Finding 1228562 (2025-001)

Material Weakness Repeat Finding
Requirement
L
Questioned Costs
-
Year
2025
Accepted
2026-09-01
Audit: 410192
Organization: Corewell Health & Affiliates (MI)

AI Summary

  • Core Issue: Four FFATA reports were not submitted on time, and all submitted reports lacked documented review and approval.
  • Impacted Requirements: Non-compliance with the Transparency Act and internal control standards as outlined in Section 200.303 of the Uniform Guidance.
  • Recommended Follow-up: Ensure adherence to the new FFATA reporting procedures and maintain documentation of reviews to prevent future delays and compliance issues.

Finding Text

2025–001 Transparency Act Reporting Identification of the federal program: Federal Agency and Program Name: U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA) Healthy Start Initiative Federal Award No: H4903591 Award Year: 2025 Assistance Listing No: 93.926 Criteria or specific requirement (including statutory, regulatory or other citation): Section 200.303 of the Uniform Guidance states the following regarding internal control: “The recipient and subrecipient must establish, document, and maintain effective internal control over the Federal award that provides reasonable assurance that the recipient or subrecipient is managing the federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. The internal controls should align with the guidance in ‘Standards for Internal Control in the Federal Government’ issued by the Comptroller General of the United States or the “Internal Control — Integrated Framework” issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” Under the requirements of the Federal Funding Accountability and Transparency Act (Pub. L. No. 109-282), as amended by Section 6202 of Pub. L. No. 110-252, hereafter referred as the “Transparency Act” that are codified in 2 CFR Part 170, “unless the recipient is exempt as provided in paragraph d. of this award term, the recipient must report each subaward that equals or exceeds $30,000 in Federal funds for a subaward to an entity or Federal Agency. The recipient must also report a subaward if a modification increases the Federal funding to an amount that equals or exceeds $30,000. All reported subawards should reflect the total amount of the subaward”. The recipient must report each subaward no later than the end of the month following the month in which the subward was made. Condition: During our audit, we noted four instances where the required Federal Funding Accountability and Transparency Act (FFATA) reports were not submitted in SAM.gov timely in FY 2025. In addition, we noted for all six FFATA reports that were submitted in SAM.gov, there was no evidence of review and approval of the reports prior to submission. Cause: Corewell implemented corrective actions effective September 1, 2025 based on prior year audit finding. Due to the timing of the implementation of the corrective action plan, the FFATA reports that were due prior to September 1, 2025 were not submitted timely and documentation supporting the review of the FFATA reports was not maintained causing a repeat finding in the current year. Effect or potential effect: Corewell did not timely submit the necessary FFATA reports under the Healthy Start Initiative (HSI) project for each first-tier subaward agreement or modifications in SAM.gov and consequently was not in compliance with the requirements under the Transparency Act. Additionally, lack of review could potentially result in incorrect information included in the reports. Questioned costs: $0 Context: Under the HSI program, there were five subrecipients that had a total of six subawards (one new agreement and five amendments) in FY 2025. Total subrecipient’s costs are $750,822 in FY 2025. The total federal expenditures for the HSI program for FY 2025 were $1,052,118. Identification as a repeat finding, if applicable: Repeat finding – 2024-001 Recommendation: We recommend management ensure that the implemented corrective action plans are followed to ensure the required FFATA reports are submitted timely and documentation retained to support the internal control review performed prior to submission of the reports. Views of responsible officials: Management has implemented a comprehensive corrective action plan to address the FFATA reporting deficiencies identified in the prior audit. Effective September 1, 2025, Corewell Health established a formal written FFATA reporting procedure that includes detailed requirements for identifying and reporting amended subawards throughout the award lifecycle. The procedure also requires documented supervisory review and approval of all FFATA submissions prior to filing to ensure completeness, accuracy, and compliance with federal reporting requirements. The procedure has been formally communicated to and implemented by the Office of Sponsored Programs and Research Finance teams. Ongoing training, monitoring, and periodic reviews of compliance with the procedure have been incorporated into operational processes to reinforce adherence to reporting requirements and to prevent recurrence. Although these corrective actions were implemented effective September 1, 2025, certain FFATA reporting deadlines applicable to the current audit period occurred before the implementation date. As a result, reports due prior to September 1, 2025 were not submitted within the required timeframe and did not include documented evidence of review before submission. Consequently, the finding was reported as a repeat finding in the current audit period. Management believes the corrective actions now in place adequately address the underlying control deficiencies and will support timely and compliant FFATA reporting going forward.

Corrective Action Plan

Finding 2025-001 Identification of the federal program: Federal Agency: U.S. Department of Health and Human Services (HHS), Health Resources and Services Administration (HRSA) Assistance Listing: 93.926 Healthy Start Initiative (HSI) Pass-Through Grantor: Not applicable Award Number: H4903591 Award Period: 5/1/2025-3/31/2026 Summary of Finding: Four instances where the required Federal Funding Accountability and Transparency Act (FFATA) reports were not submitted in SAM.gov timely in FY 2025. In addition, we noted for all six FFATA reports that were submitted in SAM.gov, there was no evidence of review and approval of the reports prior to submission. Under the HSI program, there were five subrecipients that had a total of six subawards (one new agreement and five amendments) in FY 2025. Total subrecipient’s costs are $750,822 in FY 2025. The total federal expenditures for the HSI program for FY 2025 were $1,052,118. Corrective Action Plan: Management has implemented a comprehensive corrective action plan to address the FFATA reporting deficiencies identified in the prior audit. Effective September 1, 2025, Corewell Health established a formal written FFATA reporting procedure that includes detailed requirements for identifying and reporting amended subawards throughout the award lifecycle. The procedure also requires documented supervisory review and approval of all FFATA submissions prior to filing to ensure completeness, accuracy, and compliance with federal reporting requirements. The procedure has been formally communicated to and implemented by the Office of Sponsored Programs and Research Finance teams. Ongoing training, monitoring, and periodic reviews of compliance with the procedure have been incorporated into operational processes to reinforce adherence to reporting requirements and to prevent recurrence. Although these corrective actions were implemented effective September 1, 2025, certain FFATA reporting deadlines applicable to the current audit period occurred before the implementation date. As a result, reports due prior to September 1, 2025 were not submitted within the required timeframe and did not include documented evidence of review before submission. Consequently, the finding was reported as a repeat finding in the current audit period. Management believes the corrective actions now in place adequately address the underlying control deficiencies and will support timely and compliant FFATA reporting going forward. Individuals Responsible for Corrective Action: Paula Schuiteman-Bishop, Vice President, Research Administration, Joe Fugitt, Senior Director, Research Administration, Development and Billing Integrity, Jodi Bohnhorst, Director, Research Development, Brandy Jurdzy, Manager, Research Sponsored Programs Timing of corrective action: September 1, 2025 and going forward.

