Corrective Action Plans

Finding 1161249 (2022-038)

Material Weakness 2022

Commonwealth of the Northern Mariana Islands

MP

Questioned Costs Allowable Costs / Cost Principles Eligibility

Finding No.: 2022-038 AL Program: 93.778 - Medical Assistance Program Area: Activities Allowed or Unallowed and Allowable Costs/Cost Principles Questioned Costs: $27,816,686 Contact Person(s): Geroge J. Cruz, Medicaid Director Corrective Action Plan: Condition 1: The CNMI Medicaid Office respectfull...

Finding No.: 2022-038 AL Program: 93.778 - Medical Assistance Program Area: Activities Allowed or Unallowed and Allowable Costs/Cost Principles Questioned Costs: $27,816,686 Contact Person(s): Geroge J. Cruz, Medicaid Director Corrective Action Plan: Condition 1: The CNMI Medicaid Office respectfully disagrees with this finding. Due to internal scheduling constraints and the compressed timeline required to complete the FY22 audit, the requested documents were not submitted by the specified deadline, resulting in this finding. However, the office maintains all relevant supporting documentation and is prepared to provide it upon request from the Grantor. Proposed Completion Date: Ongoing Condition 2: The CNMI Medicaid Office respectfully disagrees with this finding. Due to internal scheduling constraints and the compressed timeline required to complete the FY22 audit, the requested documents were not submitted by the specified deadline, resulting in this finding. However, the office maintains all relevant supporting documentation and is prepared to provide it upon request from the Grantor. Proposed Completion Date: Ongoing Condition 3: CNMI Medicaid Office respectfully disagrees with this finding. The agency currently does not have a Medicaid Management Information System (MMIS) in place to collect and accurately report comprehensive Benefits Paid data. All data processing is done manually, and information is maintained using Excel spreadsheets, which limits the ability to generate complete and reliable reports. Additionally, the "Benefits Paid" data provided to the auditor does not include services covered under the Certified Public Expenditures (CPE) payments made to CHCC. Therefore, these records should not be used as the sole basis for evaluating program eligibility, total expenditures, or compliance with eligibility requirements. However, the CNMI Medicaid Office maintains all relevant supporting documentation and is prepared to provide it upon request from the Grantor. Proposed Completion Date: Ongoing

View Audit 371187 Questioned Costs: $1

Finding 1161244 (2022-037)

Material Weakness 2022

Commonwealth of the Northern Mariana Islands

MP

Questioned Costs Special Tests & Provisions Subrecipient Monitoring

Finding No.: 2022-037 AL Program: 93.767 - Children’s Health Insurance Program Area: Special Tests and Provisions - Provider Eligibility (Screening and Enrollment) Questioned Costs: $7,932,110 Contact Person(s): Geroge J. Cruz, Medicaid Director Corrective Action Plan: CNMI Medicaid Office respectfu...

Finding No.: 2022-037 AL Program: 93.767 - Children’s Health Insurance Program Area: Special Tests and Provisions - Provider Eligibility (Screening and Enrollment) Questioned Costs: $7,932,110 Contact Person(s): Geroge J. Cruz, Medicaid Director Corrective Action Plan: CNMI Medicaid Office respectfully disagrees with the finding. While the office did perform OIG exclusion list validation, screenshots were not captured for each individual check. It is important to note that the OIG Exclusion List portal’s search function is limited to on-screen viewing and does not provide a built-in option to print or export search results. Additionally, the CMS access process for exclusion checks involves a rigorous background clearance, and only one personnel of three total successfully gained access. CNMI Medicaid Office acknowledges that historically, limited personnel capacity has hindered full compliance with this requirement. However, efforts are currently underway to streamline and strengthen the exclusion verification process. The office is actively developing a fully functional Program Integrity Division that will be responsible for conducting and documenting OIG exclusion checks in a consistent and compliant manner moving forward. Proposed Completion Date: Ongoing

View Audit 371187 Questioned Costs: $1

Finding 1161241 (2022-034)

Material Weakness 2022

Commonwealth of the Northern Mariana Islands

MP

Questioned Costs Allowable Costs / Cost Principles Subrecipient Monitoring

Finding No.: 2022-034 AL Program: 93.767 - Children’s Health Insurance Program Area: Activities Allowed or Unallowed and Allowable Costs/Costs Principles Questioned Costs: $1,182,511 Contact Person(s): Geroge J. Cruz, Medicaid Director Corrective Action Plan: Condition 1: The CNMI Medicaid Office re...

