Corrective Action Plans

Finding No.: 2022-046 AL Program: 97.039 - Hazard Mitigation Grant Program Area: Cash Management Questioned Costs: $2,687,277 Contact Person(s): Patrick Guerrero, Governor’s Authorized Rep., PAO Corrective Action Plan: Condition 1: HMGP respectfully disagrees with this finding. According to 31 CFR part 205, which is the default procedure if a Treasury-State Agreement (TSA) is not formally in effect, it is permissible and standard practice for a reimbursement check to clear after the disbursement request date, provided the subrecipient has submitted proof of prior payment with local funds. All checks in the samples tested are from local funds and all documents attached verified the expenses. Reimbursable funding is a recognized funding technique under 31 CFR 205.12(b)(e). This technique means that a Federal Program Agency transfers federal funds to a state after that state has already paid out the funds for Federal assistance program purposes and provided all necessary documentation. HMGP’s process operates under this reimbursement methodology: subrecipients incur costs using local funds first, then submit required documentation to HMGP for reimbursement. Consequently, the timing of reimbursement payments clearing after the request date is an inherent and necessary characteristic of this system. In absence of the TSA, the CNMI adheres to this prescribed default and the reimbursement method procedures are acceptable under the default. All expenses were processed, recorded, and supported by documentation and shows that the expense has initially been paid by non-federal, local government funds, had been processed through Munis on a reimbursement basis, and was processed no later than 30 calendar days after the reimbursement request was received. The finding suggests a deficiency, HMGP’s procedures are standard and compliant practice when operating under a reimbursement system and the default procedure. Although HMGP does believe that the current process meets federal and FEMA requirements, HMGP will develop and document a formal written procedure clearly outlining the expenditure timing process under the reimbursement system. This procedure will explain how costs are verified as incurred and demonstrate compliance with applicable federal and FEMA standards for fund control and accountability. Provide additional clarification and support documents to the auditor, if requested. Proposed Completion Date: September 30, 2025.

Finding No.: 2022-045 AL Program: 97.039 - Hazard Mitigation Grant Program Area: Allowable Costs/Cost Principles Questioned Costs: $99,924 Contact Person(s): Patrick Guerrero, Governor’s Authorized Rep., PAO Corrective Action Plan: The Hazard Mitigation Grant Program (HMGP) agrees with this finding. During the audit submission process, HMGP provided the support documents for the journal entries and reversals associated with the $99,923.27 to the auditor, as requested. However, it was only upon receiving this audit finding # 2022-049, that the discrepancy of a duplicate audit drawdown was called into question. HMGP’s ledger for this project as well as the Munis drawdown history does not indicate a remaining balance of $99,923.73 and the project related to this finding has already been closed out. To address this audit finding that HMGP received this last week on September 17th, HMGP reached out to the Department of Finance to provide related documents for the drawdowns. Based on the documents provided by DOF, the questioned cost was not a direct result of the duplicate drawdown but as a result of the reverse journal entries made by Tyler Munis staff in an effort to correct the duplicate drawdown. HMGP accurately completed all required steps to process and provided the necessary justification to process a total of $99,923.73 for professional services and submitted it to DOF. Based on the supporting documents, the $99,923.73 was comprised of: • $53,451.01- under Request for Payment Application #11, letter reference # GAR22-HM-005 received by DOF on 10/18/2021 and requested to be charged to M142352.62060. • $46,472.72- under Request for Payment Application #12, letter reference # GAR22-HM-031 received by DOF on 11/05/2021 and requested to be charged to M142352.62060. Both HMGP payment application requests show the project string was meant to be charged to 62060 which stands for Professional Services and was submitted to DOF for processing. Since the new Munis financial system portal was launch in the CNMI a month prior, HMGP personnel were not able to enter transactions directly, unlike the current process. However, when the transaction was processed on Munis, it was entered in by a Tyler Munis representative, as identified by the staff initials SMD, who was assigned to assist DOF employees with data input during the transition period and, according to the Munis transaction history, accidentally entered the debit for the $99,923.27 under the Construction project string instead of Professional Services on 12/2/2021. On 12/13/2021, SMD credited the $99,923.27 back to Construction and debited $99,923.27 to Professional Services with Journal entry # 2125. The Munis transaction history also shows various entries and reversals made under the project account that serve to correct the same journal error. HMGP personnel would not be able to review the transactions entered prior to posting, and based on the transaction logs, even after the transactions were posted, HMGP would see that those involved in processing the transactions corrected their errors. Additionally, the supporting documents associated with the drawdowns on Munis display a bank statement with a lumpsum total of various project accounts. Furthermore, most of the journal entries during the time in question either contained the same supporting documents or indicated “access denied” when selected by HMGP personnel with Munis access. The document provided to HMGP on 9/24/2025 indicated the final two transactions related to this expense was entered by Tyler Munis staff on August of 2022. In an effort to reverse the duplicate drawdowns that occurred in Professional Services, SMD reversed the $99,923.27 from professional services labeled as "REV JE 2125 DONE IN ERROR". Journal Entry (JE) 2125 refers to the debit they initially made on 12/13/2021. This credit effectively canceled out and corrected one of the two drawdowns that occurred within the Professional Services Project String. However, on the same day, SMD made a second journal entry reversal under the Construction project string with an identical PA journal comment ""REV JE 2125 DONE IN ERROR."" It is unclear as to why this transaction occurred given that original error under construction was made and corrected on December 2021. Since this incorrect journal entry was made as a debit to construction and the correct journal entry was made as a credit to professional services, the net draw would have been $0. Since $0 worth of funds were paid out and no check was cut as a result, this additional debit would not have been conspicuous to HMGP or the DOF staff. HMGP is prepared to provide the additional documentation upon request. Additionally, acknowledging that the second debit to construction in August of 2022 for $99,923.73 was recorded and was not corrected for this project, HMGP will work with DOF to correct the journal entry and return the funds to FEMA. To address the finding, a significant action step already taken is the transition that occurred in 2024 for agencies to initiate their own drawdowns. This drawdown process ensures HMGP’s direct oversight of all expenditures moving forward to reduce the risk of future duplications. HMGP created an internal drawdown tracker upon DOF’s transition to agency-initiated drawdown requests for 2024 expenses to present. HMGP will work with DOF to correct the journal entry on Munis in relation to the questioned cost and process the return of funds to FEMA. HMGP will create a tracker for all requested transactions made to DOF, such as reversals or corrections if needed as that function cannot be completed on Munis by HMGP. HMGP will review the tracker on a bi-weekly basis to ensure that all MUNIS journal entries and transfers related to HMGP to ensure expenditures are completed accurately and on a timely basis to avoid future misclassifications or duplications. HMGP will continue to ensure that all payments are correctly coded and submitted into Munis with the appropriate documentation and supporting details. HMGP will update the financial management portion of the HMGP standard operating procedures to reflect these action items. Proposed Completion Date: September 30, 2026

