or other non-standard payments. o Verification of all signatories against a current, board-approved signatory list. o A documented review step during each payroll run where the personnel action recommendation form is compared against the actual pay rate being processed. • Responsible Party: Executive Director and Financial Specialist. 2. Implement a Structured Payroll Review Process: • Action: Establish a mandatory, documented two-step review process for every payroll cycle. o Step 1: The Financial Specialist will review all payment authorization forms and verify signatories. o Step 2: The Financial Specialist will compare the pay rates in the payroll system to the approved rates on the personnel action recommendation forms and initial the review for the record. • Responsible Party: Financial Specialist. 3. Conduct Mandatory Training for Staff: • Action: Provide comprehensive and mandatory training for all relevant staff (e.g., payroll clerks, program managers) on the updated financial management policies and payroll review protocols. This training will cover: o Proper use and routing of payment authorization forms. o Verification procedures for pay rates. o The importance of maintaining proper documentation. • Responsible Party: Executive Director, in coordination with the Financial Specialist 4. Transition to New Permanent Administration: • Action: As part of the onboarding process for the new permanent Administration, the following will occur: o The Executive Director will hold a comprehensive "sit-down" session to review and reinforce all financial management and payroll protocols. o The new team will be provided with the updated Administrative Manual and all relevant training materials. o A transition checklist will be used to ensure all key financial controls are properly handed over and understood. • Responsible Party: Executive Director. 5. Verification of Effectiveness: • Action: After the new procedures are implemented, the Executive Director and Tribal Council will perform a periodic review of a sample of payroll records to ensure compliance with the new internal controls. • Responsible Party: Tribal Council and Executive Director. Proposed Completion Date: Ongoing, starting in early 2026.

View Audit 370022

Finding 1157289 (2023-005)

Material Weakness 2023

Laporte County

IN

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.303

FINDING 2023-005 Finding Subject: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds – Suspension and Disbarment: Summary of Finding: Material Weakness, Modified Opinion An effective internal control system, which would include segregation of duties, was not in place at the County in order...

FINDING 2023-005 Finding Subject: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds – Suspension and Disbarment: Summary of Finding: Material Weakness, Modified Opinion An effective internal control system, which would include segregation of duties, was not in place at the County in order to ensure compliance with requirements related to the grant agreement and the procurement and suspension and debarment compliance. Prior to entering into subawards and covered transactions with Coronavirus State and Local Fiscal Recovery Funds (CSLFRF), SLFRF funds, recipients are required to verify that contractors and subrecipients are not suspended, debarred, or otherwise excluded. Upon inquiring of the County to determine its policies and procedures related to suspension and debarment requirements for the CSLFRF, SLFRF funds, the County stated procedures were not in place to ensure vendors were not suspended or debarred prior to entering into covered transactions. The County had not performed procedures to ensure the vendors were not suspended or debarred or otherwise excluded or disqualified from participation in federal assistance programs or activities during the audit period on all of the 13 vendors determined to have covered transactions totaling $4,440,497, that were paid with SLFRF funds. The lack of internal controls and compliance under the previous Auditor Timothy J. Stabosz were systemic issues throughout the audit period. Contact Person Responsible for Corrective Action: Michael Rosenbaum Contact Phone Number and Email Address: 219-326-6808 Ext. 2226; mrosenbaum@laporteco.in.gov INDIANA STATE BOARD OF ACCOUNTS 44 Views of Responsible Official: We concur with the finding under the prior Auditor Timothy J. Stabosz. Description of Corrective Action Plan: Policies and procedures will be put in place to search on sam.gov to determine if a vendor has been suspended or disbarred. Anticipated Completion Date: August 2025

View Audit 369585

Finding 1156816 (2023-002)

Material Weakness 2023

Wichita County, Texas

TX

Reporting § 200.328

Finding: The County’s first quarter 2023 performance report incorrectly included expenditures that were incurred throughout fiscal year 2022. Cause: The County did not have adequate controls or procedures in place to identify the applicable reporting requirement and ensure the information was filed ...