Finding No.: 2022-034 AL Program: 93.767 - Children’s Health Insurance Program Area: Activities Allowed or Unallowed and Allowable Costs/Costs Principles Questioned Costs: $1,182,511 Contact Person(s): Geroge J. Cruz, Medicaid Director Corrective Action Plan: Condition 1: The CNMI Medicaid Office respectfully disagrees with this finding. Due to internal scheduling constraints and the compressed timeline required to complete the FY22 audit, the requested documents were not submitted by the specified deadline, resulting in this finding. However, the office maintains all relevant supporting documentation and is prepared to provide it upon request from the Grantor. Proposed Completion Date: Ongoing Condition 2: CNMI Medicaid Office cannot confirm to agree or disagree with the findings stated, as the information references case numbers without sufficient supporting detail. The office does not operate a Medicaid Management Information System (MMIS) and therefore cannot automatically retrieve data to link case numbers with the total benefits paid or questioned costs. Additionally, two of the three case numbers provided are associated with multiple individuals. Even if the case numbers were accurate and beneficiary names included, the office would still need to identify the provider(s) associated with the payments in question. Claims data is maintained manually in Excel spreadsheets, consolidated across beneficiaries, and processed for payment through the MUNIS system using internally generated invoice numbers. These invoice numbers are not linked to specific beneficiaries. Therefore, to properly evaluate the findings, the office would require not only the case number, but also the beneficiary’s full name and the corresponding MUNIS invoice number. The office maintains all relevant supporting documentation and is prepared to provide it upon request from the Grantor. Proposed Completion Date: Ongoing Condition 3: The CNMI Medicaid Office respectfully disagrees with this finding. Due to internal scheduling constraints and the compressed timeline required to complete the FY22 audit, the requested documents were not submitted by the specified deadline, resulting in this finding. However, the office maintains all relevant supporting documentation and is prepared to provide it upon request from the Grantor. Proposed Completion Date: Ongoing

View Audit 371187 Questioned Costs: $1

Finding 1161240 (2022-033)

Material Weakness 2022

Commonwealth of the Northern Mariana Islands

MP

Questioned Costs Special Tests & Provisions Subrecipient Monitoring

Finding No.: 2022-033 AL Program: 93.489/93.575/93.596 - CCDF Cluster Area: Special Tests and Provisions – Health and Safety Requirements Questioned Costs: $1,757,352 Contact Person(s): Roselle Teregeyo, CCDF Co-Administrator/Accountant Corrective Action Plan: Condition 1: CCDF respectfully disagree...

Finding No.: 2022-033 AL Program: 93.489/93.575/93.596 - CCDF Cluster Area: Special Tests and Provisions – Health and Safety Requirements Questioned Costs: $1,757,352 Contact Person(s): Roselle Teregeyo, CCDF Co-Administrator/Accountant Corrective Action Plan: Condition 1: CCDF respectfully disagrees with this finding. In the middle of the Fiscal year, the CCDF Program transitioned to have the Quality Rating and Improvement System or QRIS perform the announced and unannounced visits. To allow the complete transition of the CCDF Certification and monitoring system, as independent from the Child Care Licensing Program, CCDF extended all expiration dates of CCDF Providers for an additional two months. This extension was given to all CCDF providers renewing from April 2022 to December 31, 2022. With the transition, CCDF allowed for providers to meet provider requirements in a year and were only subjected to an announced visit. Any non-compliance was noted, but supported to compliance through coaching. Effective October 1, 2022, all CCDF Providers are now subjected to announced and unannounced visits. Proposed Completion Date: Completed Condition 2: CCDF respectfully disagrees with this finding. Based on our records, all providers met the annual training hours. Proposed Completion Date: Ongoing

View Audit 371187 Questioned Costs: $1

Finding 1161239 (2022-032)

Material Weakness 2022

Commonwealth of the Northern Mariana Islands

MP

Questioned Costs Eligibility

Finding No.: 2022-032 AL Program: 93.489/93.575/93.596 – CCDF Cluster Area: Eligibility Questioned Costs: $43,100 Contact Person(s): Roselle Teregeyo, CCDF Co-Administrator/Accountant Corrective Action Plan: Condition 1: For Case ID: 2827C, 2528C, 2936A, 2528B, 3062D: CCDF agrees with these findings...

