Corrective Action Plans

Finding 502484 (2021-015)

Material Weakness 2021

MH

Questioned Costs Allowable Costs / Cost Principles

Allowable Costs/Cost Principles: The College partially agrees with the finding. - Condition 1.1 - During the audit field work, the College was not able to provide the necessary documents requested by the external auditors. - Condition 1.2 - The College did not provide the necessary documents in ...

Allowable Costs/Cost Principles: The College partially agrees with the finding. - Condition 1.1 - During the audit field work, the College was not able to provide the necessary documents requested by the external auditors. - Condition 1.2 - The College did not provide the necessary documents in a timely manner to the external auditors during the audit fieldwork. Important Note: The College was able to locate the required documents BUT it was after the due date the external auditors requested for review and clarifications. The College recognizes the need to improve internal control policies and strengthen controls to ensure proper management and filing of all necessary documentation to support transactions. To fully utilize its document management system and all other College systems, regular training will be conducted to ensure proper and accurate use of its systems. September 30, 2022 Stevenson Kotton VPBAA Hatty Kabua Grant Coordinator

View Audit 324487 Questioned Costs: $1

Finding 502480 (2021-011)

Material Weakness 2021

College of the Marshall Islands

MH

Questioned Costs Allowable Costs / Cost Principles

Allowable Costs/Cost Principles: The College partially agrees with the findings. - Condition 1.1 - During the audit field work, the College was not able to provide the necessary documents requested by the external auditors. - Condition 1.2 - The College did not provide the necessary documents in...

Allowable Costs/Cost Principles: The College partially agrees with the findings. - Condition 1.1 - During the audit field work, the College was not able to provide the necessary documents requested by the external auditors. - Condition 1.2 - The College did not provide the necessary documents in a timely manner to the external auditors during the audit fieldwork. Important Note: The College was able to locate the required documents BUT it was after the due date the external auditors requested for review and clarifications. The College recognizes the need to improve internal control policies and strengthen controls to ensure proper management and filing of all necessary documentation to support transactions. To fully utilize its document management system and all other College systems, regular training will be conducted to ensure proper and accurate use of its systems. September 30, 2022 Stevenson Kotton VPBAA Pam Kaios UB Director

View Audit 324487 Questioned Costs: $1

Finding 502335 (2021-007)

Material Weakness 2021

Alfalfa County

OK

Allowable Costs / Cost Principles Questioned Costs Internal Control / Segregation of Duties § 200.303 § 200.318 § 200.84

In each of our districts we will practice oversight and due diligence over the documentation of Disaster Grant expenditures. We will review documents to ensure labor rates and equipment rates were those approved FEMA. We will acknowledge our review by signing the documents.

View Audit 324377 Questioned Costs: $1

Finding 502334 (2021-006)

Material Weakness 2021

Alfalfa County

OK

Questioned Costs Special Tests & Provisions Allowable Costs / Cost Principles § 200.303

We will research the compliancerequirements for each Major Federal Grant the County receives. Withthe compliance requirements in mind, we will establish policies and procedures to satisfy those requirements and practice oversight over federal grant activity.

View Audit 324377

Finding 502333 (2021-005)

Material Weakness 2021

Alfalfa County

OK

Internal Control / Segregation of Duties Subrecipient Monitoring Questioned Costs

The Officers of Alfalfa County will meet to discuss the County-Wide Controls over the administration of Major Federal Programs. After discussing and gaining input from all those involved, written procedures will be approved and distributed.

View Audit 324377

Finding 499933 (2021-001)

Significant Deficiency 2021

Bon Secours Charity Health System, INC

DC

Allowable Costs / Cost Principles Reporting Questioned Costs

Views of Responsible Officials and Planned Corrective Action Plan: BSCHS prepared the initial calculation of general and administrative expenses based on its understanding of the guidance in effect at the time of preparation. Management will check for updates to guidance and make necessary changes a...

Views of Responsible Officials and Planned Corrective Action Plan: BSCHS prepared the initial calculation of general and administrative expenses based on its understanding of the guidance in effect at the time of preparation. Management will check for updates to guidance and make necessary changes as appropriate.