Finding: The County’s first quarter 2023 performance report incorrectly included expenditures that were incurred throughout fiscal year 2022. Cause: The County did not have adequate controls or procedures in place to identify the applicable reporting requirement and ensure the information was filed accurately and timely. Recommendation: Management should implement policies and procedures to ensure required reports are completed accurately and filed by their respective due dates as required by the grant agreement and Uniform Guidance. Corrective Action Plan: Effective immediately, the County will put in additional controls and verify all grants are monitored under additional scrutiny and are reported accurately in quarterly reports and the County’s Annual Comprehensive Financial Report (ACFR). Staff Responsible for Implementation: Matt Davis, County Auditor; Mike Sloan, Senior Associate; Jordan Wilson, Grant Associate Implementation Date: December 31, 2025 Status: In progress

View Audit 369193

Finding 1156794 (2023-004)

Material Weakness 2023

Partners Inland Northwest

WA

Equipment & Real Property Management Special Tests & Provisions Material Weakness

2023-004 The Emergency Food Assistance Program (TEFAP) and Commodity Supplemental Food Program (CSFP) Reporting Corrective action planned: This error was identified in preparation of the 2024 audit in July 2025. We have implemented a system to track federal noncash award inflows and outflows accordi...

2023-004 The Emergency Food Assistance Program (TEFAP) and Commodity Supplemental Food Program (CSFP) Reporting Corrective action planned: This error was identified in preparation of the 2024 audit in July 2025. We have implemented a system to track federal noncash award inflows and outflows according to bills of lading provided by the Contractor. We will reconcile our inventory at a minimum annually. Anticipated completion date: October 31, 2025 Contact person responsible for corrective action: Justin Carlile Justinc@partnersinw.org

View Audit 369170

Finding 1156791 (2023-003)

Material Weakness 2023

Partners Inland Northwest

WA

Eligibility Material Weakness Significant Deficiency

2023-003 Commodity Supplemental Food Program (CSFP) Eligibility Corrective action planned: We have implemented a CSFP application system that requires each element of the application to comply with eligibility standards before continuing to the next step. Anticipated completion date: February 2, 202...

2023-003 Commodity Supplemental Food Program (CSFP) Eligibility Corrective action planned: We have implemented a CSFP application system that requires each element of the application to comply with eligibility standards before continuing to the next step. Anticipated completion date: February 2, 2025 Contact person responsible for corrective action: Justin Carlile Justinc@partnersinw.org

View Audit 369170

Finding 1156584 (2023-004)

Material Weakness 2023

City of Logansport

IN

Procurement, Suspension & Debarment § 200.1 § 200.214 § 200.303 § 200.317 § 200.318

FINDING 2023-004 Finding Subject: Drinking Water State Revolving Fund (DWSRF) Cluster - Procurement and Suspension and Debarment Contact Person Responsible for Corrective Action: Tyler Pearson, Clerk Treasurer Contact Phone Number and Email Address: 574-739-1416 clerktreasurer@cityoflogansport.org V...

FINDING 2023-004 Finding Subject: Drinking Water State Revolving Fund (DWSRF) Cluster - Procurement and Suspension and Debarment Contact Person Responsible for Corrective Action: Tyler Pearson, Clerk Treasurer Contact Phone Number and Email Address: 574-739-1416 clerktreasurer@cityoflogansport.org Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: We will develop and implement a formal process for verifying that vendors are not suspended, debarred, or otherwise excluded from receiving federal funds before entering into contracts or transactions that meet or exceed the $25,000 threshold. The City will develop a purchasing policy that reflects the applicable state laws and regulations related to procurement. The City will also maintain proper documentation to support the appropriate procurement method. Anticipated Completion Date: December 31, 2025

View Audit 368938

Finding 1156583 (2023-003)

Material Weakness 2023

City of Logansport

IN

Questioned Costs Allowable Costs / Cost Principles Internal Control / Segregation of Duties § 200.302 § 200.303 § 200.328 § 200.329 § 200.400

FINDING 2023-003 Finding Subject: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds - Activities Allowed or Unallowed, Allowable Costs/Cost Principles Contact Person Responsible for Corrective Action: Tyler Pearson, Clerk Treasurer Contact Phone Number and Email Address: 574-739-1416 cler...

FINDING 2023-003 Finding Subject: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds - Activities Allowed or Unallowed, Allowable Costs/Cost Principles Contact Person Responsible for Corrective Action: Tyler Pearson, Clerk Treasurer Contact Phone Number and Email Address: 574-739-1416 clerktreasurer@cityoflogansport.org Views of Responsible Officials: We concur with the findings. Description of Corrective Action Plan: As a measure of corrective action, I will be implementing a check sheet that will be attached to every claim sheet. This new procedure requires that you go through the check sheet and initial each item to ensure that all procedures have been followed correctly before submission. Additionally, I will also maintain a check sheet in my office since I am the last person to review each claim. This will help to ensure thoroughness and accuracy in our claims processing. Furthermore, moving forward, any grant funds will be placed into their own individual funds and distributed through an individual account. This approach will allow us to track payments for any expenses associated with these funds more effectively. Additionally, the BOT expenditure is done and in the future we will do a better job. Anticipated Completion Date: October 31,2025

View Audit 368938 Questioned Costs: $1

Finding 1156574 (2023-001)

Material Weakness 2023

On Point Nyc, Inc.