Finding No.: 2022-032 AL Program: 93.489/93.575/93.596 – CCDF Cluster Area: Eligibility Questioned Costs: $43,100 Contact Person(s): Roselle Teregeyo, CCDF Co-Administrator/Accountant Corrective Action Plan: Condition 1: For Case ID: 2827C, 2528C, 2936A, 2528B, 3062D: CCDF agrees with these findings. To address these findings, effective October 2025, CCDF will not approve applicant/s Certificate of Confirmation without a current and valid work permit. As of January 2025, CCDF Waitlist applications are no longer initially processed by one Eligibility Worker, waitlist applications must be assessed by two eligibility workers to ensure requirements and documents are met. For final approval CCDF waitlist applications are again cross checked by the Eligibility Supervisor to ensure all requirements and documentation are met. CCDF Eligibility staff will assess client files and if needed, will request for current and valid work permits. Proposed Completion Date: December 31, 2025 Condition 2: CCDF agrees with this finding. To address these findings, effective October 2025, CCDF will not approve applicant/s Certificate of Confirmation without a current and valid work permit. As of January 2025, CCDF Waitlist applications are no longer initially processed by one Eligibility Worker, waitlist applications must be assessed by two eligibility workers to ensure requirements and documents are met. For final approval CCDF waitlist applications are again cross checked by the Eligibility Supervisor to ensure all requirements and documentation are met. CCDF Eligibility staff will assess client files and if needed, will request for current and valid work permits. Proposed Completion Date: December 31, 2025 Condition 3: CCDF agrees with this finding. For Case ID 3324B: Total overpayment to provider was $300.00. CCDF will recoup the amount from the provider no later than December 2025. CCDF determined that the overpayment to provider is $300.00. CCDF will recoup $150.00 each month from the provider beginning November 2025 and the whole amount will be recouped by December 2025. As of August 2025, CCDF Provider payments are cross checked by the CCDF Accounting section. Additionally, effective October 1, 2025, CCDF Data Specialist will cross check provider payments to ensure base payment rates are applicable to each child based on the child’s age. Proposed Completion Date: December 31, 2025

View Audit 371187 Questioned Costs: $1

Finding 1161224 (2022-023)

Material Weakness 2022

Commonwealth of the Northern Mariana Islands

MP

Questioned Costs Allowable Costs / Cost Principles Eligibility

Finding No.: 2022-023 AL Program: 21.023 - Emergency Rental Assistance Program Area: Eligibility Questioned Costs: $331,985 Contact Person(s): Epiphanio Cabrera, Jr., Grants Administrator, OGM-SC Corrective Action Plan: The Office of Grant Management (OGM) respectfully disagrees with this finding. T...

Finding No.: 2022-023 AL Program: 21.023 - Emergency Rental Assistance Program Area: Eligibility Questioned Costs: $331,985 Contact Person(s): Epiphanio Cabrera, Jr., Grants Administrator, OGM-SC Corrective Action Plan: The Office of Grant Management (OGM) respectfully disagrees with this finding. The delay in document submission was attributable to internal scheduling constraints combined with the compressed timeline required to complete the FY2022 Single Audit. While the requested documentation was not provided by the auditor’s specified deadline, OGM maintains all relevant supporting records in accordance with federal grant retention requirements and remains prepared to furnish them upon request from the Grantor. Although the documentation was submitted several days beyond the deadline, the auditors informed OGM that reviewing the late submission would cause additional delays to the overall audit process. OGM disputes the questioned cost amount of $331,985, as complete and accurate records exist to substantiate the eligibility determinations of the CCERA clients in question. Given that the program concluded more than two years ago, additional time was necessary to retrieve and compile archived files. Accordingly, OGM asserts that these costs are allowable, allocable, and fully supported, and recommends that the auditors reconsider the finding in light of the shortened audit review window and the program’s recordkeeping context. Proposed Completion Date: Ongoing