View Audit 322874

Finding 498573 (2021-003)

Material Weakness 2021

Wishek Hospital Clinic Association D/b/a South Central Health

ND

Allowable Costs / Cost Principles § 200.303

Contact Person Megan Rath 2021-003 Corrective Action Plan The Association’s review and approval of expenses was undocumented. The Association will document the approval of the expenses claimed under federal programs in the future. Also, if future reports need to be submitted to HHS for Provider R...

Contact Person Megan Rath 2021-003 Corrective Action Plan The Association’s review and approval of expenses was undocumented. The Association will document the approval of the expenses claimed under federal programs in the future. Also, if future reports need to be submitted to HHS for Provider Relief Funds, a second reviewer will document approval of such reports. Completion Date The corrective action plan steps were implemented in part in 2022 with continued improvements planned to be in place by October 1, 2024.

View Audit 321318

Finding 498092 (2021-003)

Significant Deficiency 2021

Cavalier County Memorial Hospital Association

ND

Allowable Costs / Cost Principles Reporting

Finding # 2021-003 Response: The interim CFO has completed improvements in account review processes and procedures and has implemented recordkeeping improvements that improve the ability of the Organization to document, retain, and retrieve support for expenditures of federal awards. Responsible Pa...

Finding # 2021-003 Response: The interim CFO has completed improvements in account review processes and procedures and has implemented recordkeeping improvements that improve the ability of the Organization to document, retain, and retrieve support for expenditures of federal awards. Responsible Party: Jeffrey Hundman, Interim CFO Estimated Completion: 09/30/2024

View Audit 320758

Finding 497349 (2021-002)

Significant Deficiency 2021

Workforce Development Board of Eastern Arkansas

AR

Allowable Costs / Cost Principles Questioned Costs Reporting § 200.329

2021-002: Auditee has improperly tracked grant awards and expenditures. Recommendation: We recommend the WDBEA maintains an effort to properly track and report federal awards and expenditures. Action Taken: Finance Manager, Frances-Tribble Adams, has taken appropriate action and has reconciled ac...

2021-002: Auditee has improperly tracked grant awards and expenditures. Recommendation: We recommend the WDBEA maintains an effort to properly track and report federal awards and expenditures. Action Taken: Finance Manager, Frances-Tribble Adams, has taken appropriate action and has reconciled accounting records to ensure grant revenues and expenditures are adequately tracked in the future. Name of Person Responsible for Corrective Action: Frances Tribble-Adams, Finance Manager. Anticipated Completion Date of Corrective Action: July 1, 2021.

View Audit 320073

Finding 485186 (2021-003)

Material Weakness 2021

Metro Area Continuum of Care for the Homeless

NE

Questioned Costs Allowable Costs / Cost Principles Cash Management

Corrective Action Plan For Year Ended December 31, 2021 Contact Person: Jason Feldhaus, Executive Director jason@thresholdcoc.org 402.290.6106 FINDING 2021-003: Allowable Costs All receipts for expenses of the Organization are attached to the transaction in bill.com, which then gets transferred to t...

Corrective Action Plan For Year Ended December 31, 2021 Contact Person: Jason Feldhaus, Executive Director jason@thresholdcoc.org 402.290.6106 FINDING 2021-003: Allowable Costs All receipts for expenses of the Organization are attached to the transaction in bill.com, which then gets transferred to the accounting system, QuickBooks Online. Additionally, backup for landlord payments is saved in a separate folder for reference. Prior to payment approval of an expense, the approver confirms there is adequate backup for the allowable costs. A policy will be included in the updated Financial Policies and Procedures manual in 2024. Reasonable completion date: Already implemented (October 31, 2024 for policy updates) Responsible Party: Jason Feldhaus, Executive Director

View Audit 317998 Questioned Costs: $1

Finding 484912 (2021-040)

Material Weakness 2021

Commonwealth of the Northern Mariana Islands

MP

Questioned Costs Allowable Costs / Cost Principles Cash Management

Finding No.: 2021-040 AL Program: 97.050 - Presidential Declared Disaster Assistance to Individuals and Households – Other Needs Area: Allowable Costs/Cost Principles Questioned Costs: $247,774 Contact Person(s): Patrick Guerrero, Governor’s Authorized Rep., PAO Corrective Action Plan: The CNM...

