Finding 1222605 (2025-002)

Material Weakness Repeat Finding
Requirement
L
Questioned Costs
-
Year
2025
Accepted
2026-06-30
Audit: 406201
Organization: Lee Health System, Inc. (FL)
Auditor: BDO USA PC

AI Summary

  • Core Issue: The data collection form for federal programs was submitted one day late, missing the July 31, 2025 deadline.
  • Impacted Requirements: Compliance with 2 CFR Section 200.512(a) for timely submission of audit reports to the Federal Audit Clearinghouse.
  • Recommended Follow-Up: Implement a secondary review process to ensure all reporting steps are completed on time and add this to the reporting checklist.

Finding Text

2025-002: Reporting – Submission of the Data Collection Form Information on Federal Programs Federal Emergency Management Agency: Assistance Listing Number: 97.036 Assistance Listing Name: Disaster Grants - Public Assistance passed through Florida Division of Emergency Management U.S. Department of Health and Human Services Assistance Listing Number: 93.778 Assistance Listing Name: Medicaid Cluster – Medical Assistance Program Criteria In accordance with 2 CFR Section 200.512(a), the audit must be completed and the data collection form and reporting package must be submitted within the earlier of 30 calendar days after receipt of the auditor’s report, or nine months after the end of the audit period, adjusted for any extensions permitted by the Office of Management and Budget. Condition The data collection form and reporting package for the period ended October 31, 2024 was not filed with the Federal Audit Clearinghouse (FAC) by the deadline of July 31, 2025. This finding pertains to the federal programs identified and tested as major programs for the audit period ended October 31, 2024, which are noted above. Cause The data collection form and reporting package for the period ended October 31, 2024 was submitted one day after the reporting deadline of July 31, 2025 due to an oversight in management’s identification of the correct record to submit within the FAC system. Effect Untimely reporting could affect future funding from government agencies. Questioned Costs None noted. Recommendation We recommend that management review its internal control process over reporting to ensure there are multiple individuals involved in the process to ensure reporting requirements are properly met. Views of Responsible Officials Management acknowledges finding 2025-002: Reporting – Submission of the Data Collection Form related to the timely submission of the Single Audit reporting package to the Federal Audit Clearinghouse (FAC). The established process requires a two-step procedure: (1) certification of the submission and (2) final submission to the FAC. While management completed the certification step by the required due date, the final submission step was not completed until one day after the deadline. As a result, the overall submission was not considered timely. The delay was the result of an oversight in the final step of the submission process. Going forward Management will add a validation step with a secondary review by another team member to validate that both steps have been clearly completed and we will add this to our reporting checklist that is part of the Single Audit Process Narrative. Management believes these enhancements will ensure the completeness and timeliness of future submissions and mitigate the risk of recurrence. The corrective actions have been implemented and are in operation as of June 30, 2026. Management believes these enhancements significantly strengthen the control environment over the submission process and reduce the risk of recurrence.

Corrective Action Plan

2025-002: Reporting – Submission of the Data Collection Form Information on Federal Programs Federal Emergency Management Agency Assistance Listing Number: 97.036 Assistance Listing Name: Disaster Grants - Public Assistance passed through Florida Division of Emergency Management U.S. Department of Health and Human Services Assistance Listing Number: 93.778 Assistance Listing Name: Medicaid Cluster – Medical Assistance Program Management will implement and maintain the following corrective actions:  Management has added a validation step with a secondary review by another team member to validate that all steps relating to submission have been clearly completed.  Management has also added this to our reporting checklist that is part of the Single Audit Process Narrative. Responsible Party: Controller, under the oversight of the Vice President of Financial Services/Chief Financial Officer, in coordination with the Grants function. Completion date: June 30, 2026

Categories

Internal Control / Segregation of Duties Reporting

Other Findings in this Audit

  • 1222604 2025-002
    Material Weakness Repeat

Programs in Audit

ALN Program Name Expenditures
97.036 DISASTER GRANTS - PUBLIC ASSISTANCE (PRESIDENTIALLY DECLARED DISASTERS) $172.49M
93.778 MEDICAL ASSISTANCE PROGRAM $1.32M
93.870 MATERNAL, INFANT AND EARLY CHILDHOOD HOME VISITING GRANT $337,440
93.699 STATE AND NATIONAL TOBACCO CESSATION SUPPORT SYSTEMS $255,422
93.994 MATERNAL AND CHILD HEALTH SERVICES BLOCK GRANT TO THE STATES $67,117
93.767 CHILDREN'S HEALTH INSURANCE PROGRAM $17,708