View Audit 371187 Questioned Costs: $1

Finding 1161221 (2022-020)

Material Weakness 2022

Commonwealth of the Northern Mariana Islands

MP

Questioned Costs Matching / Level of Effort / Earmarking Subrecipient Monitoring

Finding No.: 2022-020 AL Program: 17.225 - Unemployment Insurance Area: Eligibility Questioned Costs: $80,773 Contact Person(s): Zachary Taitano, PUA Program Manager, DOL Corrective Action Plan: Condition 1: The CNMI agrees that the expenditure listing from the Financial System is significantly lowe...

Finding No.: 2022-020 AL Program: 17.225 - Unemployment Insurance Area: Eligibility Questioned Costs: $80,773 Contact Person(s): Zachary Taitano, PUA Program Manager, DOL Corrective Action Plan: Condition 1: The CNMI agrees that the expenditure listing from the Financial System is significantly lower than the listing generated from the HireMarianas Portal. This discrepancy is due to the fact that the expenditure listing reflects only disbursed payments, whereas the HireMarianas Portal listing includes transactions that were removed, cancelled, or rejected by the claimant’s financial institution. Additionally, the HireMarianas listing includes payments that were cancelled and subsequently reissued through the portal, which may result in what appear to be duplicate entries. Proposed Completion Date: Completed Condition 2: The CNMI partially agrees with this finding. While it is acknowledged that 8 of the 11 identified users’ SAVE verification results were uploaded onto the HireMarianas Portal late, all claimants were of Qualified Alien status in accordance with the definition provided through the Immigration and Nationality Act (INA). Moreover, all SAVE responses are now on the respective applicants’ supporting documents tab on the HireMarianas Portal. Proposed Completion Date: Ongoing

View Audit 371187 Questioned Costs: $1

Finding 1161192 (2022-012)

Material Weakness 2022

Commonwealth of the Northern Mariana Islands

MP

Questioned Costs School Nutrition Programs Matching / Level of Effort / Earmarking

Finding No.: 2022-012 AL Programs: 10.542 - Pandemic EBT Food Benefits (P-EBT) Area: Eligibility Questioned Costs: $58,494 Contact Person(s): Margaret Aldan, NAP Administrator Corrective Action Plan: Condition 1 & 2: CNMI NAP respectfully disagrees. Audit finding states that documentation supporting...

Finding No.: 2022-012 AL Programs: 10.542 - Pandemic EBT Food Benefits (P-EBT) Area: Eligibility Questioned Costs: $58,494 Contact Person(s): Margaret Aldan, NAP Administrator Corrective Action Plan: Condition 1 & 2: CNMI NAP respectfully disagrees. Audit finding states that documentation supporting eligibility determinations were not provided. Finding further states that CNMI NAP lacks monitoring control over the listing of validated eligibility roster data that were not uploaded into MAVEN eligibility system due to data entry capacity limitations (sic) were not being maintained; and Distributed coupons were not reconciled to the recorded expenditures for redeemed coupons. The resulting effect being that CNMI NAP is in noncompliance with the applicable eligibility requirements and questioned costs for condition 1. CNMI NAP was informed that this finding had been cleared so we are perplexed as to the re-emergence of this audit finding. CNMI NAP contends that: 1. Eligibility for P-EBT benefits is not determined by CNMI NAP. P-EBT eligibility was determined by identifying children who qualified for free or reduced-price school meals and then correlating that with a reduction of in-person schooling due to COVID-19. Children in households receiving SNAP and young children, under age six, were also eligible, provided their schools or childcare facilities closed or reduced hours for at least five consecutive days due to the pandemic. This data was provided by PSS, as well as the listing of eligible children that corresponded to this data set. 2. There are no “validated eligibility roster data case files” that were not uploaded into MAVEN due to data entry capacity limitations. All rosters provided by PSS were uploaded into MAVEN as this is the only way a case file can be generated in the system. 3. CNMI NAP has reconciled all benefits issued, including the P-EBT benefits for the audit year in question. This is a mandatory, non-negotiable process. Proposed Completion Date: Ongoing