Finding No.: 2022-014 AL Program: 15.875 - Economic, Social, and Political Development of the Territories Area: Cash Management Questioned Costs: $482,041 Contact Person(s): Tracy B. Norita, Secretary of Finance / Nerissa B. Karakaya, CIP COTR Corrective Action Plan: Condition 1 (N. Karakaya): CIP agrees with the finding. However, this timing is inherent in our established process. For the Capital Improvement Program (CIP), once an expense is entered into Tyler Munis and posted, we request a drawdown for those expenses. The check clearing date will naturally occur after the drawdown request date because payment disbursement and check clearing are subsequent steps in the payment process. Our practice ensures that: • Drawdowns are based on recorded, approved, and posted expenditures, not on projected or unverified costs. • Requests for reimbursement are fully supported by documented and posted expenses, which comply with grant requirements. Corrective Action / Process Enhancement: Although we believe the current procedure meets federal and grantor requirements, we will: 1. Document the Existing Process: Prepare a written procedure that explains the sequence of posting expenses in Tyler Munis, requesting drawdowns, and issuing checks, to clarify why check clearing dates follow drawdown requests. 2. Communicate with Auditor/Grantor: Provide the written procedure to the auditors and grantor to ensure shared understanding of the process. 3. Consider Additional Controls (if recommended): If the grantor or auditor recommends further safeguards, CIP will evaluate and implement feasible enhancements. Proposed Completion Date: December 31, 2025

Cash Management: The College agrees with the finding. To strengthen internal controls over cash management, the College will establish written guidelines that will clearly define timelines, responsibilities, and approval processes for drawdown and disbursements. The College will reconcile drawdowns to expenditures on a monthly/quarterly basis.

Cash Management College of the Marshall Islands acknowledges the finding and agrees that the absence of written cash management procedures and the lack of supporting expenditure listings for drawdowns created gaps in compliance with federal requirements. These issues stemmed from inadequate internal controls and the limitations of the previous manual filing system, which made it difficult to verify that drawdowns were fully supported by incurred expenditures during the audit fieldwork. To address this, the College has drafted new cash management policies and procedures in accordance with 2 CFR 200.305, which are now being circulated for review and approval. These policies will require maintaining detailed expenditure listings to support every reimbursement request and ensuring that funds are drawn only after related costs have been incurred. The College has also upgraded and institutionalized a cloud-based filing system to ensure complete documentation and easy retrieval of drawdown support records. With the upgraded systems and the support of newly hired skilled staff, the College is now better equipped to comply with cash management requirements. Staff have been trained and will continue to be trained twice a year on federal cash management and documentation standards to prevent recurrence of similar issues in future audits.