Finding No.: 2021-040 AL Program: 97.050 - Presidential Declared Disaster Assistance to Individuals and Households – Other Needs Area: Allowable Costs/Cost Principles Questioned Costs: $247,774 Contact Person(s): Patrick Guerrero, Governor’s Authorized Rep., PAO Corrective Action Plan: The CNMI disagrees with this finding. The Lost Wages Assistance Program is not a reimbursement program. A drawdown of funds obligated was needed prior to services being rendered. After all payments were made, eligible expenses were calculated and submitted in the Lost Wages Assistance Program Final Closeout that was submitted to FEMA. After the closeout, the CNMI understands that the remaining funds will need to return the overdrawn amount. The final closeout document was received from FEMA on June 13, 2024.

View Audit 317760 Questioned Costs: $1

Finding 484897 (2021-031)

Material Weakness 2021

Commonwealth of the Northern Mariana Islands

MP

Questioned Costs Allowable Costs / Cost Principles

Finding No.: 2021-031 AL Program: 21.027 - Coronavirus State and Local Fiscal Recovery Funds Area: Allowable Costs/Cost Principles Questioned Costs: $1,035,442 Contact Person(s): Thomasa DLG. Naraja, Sr. Financial Analyst, SOF Corrective Action Plan: The Department of Finance agrees with t...

Finding No.: 2021-031 AL Program: 21.027 - Coronavirus State and Local Fiscal Recovery Funds Area: Allowable Costs/Cost Principles Questioned Costs: $1,035,442 Contact Person(s): Thomasa DLG. Naraja, Sr. Financial Analyst, SOF Corrective Action Plan: The Department of Finance agrees with this finding. To address the findings identified, the Department of Finance (DOF) will conduct a thorough review of policies and procedures related to allowable costs/cost principles. We will review the $1,035,442 in questioned costs to identify specific deficiencies in documentation and expand our sample to ensure all instances of insufficient documentation are captured. The DOF will review current policies and procedures governing allowable costs/cost principles. This review aims to identify any gaps or ambiguities that may have contributed to the audit findings. The DOF is committed to updating these policies and procedures promptly to clarify requirements for documenting costs and strengthen controls over compliance. Proposed Completion Date: Ongoing

View Audit 317760 Questioned Costs: $1

Finding 484892 (2021-026)

Material Weakness 2021

Commonwealth of the Northern Mariana Islands

MP

Questioned Costs Allowable Costs / Cost Principles

Finding No.: 2021-026 AL Program: 21.019 - Coronavirus Relief Fund Area: Allowable Costs/Cost Principles Questioned Costs: $20,341,913 Contact Person(s): Ryan Camacho, Sr. Financial Analyst / Pam Marigmen, Sr. Financial Analyst, SOF Office Corrective Action Plan: The Department of Finance ...

Finding No.: 2021-026 AL Program: 21.019 - Coronavirus Relief Fund Area: Allowable Costs/Cost Principles Questioned Costs: $20,341,913 Contact Person(s): Ryan Camacho, Sr. Financial Analyst / Pam Marigmen, Sr. Financial Analyst, SOF Office Corrective Action Plan: The Department of Finance agrees with this finding under ALN# 21.019. We have completed our review and proposed adjustments to accurately reflect expenditures in compliance with grant policies and requirements. Moving forward, we have implemented policies and procedures to ensure that all documentation is uploaded to the new financial system, and proper review and documentation are included to verify the allowability of expenditures within grant policies and requirements. Proposed Completion Date: Completed

View Audit 317760 Questioned Costs: $1

Finding 484853 (2021-017)

Material Weakness 2021

Commonwealth of the Northern Mariana Islands

MP

Questioned Costs Allowable Costs / Cost Principles

Finding No.: 2021-017 AL Program: 15.875 - Economic, Social, and Political Development of the Territories Area: Allowable Costs/Cost Principles Questioned Costs: $402,941 Contact Person(s): Jazmin Camacho, Sr. Financial Analyst, OMB Corrective Action Plan: Condition 1 & 2: The OMB disagrees...