NY

§ 200.512

December 10, 2024 Person responsible: Sam Rivera, Executive Director Fiscal Year Ended June 30, 2023 Section III – Federal Awards Findings and Questioned Costs Item 2023 – 001 Federal Assistance Listing Number: 93.914 and 93.243 HIV Emergency Relief Project Grants Substance Abuse and Mental Health S...

December 10, 2024 Person responsible: Sam Rivera, Executive Director Fiscal Year Ended June 30, 2023 Section III – Federal Awards Findings and Questioned Costs Item 2023 – 001 Federal Assistance Listing Number: 93.914 and 93.243 HIV Emergency Relief Project Grants Substance Abuse and Mental Health Services Projects of Regionals and National Significance Condition The Organization’s Data Collection Form was not submitted to the Federal Audit Clearinghouse within the nine-month period for the year ended June 30, 2023. Views of Responsible Officials and Corrective Action Additional time was needed to complete accurate fiscal records for the year ended June 30, 2023. Monthly closings and fiscal records reconciliations for the year ending June 30, 2024, are timely being conducted. Timely filing of the Data Collection form for the year ended June 30, 2024 is anticipated.

View Audit 368915

Finding 1156443 (2023-001)

Material Weakness 2023

Planned Parenthood Great Northwest, Hawai'i, Alaska, Indiana, Kentucky

WA

Reporting Internal Control / Segregation of Duties Allowable Costs / Cost Principles

Managements Corrective Action Plan Year Ending – December 31, 2023 In response to the Single Audit performed by Baker Tilly US, LLP for calendar year ending December 31, 2023. Schedule of finding and Questioned Costs: Section III – Federal Award Findings: 2023-001 – Reporting Contact: Jennifer Moore...

Managements Corrective Action Plan Year Ending – December 31, 2023 In response to the Single Audit performed by Baker Tilly US, LLP for calendar year ending December 31, 2023. Schedule of finding and Questioned Costs: Section III – Federal Award Findings: 2023-001 – Reporting Contact: Jennifer Moore Title: Controller Phone number: 310-795-0257 Federal Assistance # 93.217 Estimated Completion Date – September 2024 and 2025 Corrective Action - Planned Parenthood Great Northwest, Hawai’i, Indiana, Kentucky has implemented a process improvement plan in 2024 that addresses each of the findings: • In 2024, a new team has taken over the reporting and filing process for our grant awards, including federal. This team is responsible for submitting the reporting and draws by the designated timeline, and it is confirmed as part of the month-end close process. • During this time, we have established a grant tracking document that notates – o The reporting month o Dollar amount expected o Date submitted ▪ This date should always be within the month following the required filing o Date the funding was received o An area to document any information or changes worth noting • In 2025, the following additional items have been added to the tracking document to allow for greater oversight – o Review approval o Reporting requirements o Deadlines (monthly, quarterly, etc.) o Proof of submission

View Audit 368718

Finding 1156120 (2023-009)

Material Weakness 2023

City of Stamford, Connecticut

CT

Reporting

2023-009 – Material Weakness & Noncompliance: SEFA and SESA Accuracy Corrective Action: Require Grants Department to reconcile SEFA and SESA quarterly to general ledger. Develop checklist for grant entry (program name, ALN, award year, grant number). Implement ERP grant tracking functionality. Timel...

2023-009 – Material Weakness & Noncompliance: SEFA and SESA Accuracy Corrective Action: Require Grants Department to reconcile SEFA and SESA quarterly to general ledger. Develop checklist for grant entry (program name, ALN, award year, grant number). Implement ERP grant tracking functionality. Timeline: Initiated in FY25; verified in FY26 reporting. Responsible Party: Grants Officer with Staff Accountant assigned to grants portfolio

View Audit 368535

Finding 1156113 (2023-011)

Material Weakness 2023

City of Stamford, Connecticut

CT

Reporting Eligibility Significant Deficiency § 200.512

2023-011 – Significant Deficiency: Late Single Audit Reporting Packages Corrective Action: Centralize grant management and reporting in the Grants Department. Require reconciliation of SEFA and SESA to the general ledger and project subledgers. Mandate annual training for department grant personnel ...