View Audit 371187 Questioned Costs: $1

Finding 1161191 (2022-011)

Material Weakness 2022

Commonwealth of the Northern Mariana Islands

MP

Subrecipient Monitoring School Nutrition Programs Eligibility § 200.334

Finding No.: 2022-011 AL Program: 10.542 - Pandemic EBT Food Benefits (P-EBT) Area: Activities Allowed or Unallowed Questioned Costs: $-0- Contact Person(s): Margaret Aldan, NAP Administrator Corrective Action Plan: CNMI NAP respectfully disagrees with this finding. The April 2022 Compliance Supplem...

Finding No.: 2022-011 AL Program: 10.542 - Pandemic EBT Food Benefits (P-EBT) Area: Activities Allowed or Unallowed Questioned Costs: $-0- Contact Person(s): Margaret Aldan, NAP Administrator Corrective Action Plan: CNMI NAP respectfully disagrees with this finding. The April 2022 Compliance Supplement referenced by the auditor states: Special Tests and Provisions. 1. Verification of Free and Reduced-Price Applications (NSLP) Compliance Requirements: By November 15th of each school year, the LEA (or state in certain cases) must verify the current free and reduced-price eligibility of households selected from a sample of applications that it has approved for free and reduced-price meals, unless the LEA is otherwise exempt from the verification requirement. The verification sample size is based on the total number of approved applications on file on October 1st. A state agency may, with FNS approval, assume from LEAs under its jurisdiction the responsibility for performing the verifications. If the LEA performs the verification function it must be in accordance with instructions provided by the state agency. The LEA must follow up on children whose eligibility status has changed as the result of verification activities to put them in the correct category. CNMI NAP response: The 2022 Compliance Supplement states that the LEA, in this instance, PSS, is responsible for verifying the current free and reduced-price eligibility of households unless the LEA is exempt from the verification requirement. PSS is not exempt from the verification requirement and the CNMI NAP has never given instructions to PSS for data collection as it is the PSS’ responsibility to supply the data to NAP for P-EBT. NAP’s role is to distribute the benefits only. Similar to the SUN Bucks (S-EBT) program, PSS furnishes the student listing to NAP, after which NAP distributes the benefits according to the listing provided by PSS. Proposed Completion Date: Ongoing

View Audit 371187

Finding 1160272 (2022-003)

Material Weakness 2022

Monroe County Commission

AL

Eligibility Special Tests & Provisions

Response/Views: The County Engineer and Assistant Engineer were declared eligible workers since they performed essential duties during the pandemic, as outlined in the January 2022 Overview of the Final Rule. These employees were discussed in various work sessions; however, they were not properly in...

Response/Views: The County Engineer and Assistant Engineer were declared eligible workers since they performed essential duties during the pandemic, as outlined in the January 2022 Overview of the Final Rule. These employees were discussed in various work sessions; however, they were not properly included in the resolution. Because the County was not a participant in IAC (Investing in Alabama Counties), we did not receive additional guidance. We elected not to pay 8 percent of ARPT funding ($4,027,142.00), which amounts to $322,171.36, to join. As a result, we were unable to obtain specific guidance from either the ACCA office or the Examiners' office on questions related to ARPT. We still have ARPT funds on hand. Corrective Action Planned: If our explanation does not fully satisfy this finding, the County is prepared to reimburse this expense from the General Fund to the ARPT fund account. The ARPT account still maintains a balance, and funds are available to be expended through December 31, 2026. It is important to note that the County received very limited guidance from both the ACCA office and the Examiners of Public Accounts personnel regarding this matter.

View Audit 370661

Finding 1160136 (2022-018)

Material Weakness 2022

College of the Marshall Islands

MH

Subrecipient Monitoring Eligibility Reporting § 200.303

Reporting College of the Marshall Islands acknowledges the finding and agrees that both the Section II source data file of the Annual Performance Report (APR) and the required Final Performance Report could not be provided during the audit. This occurred due to inadequate internal controls and the l...