Finding No.: 2021-017 AL Program: 15.875 - Economic, Social, and Political Development of the Territories Area: Allowable Costs/Cost Principles Questioned Costs: $402,941 Contact Person(s): Jazmin Camacho, Sr. Financial Analyst, OMB Corrective Action Plan: Condition 1 & 2: The OMB disagrees with this finding. Compact Impact grants often operate on a reimbursement basis.  This means that when the award is received, we request payment or a transfer of expenses to cover prior expenses that have already been incurred and paid.  Therefore, the memo that was processed for such request and other supporting documents can be provided.  Condition 3: We agree and acknowledge the concerns regarding CNMI’s enforcement of recordkeeping and monitoring controls over compliance with allowable costs and costs principles. We also recognize the issues related to monitoring cumulative expenditures and approved funding limits. We are taking immediate steps to address these shortcomings and will implement corrective actions to ensure compliance and proper monitoring going forward. We appreciate your patience and understanding as we work to rectify these issues. Proposed Completion Date: Ongoing

View Audit 317760 Questioned Costs: $1

Finding 484842 (2021-012)

Significant Deficiency 2021

Commonwealth of the Northern Mariana Islands

MP

Questioned Costs Allowable Costs / Cost Principles

Finding No.: 2021-012 AL Program: 10.539 - CNMI Nutrition Assistance Area: Allowable Costs/Cost Principles Questioned Costs: $1,620 Contact Person(s): Margaret Aldan, NAP Administrator Corrective Action Plan: Condition 1: The CNMI-NAP disagrees with this finding. The following employee is ...

Finding No.: 2021-012 AL Program: 10.539 - CNMI Nutrition Assistance Area: Allowable Costs/Cost Principles Questioned Costs: $1,620 Contact Person(s): Margaret Aldan, NAP Administrator Corrective Action Plan: Condition 1: The CNMI-NAP disagrees with this finding. The following employee is not a NAP employee. When work is performed for NAP, the hours spent will be compensated but in a Journal Entry procedure. This is a fund transfer from one account to another under the MOA. Conditions 2 and 3: CNMI-NAP disagrees with the finding. The attached NOPAs and other payroll documents indicated the correct pay rate specified to the employees. Please refer to the supporting documents provided to clear this finding. Proposed Completion Date: Ongoing

View Audit 317760 Questioned Costs: $1

Finding 481173 (2021-002)

Material Weakness 2021

Regional Office of Education #47

IL

Allowable Costs / Cost Principles Cash Management Questioned Costs § 200.302

FINDING 2021-002 – Lack of Written Policies for Federal Grants (Repeated from Prior Year Findings 20-003, 19-004, 18-003, and 17-002) CONDITION: As of April 2021, Regional Office developed, but did not implement written procedures concerning cash management, the determination of allowability ...

FINDING 2021-002 – Lack of Written Policies for Federal Grants (Repeated from Prior Year Findings 20-003, 19-004, 18-003, and 17-002) CONDITION: As of April 2021, Regional Office developed, but did not implement written procedures concerning cash management, the determination of allowability of costs in accordance with Subpart E – Cost Principles of the Uniform Guidance and the terms and conditions of the federal award. For the period of July 2020 through March 2021 the Regional Office utilized informal procedures in which each purchase made or cost allocated to the IDEA – Improvement Grant - Part D was reviewed for allowability by an individual with knowledge of the budget, allowable costs and activities, and the cash management requirements. The allowability determinations were based on the amounts included in the budgets for the IDEA – Improvement Grant - Part D approved by, and the grant periods set by, the Illinois State Board of Education. PLAN: The Regional Office has developed written policies and procedures related to the Uniform Guidance. ANTICIPATED DATE OF COMPLETION: Fiscal Year 2021 CONTACT PERSON: Mr. Chris Tennyson, Regional Superintendent for Lee, Ogle, and Whiteside Counties.