2023-011 – Significant Deficiency: Late Single Audit Reporting Packages Corrective Action: Centralize grant management and reporting in the Grants Department. Require reconciliation of SEFA and SESA to the general ledger and project subledgers. Mandate annual training for department grant personnel on federal/state reporting requirements. Timeline: Initiated with ERP implementation FY24; full compliance by FY26 reporting. Responsible Party: Grants Officer with support from Controller’s Office

View Audit 368535

Finding 1156031 (2023-010)

Material Weakness 2023

City of Stamford, Connecticut

CT

Questioned Costs Allowable Costs / Cost Principles Internal Control / Segregation of Duties § 200.302

2023-010 – Material Weakness & Noncompliance, Activities Allowed or Unallowed, Allowable Costs/Cost Principles, and Period of Performance: FEMA Disaster Grants (ALN 97.036) Corrective Action: Develop an improved detailed tracking system for force account labor and materials. Require contemporaneous ...

2023-010 – Material Weakness & Noncompliance, Activities Allowed or Unallowed, Allowable Costs/Cost Principles, and Period of Performance: FEMA Disaster Grants (ALN 97.036) Corrective Action: Develop an improved detailed tracking system for force account labor and materials. Require contemporaneous documentation of payroll and invoices tied to FEMA projects. Grants Officer to oversee federal disaster recovery funds. Timeline: New procedures adopted October 2025; effective for any new FEMA claims. Responsible Party: Grants Officer in coordination with relevant departments

View Audit 368535 Questioned Costs: $1

Finding 1155970 (2023-005)

Material Weakness 2023

Incline Village General Improvement District

NV

Internal Control / Segregation of Duties Reporting Matching / Level of Effort / Earmarking § 200.512

(2023-005) Late Submission of Single Audit Reporting Package Criteria Per 2 CFR § 200.512(l), non-federal entities must submit the Single Audit reporting package to the Federal Audit Clearinghouse within the earlier of 30 calendar days after receipt of the auditor’s report or nine months after the f...

(2023-005) Late Submission of Single Audit Reporting Package Criteria Per 2 CFR § 200.512(l), non-federal entities must submit the Single Audit reporting package to the Federal Audit Clearinghouse within the earlier of 30 calendar days after receipt of the auditor’s report or nine months after the fiscal year-end. Condition The District’s reporting package for the fiscal year ended June 30, 2023, was not submitted to the Federal Audit Clearinghouse within the required timeframe. As of the date of this report, the reporting package has not yet been submitted. Cause The District did not have adequate procedures in place to ensure timely completion of the financial audit and preparation of the reporting package. Effect The District did not comply with the Uniform Guidance submission deadline, which may impact the timeliness of federal oversight and potentially affect future federal funding decisions. Questioned Costs No questioned costs were identified as a result of our procedures. Context/Sampling The FY2023 Single audit was performed in 2025 after it was determined that the grant funds were expended on eligible activities, triggering the Single Audit requirement. The delay was due to the District not identifying the requirement timely and lacking procedures to ensure prompt submission. Recommendation We recommend that the District implement processes and internal controls to ensure future Single Audits are completed and submitted within the required timeframe. Management’s Corrective Action Planned Management concurs with the recommendation. IVGID will establish a procedure to review and reconcile grants both federal and state at year-end to determine the need for a single audit and submission to the required agencies.

View Audit 368379

Finding 1155969 (2023-004)

Material Weakness 2023

Incline Village General Improvement District

NV

Procurement, Suspension & Debarment § 200.214

(2023-004) Documentation of Purchasing Compliance - Significant deficiency Criteria Per CFR §180.300 and 2 CFR §200.214, the District must verify vendors are not suspended or debarred or otherwise excluded from participating in a covered transaction. This verification may be accomplished by checking...