Reporting College of the Marshall Islands acknowledges the finding and agrees that both the Section II source data file of the Annual Performance Report (APR) and the required Final Performance Report could not be provided during the audit. This occurred due to inadequate internal controls and the limitations of the previous manual filing system, which led to incomplete retention and difficulty retrieving submitted reports during the audit fieldwork. To correct this, the College has upgraded and institutionalized a cloud-based filing system to ensure all source data files, APR submissions, and Final Performance Reports are properly stored, organized, and easily accessible. Internal control policies and procedures have been strengthened to require that all performance reports are submitted on time, with verified source data and confirmation of successful submission retained in the system. The TRIO Office has established a reporting calendar, supervisory review process, and digital archive protocol to ensure all APR and final reports are prepared, submitted, and properly retained. With the upgraded systems and the support of newly hired skilled staff, the College is now better equipped to meet federal reporting requirements. Staff have been trained— and will continue to be trained twice a year—on performance reporting procedures and federal reporting standards to prevent recurrence of similar issues in future audits.

View Audit 370531

Finding 1160135 (2022-017)

Material Weakness 2022

College of the Marshall Islands

MH

Questioned Costs Subrecipient Monitoring Eligibility § 200.303

Eligibility College of the Marshall Islands acknowledges the finding and agrees that several participant files lacked the required eligibility documentation, including proof of citizenship/residency, verification of academic support needed, documentation of age and grade level at initial selection, ...

Eligibility College of the Marshall Islands acknowledges the finding and agrees that several participant files lacked the required eligibility documentation, including proof of citizenship/residency, verification of academic support needed, documentation of age and grade level at initial selection, and confirmation of first-generation or low- income status. These gaps resulted from weak internal controls and the limitations of the previous manual filing system, which hindered proper tracking and retention of eligibility records during the audit fieldwork. To address these deficiencies, the College has upgraded and institutionalized a cloud-based filing system to ensure complete, organized, and easily retrievable participant eligibility documentation. Internal control policies and procedures have been strengthened to require that all eligibility documents including citizenship/residency proof, age and grade verification, academic support need assessments, and first-generation/low-income eligibility forms—are obtained, reviewed, and approved before a student is enrolled and receives any program benefits or stipends. The TRIO Office has implemented a new eligibility checklist and supervisory review process to verify completeness and compliance for every participant file. With the upgraded systems and the support of newly hired skilled staff, the College is now better positioned to maintain accurate eligibility records. Staff have been trained and will continue to be trained twice a year on federal eligibility requirements and documentation standards to prevent recurrence of similar issues in future audits.

View Audit 370531 Questioned Costs: $1

Finding 1160034 (2022-007)

Material Weakness 2022

US Helping Us, People Into Living, Inc.

DC

Eligibility

Views of Responsible Officials and Corrective Action: To address this issue and ensure future compliance, we have implemented the following measures: • Eligibility Verification Protocols: We have developed and implemented standardized eligibility screening procedures for all HHS-funded programs. The...

Views of Responsible Officials and Corrective Action: To address this issue and ensure future compliance, we have implemented the following measures: • Eligibility Verification Protocols: We have developed and implemented standardized eligibility screening procedures for all HHS-funded programs. These protocols include: • Clear definitions of eligibility criteria based on program guidelines. • Required documentation (e.g., income verification, residency, age, or disability status). • A checklist to ensure all required documents are collected and reviewed. • Documentation Standards: All eligibility determinations are now documented and retained in participant files. We have adopted a secure digital system to store and manage these records, ensuring they are accessible for audit and monitoring purposes . • Staff Training: Program staff have received training on eligibility requirements and documentation standards. Training materials include examples of acceptable documentation and instructions for handling incomplete or missing information. Monitoring and Oversight • We have instituted periodic internal audits to review participant files for compliance with eligibility documentation requirements. • Supervisors are required to review and approve eligibility determinations before services are rendered. Policy Updates Our program policies have been updated to include: • Mandatory eligibility screening and documentation procedures. • Retention requirements aligned with 2 CFR § 200.334. • Procedures for handling exceptions and documenting justifications. Commitment to Compliance We are committed to ensuring that all participants in HHS-funded programs meet the required eligibility criteria and that our documentation practices fully comply with Federal regulations. We appreciate the audit team's diligence and will continue to cooperate fully to resolve this finding.