View Audit 317271

Finding 481026 (2021-002)

None 2021

Putnam County Hospital

IN

Questioned Costs Allowable Costs / Cost Principles Reporting

Corrective action: Management understands the due date for single audit reporting package submission to the Federal Audit Clearinghouse and filed the 2021 single audit reporting package in August 2024.

View Audit 317132

Finding 480926 (2021-008)

Material Weakness 2021

Puerto Rico Electric Power Authority

PR

Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking Subrecipient Monitoring § 200.302 § 200.303

Management acknowledges the findings and has implemented a corrective action plan to enhance compliance with Federal awards. This plan includes developing Standard Operating Procedures (SOPs) for grant management activities, identifying and documenting existing internal controls, and maintaining con...

Management acknowledges the findings and has implemented a corrective action plan to enhance compliance with Federal awards. This plan includes developing Standard Operating Procedures (SOPs) for grant management activities, identifying and documenting existing internal controls, and maintaining constant communication with stakeholders to prevent material noncompliance. Additionally, PREPA will provide training to staff on the new SOPs and establish a monitoring mechanism to continuously assess and improve the effectiveness of these controls. The corrective action plan, supervised by Mr. Ezequiel Nieves from the PREPA Disaster Funding Management Office, is expected to be completed by July 2025. Management is committed to addressing deficiencies, ensuring that processes and controls are robust and effective, and that Federal awards are managed transparently and in full compliance with all regulatory requirements. Effective June 1, 2021, the Authority transitioned the management and operation of its transmission and distribution network as well as certain back- office functions, including billing, collections and accounting, to a third party. The third-party operator is reviewing operating procedures and controls within its responsibilities to make the necessary improvements. Management will work to address these findings with the assistance of the third-party operators, where applicable. Also, effective July 1, 2023, the Authority transitioned the management and operation of its generation assets as well as certain back- office functions to a third party. The thirdparty operator is reviewing operating procedures and controls within its responsibilities to make the necessary improvements. In addition, the Authority will also be implementing and monitoring corrective actions taken by the new generation segment operator. Contact Name Responsible for Corrective Action Plan - Ezequiel Nieves Estimated Completion Date - July 2025

View Audit 317030

Finding 479433 (2021-002)

Material Weakness 2021

Unity Medical Center INC

TN

Reporting Allowable Costs / Cost Principles Material Weakness § 200.303 § 200.507

2 CFR Part 200.303(a) states that the auditee must establish and maintain effective internal control over the federal award that provides reasonable assurance that the auditee is managing the federal award in compliance with federal statutes, regulations, and terms and conditions of the federal awar...

2 CFR Part 200.303(a) states that the auditee must establish and maintain effective internal control over the federal award that provides reasonable assurance that the auditee is managing the federal award in compliance with federal statutes, regulations, and terms and conditions of the federal award. Section 200.507 of the Uniform Guidance states that the program-specific audit shall be completed, and reporting required submitted within the earlier of 30 calendar days after receipt of the auditors’ report, or nine months after the end of the audit, unless a longer period is specified in a program-specific audit guide. During 2023, we have strengthened internal controls related to review of the quarterly lost revenue calculations and reporting in the PRF reporting portal. Going forward, we will complete our audits and submit the required reports by the deadlines. We have taken appropriate steps to identify all other assistance received by quarter during the period of availability on the PRF report going forward.

View Audit 315964

Finding 478867 (2021-005)

Significant Deficiency 2021

Detroit Central City Cmh, Inc.

MI

Questioned Costs Program Income Subrecipient Monitoring § 200.307

FINDINGS - FEDERAL AWARDS Finding Number: 2021005 Finding Type: Significant Deficiency Condition: Program income was not used by DCCCMH to meet their matching requirements. DCCCMH reported allowable net program costs in excess of actual net allowable program costs of $15,569 and $3,446 for grants...