(2023-004) Documentation of Purchasing Compliance - Significant deficiency Criteria Per CFR §180.300 and 2 CFR §200.214, the District must verify vendors are not suspended or debarred or otherwise excluded from participating in a covered transaction. This verification may be accomplished by checking the Excluded Parties List System (EPLS) maintained by the General Services Administration (GSA); collecting a certification from the entity, or adding a clause or condition to the covered transaction with that entity. Condition During our testing of suspension and debarment compliance, we noted that the District did not retain documentation demonstrating that vendors were verified as not suspended, debarred, or otherwise excluded from participation in federal programs prior to execution of two contracts, each with expenditures exceeding $25,000. Cause The District did not have formalized procedures to ensure suspension and debarment verifications were performed and documented prior to executing covered contracts. Effect Without adequate verification and documentation, there is a risk that the District could contract with vendors who are ineligible to receive federal funds, resulting in noncompliance with federal regulations. Questioned Costs No questioned costs were identified as a result of our procedures. Context/Sampling Two vendor contracts with expenditures greater than $25,000 were selected for testing. In both cases, the District did not provide documentation of suspension and debarment verification at the time of contract execution. Recommendation We recommend that the District implement procedures to verify vendor eligibility prior to entering into federally funded contracts. Acceptable methods include retaining a SAM.gov screenshot, obtaining vendor certification, or including a suspension and debarment clause in the contract. The District should also ensure documentation is retained in the procurement file and assign responsibility for this task to appropriate staff. Training and periodic reviews should be conducted to reinforce compliance and reduce the risk of using ineligible vendors. Management’s Corrective Action Planned Management concurs with the recommendation. IVGID will implement a procedure to document the procurement process and review of suspension and debarment for all vendors that undergo the bidding process.

View Audit 368379

Finding 1155827 (2023-006)

Material Weakness 2023

Nebraska Association for Developmental Housing

IA

Questioned Costs Special Tests & Provisions Subrecipient Monitoring

Finding 2023-006 Due to cash flow constraints, the Project was not able to repay the replacement reserve. The Project will repay the replacement reserve when cash is available. If cash becomes available, the anticipated completion date is June 30, 2024.

View Audit 368219 Questioned Costs: $1

Finding 1155826 (2023-005)

Material Weakness 2023

Nebraska Association for Developmental Housing

IA

Questioned Costs Special Tests & Provisions Subrecipient Monitoring

Finding 2023-005 Due to the financial situation the Project is in at June 30, 2023, making this deposit is impossible. HUD has agreed to suspend the monthly required debt service savings deposit effective September 1, 2019. Management is negotiating with HUD to get the past debt service saving depos...

Finding 2023-005 Due to the financial situation the Project is in at June 30, 2023, making this deposit is impossible. HUD has agreed to suspend the monthly required debt service savings deposit effective September 1, 2019. Management is negotiating with HUD to get the past debt service saving deposit requirement suspended permanently. If management is successful in negotiations with HUD, the anticipated completion date is June 30, 2024.

View Audit 368219 Questioned Costs: $1

Finding 1155825 (2023-004)

Material Weakness 2023

Nebraska Association for Developmental Housing

IA

Questioned Costs Special Tests & Provisions Subrecipient Monitoring

Finding 2023-004 Due to cash flow constraints, the Project was not able to repay the nonprofit sponsor’s foundation. The Project will repay the nonprofit sponsor’s foundation when cash is available. If cash becomes available, the anticipated completion date is June 30, 2024.

View Audit 368219 Questioned Costs: $1

Finding 1155824 (2023-003)

Material Weakness 2023

Nebraska Association for Developmental Housing

IA

Questioned Costs Special Tests & Provisions Subrecipient Monitoring

Finding 2023-003 Due to cash flow constraints, the Project was not able to repay the nonprofit sponsor’s foundation. The Project will repay the nonprofit sponsor’s foundation when cash is available. If cash becomes available, the anticipated completion date is June 30, 2024.

View Audit 368219 Questioned Costs: $1

Finding 1155814 (2023-004)

Material Weakness 2023

The International Center for Journalists, Inc.

DC

Cash Management Matching / Level of Effort / Earmarking § 200.303

Views of Responsible Officials: The cause is related to the digital nature of the drawdown process and staff turnover. ICFJ will institute a procedure to capture drawdown information and/or create a documentation at the time of drawdown. Storage of the documentation will be incorporated into ICFJ’s ...

Views of Responsible Officials: The cause is related to the digital nature of the drawdown process and staff turnover. ICFJ will institute a procedure to capture drawdown information and/or create a documentation at the time of drawdown. Storage of the documentation will be incorporated into ICFJ’s digital records storage.

View Audit 368202

Finding 1155813 (2023-003)

Material Weakness 2023

The International Center for Journalists, Inc.

DC

Subrecipient Monitoring Reporting § 200.328

Views of Responsible Officials and Planned Corrective Actions: ICFJ's financial and programmatic reports are primarily digital. ICFJ uses access restricted SharePoint and Salesforce applications for all document storage. Finance, Programs and IT has worked together to improve completeness and consis...