View Audit 370488

Finding 1159822 (2022-006)

Material Weakness 2022

Republic of Palau

PW

Questioned Costs Subrecipient Monitoring Eligibility

We concur with the finding. Beginning in FY25, claimants have been required to come in and correct errors on their weekly claim forms. Regarding the overpayment, the claimant has been provided with a completed overpayment waiver form covering the two weeks of paid benefits.

View Audit 370385 Questioned Costs: $1

Finding 1157880 (2022-077)

Material Weakness 2022

The Virgin Islands Hsg Finance Authority - Paradise Mills Apartments

FL

Special Tests & Provisions Eligibility Matching / Level of Effort / Earmarking § 200.303

The Government concurs with the auditor's findings and recommendations. DHS has onboarded a Director of Program Integrity who will be responsible for establishing The Quality Control Unit, which will work with the Medical Eligibility Quality Control (MFCU) on behalf of the Medicaid Program.

View Audit 369907

Finding 1157878 (2022-075)

Material Weakness 2022

The Virgin Islands Hsg Finance Authority - Paradise Mills Apartments

FL

Internal Control / Segregation of Duties Eligibility Reporting § 200.303

The Government concurs with the auditor's findings and recommendations. DHS staff will work with PMO, hired to assist with the Public Health Emergency Unwind and establish Standard Operating Policies and Procedures (SOPPs) on certification and recertification processes and procedures. DHS is also in...

The Government concurs with the auditor's findings and recommendations. DHS staff will work with PMO, hired to assist with the Public Health Emergency Unwind and establish Standard Operating Policies and Procedures (SOPPs) on certification and recertification processes and procedures. DHS is also in the process of hiring a Program Integrity Director and Medical Eligibility Quality Control (MEQC) staff, whose responsibility will be to review completed case files.

View Audit 369907

Finding 1157866 (2022-069)

Material Weakness 2022

The Virgin Islands Hsg Finance Authority - Paradise Mills Apartments

FL

Matching / Level of Effort / Earmarking Special Tests & Provisions Subrecipient Monitoring § 200.303

The Government concurs with the auditor's findings and recommendations. An internal audit process is in place and is being utilized. Specifically, this includes exchanging caseloads between workers and having the eligibility and subsidy determinations cross-checked by the different worker based on t...

The Government concurs with the auditor's findings and recommendations. An internal audit process is in place and is being utilized. Specifically, this includes exchanging caseloads between workers and having the eligibility and subsidy determinations cross-checked by the different worker based on the federally and locally established policies.

View Audit 369907

Finding 1157865 (2022-068)

Material Weakness 2022

The Virgin Islands Hsg Finance Authority - Paradise Mills Apartments

FL

Special Tests & Provisions Subrecipient Monitoring Eligibility § 200.303

The Government concurs with the auditor's findings and recommendations. While DHS remains in compliance with this finding from previously audited years, the untimely submission resulted in this finding. Moving forward, a shared file will be established to ensure that the requisite information for ea...

The Government concurs with the auditor's findings and recommendations. While DHS remains in compliance with this finding from previously audited years, the untimely submission resulted in this finding. Moving forward, a shared file will be established to ensure that the requisite information for each year is readily available for audit purposes.

View Audit 369907

Finding 1157861 (2022-064)

Material Weakness 2022

The Virgin Islands Hsg Finance Authority - Paradise Mills Apartments

FL

Subrecipient Monitoring Eligibility Matching / Level of Effort / Earmarking § 200.303

The Government concurs with the auditor's findings and recommendations. The DHS has implemented a checklist as an added internal control step to comply with the Federal requirements for review of provider enrollment applications by the provider relations staff.

View Audit 369907

Finding 1157824 (2022-054)

Material Weakness 2022

The Virgin Islands Hsg Finance Authority - Paradise Mills Apartments

FL

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

The Government concurs with the auditor's findings and recommendations. VIDE acknowledges the findings related to the participation of private school children in the COVID-19 Education Stabilization Fund (ESF-SEA) program. VIDE is committed to rectifying these issues and enhancing our systems to ens...

