Finding 1215560 (2025-003)

Material Weakness Repeat Finding
Requirement
L
Questioned Costs
-
Year
2025
Accepted
2026-05-26

AI Summary

  • Core Issue: The Hospital lacks effective internal controls over reporting, with reports submitted by one person without any review.
  • Impacted Requirements: This violates 2 CFR 200.303, which mandates proper internal controls to ensure compliance with federal award terms.
  • Recommended Follow-Up: Implement a review and reconciliation process for reports to ensure accuracy and compliance with federal requirements.

Finding Text

U.S. Department of Health and Human Services Congressional Directives - 93.493 Award# CE152271 Criteria or Specific Requirement – Reporting and Significant Deficiency Per 2 CFR 200.303, the non-federal entities receiving federal awards (i.e ., auditee management) establish and maintain internal control design to reasonably ensure compliance with federal statutes, regulations, and the terms and conditions of the federal award. Condition – During our test work over the Congressional Directive grant, we noted the Hospital did not maintain effective internal controls over reporting. Reports were prepared and submitted by a single individual without evidence of supervisory or independent review prior to submission. Cause – The Hospital's controls to ensure reports are filed timely and accurately were not operating effectively. Effect or Potential Effect - Without an established review process, there is an increased risk that required federal reports may contain errors, omissions, or noncompliant information, which may not be detected or corrected timely. Questioned Costs – None noted. Context – One federal financial report was required to be submitted and selected for testing. We noted there was no review process in place over the report submitted. While no material errors were identified during audit testing, the control deficiency increases the risk of noncompliance with federal reporting requirements. Identification as a Repeat Finding, if applicable – Not applicable. Recommendation – We recommend the Hospital incorporate a review and reconciliation process of the required reports to the underlying grant and accounting records. Views of Responsible Official and Planned Corrective Actions – Management agrees with finding. See corrective action plan.

Corrective Action Plan

Personnel Responsible for Corrective Action: Karla Clubine, Chief Executive Officer, David Cichocki, Chief Financial Officer Anticipated Completion Date: June 30, 2026 Views of Responsible Officials and Planned Corrective Action: Management accepts the recommendation. It will implement a review and reconciliation process of the required reports to the underlying grant and accounting records.

Categories

Reporting Internal Control / Segregation of Duties Significant Deficiency Matching / Level of Effort / Earmarking

Other Findings in this Audit

  • 1215558 2025-005
    Material Weakness Repeat
  • 1215559 2025-002
    Material Weakness Repeat
  • 1215561 2025-004
    Material Weakness Repeat

Programs in Audit

ALN Program Name Expenditures
10.766 COMMUNITY FACILITIES LOANS AND GRANTS $3.20M
93.493 CONGRESSIONAL DIRECTIVES $1.10M