Management will ensure that all nongrant expenditures are kept to a minimum until the cash balance of NVT is in excess of the unearned grant revenue and restricted fund balance. A large part of this problem in the current year was the amount of money paid to the Village’s accountants/consultant in prior years. This has been resolved and the new accountant’s fees are much more in line with reasonable amounts.

Planned Corrective Action: ACCEPT was approved by the Nevada Department of Public and Behavioral Health to submit RFRs as soon as possible in FY22. ACCEPT has followed this approval and submitted all requests by the 15th day of the month following the aforementioned month. Name of Contact Person: Gwen Taylor, Executive Director

Planned Corrective Action: The Quality Management Director and Executive Director have worked together to create a process with appropriate checks and balances regarding moving expense across individual grants and major funds. This process will consist of multiple levels of approval and specific documentation. Any entries will be processed in a timely manner and all expenditure reports will be checked for errors monthly. This process will ensure that expenditure reports are accurate at the time they are submitted for reimbursement. Name of Contact Person: Gwen Taylor, Executive Director

The Government concurs with the auditor's findings and recommendations. DHS is in the process of composing the solicitation for bid on the project to cover all periods outstanding.

The Government concurs with the auditor's findings and recommendations. VIDE acknowledges the findings related to cash management processes under the U.S. Department of Education Consolidated Grant. VIDE is committed to implement corrective actions to enhance cash management procedures and maintain compliance with U.S. Department of Education conditions. VIDE will reinforce its procedure that mandates completion of all drawdown requests within 24 hours after receiving the request from the TPFA. To maintain compliance and prevent any delays in processing drawdown requests, VIDE will ensure designated individuals are trained to process requests when the primary staff member is unavailable. VIDE will conduct weekly reconciliations of all drawdown requests and disbursements, developing a process for investigating and resolving discrepancies, and maintaining detailed records of all reconciliations.

The Government concurs with the auditor's findings and recommendations. The Government of the Virgin Islands (GVI) is implementing significant reforms to strengthen financial accountability and improve internal controls within its agencies. The Executive Order directing CFOs of the Government agencies to report to the Department of Finance aims to streamline financial oversight and ensure that public funds are being managed effectively. The introduction of a Public Finance Policy to standardize procedures and ensure compliance with Cash Management regulations (including CFRs and other compliance rules) is an important step in maintaining transparency and minimizing financial risks across the various government agencies.

The Government concurs with the auditor's findings and recommendations. OTAG has updated policies and procedures to address pre-award costs, scope of work, and payout to vendors to abide with the 90 days close out process. OTAG is training new personnel and monitoring implementation.

The Government concurs with the auditor's findings and recommendations. OTAG was not able to complete the preparation and submission of the SF-270 report for Fiscal Year 2022. However, OTAG has developed a Policies and Procedures Manual for FY2023. In addition, a Reimbursement Specialist was hired to ensure separation of duties in financial reporting.

The Government concurs with the auditor's findings and recommendations. DOH will revise drawdown Standard Operating Procedures (SOPs) to mandate that all supporting documents include a signature or initial to certify that a proper review was conducted. DOH will update drawdown SOPs for Fiscal Year 2025, ensuring that all drawdown documentation includes a review confirmation. DOH will also incorporate this updated procedure into Federal Grants update training in December 2024 and make it accessible to all staff on Business Process Improvement SharePoint site.

2022‐008 Grant Expenditures (Material Weakness) Recommendation: The Organization’s accounting system should be modified to accommodate expense tracking by individual grant and policies and procedures should be implemented to require direct expenses be assigned to specific grants. A method should be established to allocate indirect costs in accordance with federal regulations. Policies and procedures are also needed to provide appropriate oversight of all grant accounting including reporting. Action Taken (Unaudited): Management has updated its control procedures to include proper written policies for the internal control over financial reporting to ensure conformity with U.S. GAAP. Dan Watkins is responsible for this corrective action. A review process and coding within the accounting system was completed in January 2025. All invoices and staff time are evaluated for the level of effort towards each grant.

We are in receipt of the Findings Required to be Reported by Government Auditing Standards, regarding Reporting and Activities Allowed/Unallowed and Cost Principles. Management agrees with the finding. After correcting the calculation of expenses to include reimbursement from other sources, the Hospital still has sufficient lost revenues and expenses to cover the amount of provider relief funding received. Management will perform a detailed analysis of the reporting requirements in accordance with the final guidelines set by HRSA for future reporting periods. As deemed necessary, the Hospital will modify policies and procedures over federal grant reporting The CFO, Hong Wade, will be responsible to ensure this is accomplished. The corrective action plan will be implemented by December 31, 2025.

We agree with the recommendations offered and will establish and implement a comprehensive indirect cost allocation policy that aligns with Uniform Guidance requirements.