Views of Responsible Officials and Planned Corrective Actions: ICFJ's financial and programmatic reports are primarily digital. ICFJ uses access restricted SharePoint and Salesforce applications for all document storage. Finance, Programs and IT has worked together to improve completeness and consistency of all financial and programmatic records storage.

View Audit 368202

Finding 1155812 (2023-002)

Material Weakness 2023

The International Center for Journalists, Inc.

DC

Subrecipient Monitoring Reporting

Views of Responsible Officials: All applicable subawards (including any cost-related modifications) are now registered in the FFATA Subaward Reporting System (FSRS.gov). ICFJ’s Budget & Compliance Officer carefully reviews all new Federal awards received by ICFJ to ensure all applicable subawards ar...

Views of Responsible Officials: All applicable subawards (including any cost-related modifications) are now registered in the FFATA Subaward Reporting System (FSRS.gov). ICFJ’s Budget & Compliance Officer carefully reviews all new Federal awards received by ICFJ to ensure all applicable subawards are registered at FSR.gov in compliance with FFATA requirement. Periodic trainings on FFATA compliance for all staff who work on federally-funded awards have been conducted and are scheduled at least annually. FFATA requirement is a checklist item during onboarding of new awards.

View Audit 368202

Finding 1155805 (2023-005)

Material Weakness 2023

The International Center for Journalists, Inc.

DC

Matching / Level of Effort / Earmarking Subrecipient Monitoring § 200.306

Views of Responsible Officials: ICFJ will implement procedures and control processes to track cost share requirements and the progress towards the requirements. Support for the cost share claimed should also be available upon request.

View Audit 368202

Finding 1155745 (2023-002)

Material Weakness 2023

Baycare Health System, Inc. and Affiliates

FL

Reporting § 200.303 § 200.502 § 200.510

The grant accounting and SEFA preparation process will be refined, improved and documented. Internal resources will be reallocated to ensure sufficient coverage of these processes, and the primary accountability and oversight will shift to System Accounting. Management will ensure that in preparatio...

The grant accounting and SEFA preparation process will be refined, improved and documented. Internal resources will be reallocated to ensure sufficient coverage of these processes, and the primary accountability and oversight will shift to System Accounting. Management will ensure that in preparation of the SEFA, (1) a team member will assemble the initial reconciliation, (2) management will review the initial reconciliation and review the consolidation from all BayCare entities to the combined SEFA, (3) A final review will be conducted by the Director of Accounting. Sign-off from each preparer/reviewer shall be required. Meetings will be conducted as needed with departments outside of Hospital Finance to ensure completeness and accuracy of data. Start September 2025, Finalized Q1 2026

View Audit 368033

Finding 1155735 (2023-001)

Material Weakness 2023

Baycare Health System, Inc. and Affiliates

FL

Reporting § 200.303

As PRF ended in 2023, no corrective action deemed appropriate for this specific program going forward. However, Management will ensure that in preparation of the SEFA, (1) a team member will assemble the initial reconciliation, (2) management will review the initial reconciliation and review the con...

As PRF ended in 2023, no corrective action deemed appropriate for this specific program going forward. However, Management will ensure that in preparation of the SEFA, (1) a team member will assemble the initial reconciliation, (2) management will review the initial reconciliation and review the consolidation from all BayCare entities to the combined SEFA, (3) A final review will be conducted by the Director of Accounting. Sign-off from each preparer/reviewer shall be required. Meetings will be conducted as needed with departments outside of Hospital Finance to ensure completeness and accuracy of data. Complete. AL No. 93.498 ended in 2023.

View Audit 368033

Finding 1155735 (2023-001)

Material Weakness 2023

Baycare Health System, Inc. and Affiliates

FL

Reporting § 200.303

The grant accounting and SEFA preparation process will be refined, improved and documented. Internal resources will be reallocated to ensure sufficient coverage of these processes, and the primary accountability and oversight will shift to System Accounting. Management will ensure that in preparatio...

The grant accounting and SEFA preparation process will be refined, improved and documented. Internal resources will be reallocated to ensure sufficient coverage of these processes, and the primary accountability and oversight will shift to System Accounting. Management will ensure that in preparation of the SEFA, (1) a team member will assemble the initial reconciliation, (2) management will review the initial reconciliation and review the consolidation from all BayCare entities to the combined SEFA, (3) A final review will be conducted by the Director of Accounting. Sign-off from each preparer/reviewer shall be required. Meetings will be conducted as needed with departments outside of Hospital Finance to ensure completeness and accuracy of data. Start September 2025, Finalized Q1 2026

View Audit 368033

Corrective Action Plans

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