FINDINGS - FEDERAL AWARDS Finding Number: 2021005 Finding Type: Significant Deficiency Condition: Program income was not used by DCCCMH to meet their matching requirements. DCCCMH reported allowable net program costs in excess of actual net allowable program costs of $15,569 and $3,446 for grants M10071L5F011912 and Ml0439L5F011903, respectively. Management Response: Management acknowledges that program income generated from specific programs is to be used to cover net allowable program costs or to meet matching requirements. DCCCMH will implement measures to track program income for grant programs and will use program income to offset allowable program costs when preparing financial status reports. A final review of the use of program income will be performed by the Finance team before the annual audit commences. These measures will be incorporated into the updates to the financial policies and procedures for grant programs.

View Audit 315464 Questioned Costs: $1

Finding 478552 (2021-006)

Material Weakness 2021

City of Adelanto

CA

Questioned Costs Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.300 § 200.306 § 200.308 § 200.309 § 200.403

Corrective action has been immediately implemented in response to the auditors' recommendation. As financial reporting is still in process of getting to current, the City anticipates findings to be reduced in future fiscal years.

View Audit 315185 Questioned Costs: $1

Finding 478312 (2021-006)

Significant Deficiency 2021

City of Compton

CA

Questioned Costs Allowable Costs / Cost Principles Subrecipient Monitoring

Management Response and Corrective Action Plan City's Response: The City concurs with the recommendation. Corrective Action Plan: The City has other eligible costs that were not claimed for this grant that can be used to offset the questioned cost. Procedures are already in place to enhance payrate ...

Management Response and Corrective Action Plan City's Response: The City concurs with the recommendation. Corrective Action Plan: The City has other eligible costs that were not claimed for this grant that can be used to offset the questioned cost. Procedures are already in place to enhance payrate calculations in the future. Planned Implementation Date: Implemented as of April 2024 Responsible Person(s): City Controller

View Audit 314981 Questioned Costs: $1

Finding 478311 (2021-008)

Significant Deficiency 2021

City of Compton

CA

Allowable Costs / Cost Principles Subrecipient Monitoring HUD Housing Programs

Management Response and Corrective Action Plan City's Response: The City concurs with the recommendation. Corrective Action Plan: The general accounting policy will be updated for the accountant to check the payroll register to accrue retroactive pay changes to the correct period. The payroll policy...

Management Response and Corrective Action Plan City's Response: The City concurs with the recommendation. Corrective Action Plan: The general accounting policy will be updated for the accountant to check the payroll register to accrue retroactive pay changes to the correct period. The payroll policy will also be updated to require that timecards be updated with supervisor signature if changes are made to change allocation to another fund. Planned Implementation Date: June 30, 2024 Responsible Person(s): City Controller

View Audit 314981

Finding 478308 (2021-004)

None 2021

City of Compton

CA

Allowable Costs / Cost Principles HUD Housing Programs

Management Response and Corrective Action Plan City's Response: The City concurs with the recommendation. Corrective Action Plan: The payroll policy will be updated to require that timecards be updated with supervisor signature if changes are made to change allocation to another fund. Planned Implem...

Management Response and Corrective Action Plan City's Response: The City concurs with the recommendation. Corrective Action Plan: The payroll policy will be updated to require that timecards be updated with supervisor signature if changes are made to change allocation to another fund. Planned Implementation Date: June 30, 2024 Responsible Person(s): City Controller

View Audit 314981

Finding 478307 (2021-003)

Significant Deficiency 2021

City of Compton

CA

HUD Housing Programs Allowable Costs / Cost Principles

Management Response and Corrective Action Plan City's Response: The City concurs with the recommendation. Corrective Action Plan: The general accounting policy will be updated for the accountant to check the payroll register to accrue retroactive pay changes to the correct period. Planned Implementa...

Management Response and Corrective Action Plan City's Response: The City concurs with the recommendation. Corrective Action Plan: The general accounting policy will be updated for the accountant to check the payroll register to accrue retroactive pay changes to the correct period. Planned Implementation Date: June 30, 2024 Responsible Person(s): City Controller

View Audit 314981

Corrective Action Plans

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