We agree with the recommendations offered and will establish updated policies and procedures to address the finding while considering appropriate measures for operating programs that are on a cost reimbursement basis. We have addressed this finding to our government partners. Specific government partners have requested the continuation of cash advances in the manner which we have been operating. We have worked with the other government partners and have come up with an incremental funding plan based on needs that are appropriate in maintaining the operational requirements set forth by the awards. Periodically we updated the government partners on program funds that have been used or those funds that are excess.

Current leadership and Management has implemented robust policies and procedures to ensure compliance with federal drawdown requirements. Currently, all drawdowns are based on 1/12th of the approved annual budget and are fully supported by actual expenditures recorded in the General Ledger. These expenditures exceed the amount of the monthly drawdown, ensuring we are not drawing funds in advance. Previous acceleration of drawdowns in prior years was not aligned with best practices and stemmed from poor cash flow management and inadequate internal controls. Our corrective action plan directly addresses these issues through strengthened oversight and improved fiscal discipline. Furthermore, in alignment with the Department of Health and Human Services’ “Defend the Spend” (DOGE) initiative, all drawdowns are now required to be substantiated by actual, documented expenses reflected in the General Ledger.

Finding Reference: 2022-001 Description of Finding: Significant Deficiency in Internal Controls over Compliance. Identification of the Federal Program: U.S. Department of the Treasury CFDA 20.019 Criteria or Specific Requirement: Recipients of federal awards must establish internal controls over reports that are prepared and submitted. Finding/Condition: Pursuant to the reporting requirement set forth by the Department of the Treasury, the Organization is required to submit the single audit to the Federal Audit Clearinghouse within 30 days of the issuance of the audit report or nine months after the end of the Organization’s fiscal year. During our reporting period we noted that the audit was not completed and filed timely. Cause: The Organization met the requirements for a single audit for the first time during the year ended December 31, 2022. Due to a lack of expertise in federal grant reporting requirements, the Organization overlooked the requirement to perform a single audit and file with the clearinghouse in a timely manner Corrective Action: In June 2025, Monterey County Business Council employed a CFO Consultant with 30+ years’ experience in finance and accounting who has performed a deep dive into the accounting framework. The Consultant has been engaged to assist the Organization in completing financial and single audits for the years ended December 31, 2022, 2023, and 2024. It is expected that the Organization will be caught up with federal clearinghouse filings by the end of 2025 or early 2026 at the latest. Under the consultant’s guidance, the Organization has made progress in financial reporting and will be filing the 2022 audit by August 30, 2025. Audits for subsequent years will be audited thereafter. Name of Responsible Person: Chris Steinbruner, CPA Questioned Cost: None Chris Steinbruner, CPA MCBC Board Member (831)-222-6111

2022 – 007: Cash Collateralization Condition: During our review of the Organization’s cash, it was noted that as of September 30, 2022, they have not collateralized cash balances in excess of the amounts insured by the Federal Deposit Insurance Corporation. Cash balances of $11,685,898 were uninsured at September 30, 2022. Unearned revenue was reported at approximately $10,704,037 which includes advance payments of Federal funds. Corrective Action Plan: Management will review options with their bank to have a cash collateralization agreement put in place.

The funds from the project came from several different grant sources. Bills were due and our consultant DLZ advised us on how to pay these bills even if they were paid from grants other than from the correct grant sources.

Again started before I got here. I did what I was told by DLZ our Consultant.

View of Responsible Officials and Corrective Action Plan The excess drawdown may have occurred due to the carry fund balance being included as a debit balance on the trial balance during review of drawdown expenses and not adjusted to reduce the amount of the drawdown(s). The error was discovered when the Accounting Manager was in the process of preparing the SEFA schedule. The Accounting Manager disclosed this error to the auditor during the course of the audit. Corrective Action Plan Timeline AAIHB will consult with the Program Manager and awarding agency to determine the appropriate resolution of the excess drawdown within 30 days. AAIHB finance office has a process in place of reviewing drawdowns and monitoring expenses as grants approach the end of the project funding period. Designation of Employee Position Responsible for Meeting Deadline Accounting Manager and Finance Director

Finding Reference Number: SA2022-007 Compliance with Grant Invoicing Requirements AL Number: 20.205 Assistance Listing Title: Highway Planning and Construction Cluster Federal Agency: Department of Transportation Pass Through Entity: California Department of Transportation Federal Award Identification Number: ATPL-5238(068) • Fiscal Year of Initial Finding: 2022 • Name(s) of the contact person: Ryan Chapman, Public Works Director, Engineering and Transportation • Corrective Action Plan: The Public Works Engineering and Transportation department updated its standard operating procedure of Monitoring Federal Grant Funded Projects Invoicing section to include steps required for reimbursements with filing frequency of over six months. • Anticipated Completion Date: August 2025