Categories

Subrecipient Monitoring Reporting

Programs in Audit

ALN Program Name Expenditures
93.817 HOSPITAL PREPAREDNESS PROGRAM (HPP) EBOLA PREPAREDNESS AND RESPONSE ACTIVITIES $1.97M
93.926 HEALTHY START INITIATIVE $1.05M
12.420 MILITARY MEDICAL RESEARCH AND DEVELOPMENT $642,379
93.914 HIV EMERGENCY RELIEF PROJECT GRANTS $605,792
93.304 RACIAL AND ETHNIC APPROACHES TO COMMUNITY HEALTH $566,317
93.847 DIABETES, DIGESTIVE, AND KIDNEY DISEASES EXTRAMURAL RESEARCH $431,371
21.027 CORONAVIRUS STATE AND LOCAL FISCAL RECOVERY FUNDS $389,843
93.917 HIV CARE FORMULA GRANTS $367,033
93.853 EXTRAMURAL RESEARCH PROGRAMS IN THE NEUROSCIENCES AND NEUROLOGICAL DISORDERS $357,691
93.307 MINORITY HEALTH AND HEALTH DISPARITIES RESEARCH $327,095
93.153 COORDINATED SERVICES AND ACCESS TO RESEARCH FOR WOMEN, INFANTS, CHILDREN, AND YOUTH $303,087
93.855 ALLERGY AND INFECTIOUS DISEASES RESEARCH $228,050
93.394 CANCER DETECTION AND DIAGNOSIS RESEARCH $186,864
93.136 INJURY PREVENTION AND CONTROL RESEARCH AND STATE AND COMMUNITY BASED PROGRAMS $180,779
93.301 SMALL RURAL HOSPITAL IMPROVEMENT GRANT PROGRAM $153,237
93.276 DRUG-FREE COMMUNITIES SUPPORT PROGRAM GRANTS $117,077
93.217 FAMILY PLANNING SERVICES $115,839
93.865 CHILD HEALTH AND HUMAN DEVELOPMENT EXTRAMURAL RESEARCH $108,733
93.889 NATIONAL BIOTERRORISM HOSPITAL PREPAREDNESS PROGRAM $107,415
93.226 RESEARCH ON HEALTHCARE COSTS, QUALITY AND OUTCOMES $105,989
93.866 AGING RESEARCH $105,341
93.516 PUBLIC HEALTH TRAINING CENTERS PROGRAM $104,627
93.110 SPECIAL PROJECTS OF REGIONAL AND NATIONAL SIGNIFICANCE $100,988
93.092 AFFORDABLE CARE ACT (ACA) PERSONAL RESPONSIBILITY EDUCATION PROGRAM $92,663
93.788 OPIOID STR $86,453
93.395 CANCER TREATMENT RESEARCH $85,500
93.331 PARTNERSHIPS TO IMPROVE COMMUNITY HEALTH $83,754
93.988 COOPERATIVE AGREEMENTS FOR DIABETES CONTROL PROGRAMS $73,965
93.994 MATERNAL AND CHILD HEALTH SERVICES BLOCK GRANT TO THE STATES $71,661
93.778 GRANTS TO STATES FOR MEDICAID $65,145
93.838 LUNG DISEASES RESEARCH $53,434
93.946 COOPERATIVE AGREEMENTS TO SUPPORT STATE-BASED SAFE MOTHERHOOD AND INFANT HEALTH INITIATIVE PROGRAMS $49,956
93.837 CARDIOVASCULAR DISEASES RESEARCH $41,412
93.867 VISION RESEARCH $31,808
93.959 BLOCK GRANTS FOR PREVENTION AND TREATMENT OF SUBSTANCE ABUSE $30,289
93.080 BLOOD DISORDER PROGRAM: PREVENTION, SURVEILLANCE, AND RESEARCH $29,488
12.300 BASIC AND APPLIED SCIENTIFIC RESEARCH $24,000
93.178 NURSING WORKFORCE DIVERSITY $20,174
93.940 HIV PREVENTION AND SURVEILLANCE ACTIVITIES-HEALTH DEPARTMENT BASED $19,959
93.397 CANCER CENTERS SUPPORT GRANTS $12,612
93.243 SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES PROJECTS OF REGIONAL AND NATIONAL SIGNIFICANCE $11,684
93.825 NATIONAL EBOLA TRAINING AND EDUCATION CENTER (NETEC) $5,653
93.310 TRANS-NIH RESEARCH SUPPORT $3,400
93.839 BLOOD DISEASES AND RESOURCES RESEARCH $2,325
93.399 CANCER CONTROL $200