The Government concurs with the auditor's findings and recommendations. VIDE acknowledges the findings related to the participation of private school children in the COVID-19 Education Stabilization Fund (ESF-SEA) program. VIDE is committed to rectifying these issues and enhancing our systems to ensure equitable services for private school children. OMB will develop and implement a formal policy and procedures that outline the process for ensuring the participation of private school children in compliance with federal regulations. This will include guidelines for timely consultation with nonpublic schools and documentation of services provided. OMB will create a consultation schedule to ensure that timely consultations with nonpublic schools are conducted each fiscal year. The schedule will outline key dates for initiating and completing consultations to meet compliance requirements. OMB will collaborate with the Department of Education to develop control measure to ensure that all private schools expenditures are equal on a per-pupil basis to the expenditures for participating public school children and their teachers and other educational personnel.

View Audit 369907

Finding 1157798 (2022-038)

Material Weakness 2022

The Virgin Islands Hsg Finance Authority - Paradise Mills Apartments

FL

Special Tests & Provisions Subrecipient Monitoring Eligibility § 200.303

The Government concurs with the auditor's findings and recommendations. VIDOL will be implementing a RESEA case management system for reporting and program services. This case management system is currently in configuration phase of the project. Live production is expected by the 2nd quarter 2025. T...

The Government concurs with the auditor's findings and recommendations. VIDOL will be implementing a RESEA case management system for reporting and program services. This case management system is currently in configuration phase of the project. Live production is expected by the 2nd quarter 2025. This system will be the official system of record for recording all services for RESEA claimants that participate in the program.

View Audit 369907

Finding 1157795 (2022-035)

Material Weakness 2022

The Virgin Islands Hsg Finance Authority - Paradise Mills Apartments

FL

Questioned Costs Eligibility Matching / Level of Effort / Earmarking § 200.303

The Government concurs with the auditor's findings and recommendations. The agency has commenced reviewing the agency retention policies and training with staff on keeping records and files in a systematic sequence. In the third quarter of FY2025, the agency will be launching an electronic record ke...

The Government concurs with the auditor's findings and recommendations. The agency has commenced reviewing the agency retention policies and training with staff on keeping records and files in a systematic sequence. In the third quarter of FY2025, the agency will be launching an electronic record keeping system for claims files that will provide a more comprehensive and structured mechanism for record retention. VIDOL staff will also be engaging with USDOL to have programmatic technical assistance with record retention. The agency is also engaging with USDOL to implement data validation in the operations which is intended to verify that eligibility and records are maintained. The agency’s Integrity unit will commence regular compliance reviews for claimant eligibility in the 2nd quarter of FY2025, this review will assist in mitigating past errors and provide feedback on corrective actions that will assist in proper record retention.

View Audit 369907 Questioned Costs: $1

Finding 1155085 (2022-003)

Material Weakness 2022

Hill Country Community Clinic, Inc.

CA

Special Tests & Provisions Eligibility

Management acknowledges the finding. We will conduct mandatory training sessions for all relevant personnel to ensure a clear understanding of the Sliding Fee Discount Program requirements and policy. Training will include proper documentation practices, eligibility verification, and procedures for ...

Management acknowledges the finding. We will conduct mandatory training sessions for all relevant personnel to ensure a clear understanding of the Sliding Fee Discount Program requirements and policy. Training will include proper documentation practices, eligibility verification, and procedures for applying discounts consistently. We will review and update our sliding fee discount policy to ensure clarity, consistency, and compliance with regulatory requirements. We will provide an annual review and obtain board approval of the Sliding Fee Discounting Program scheduled on an annual basis. Regular internal audits will be conducted to review the application of sliding fee discounts and identify any discrepancies before external audits. Results of internal audits will be shared with management, and corrective actions will be taken as necessary. We will assess the feasibility of implementing system controls or automated alerts within our electronic health record (EHR) and billing systems to reduce errors in discount applications. Additional oversight measures may be introduced to ensure all eligible patients receive the correct discount in accordance with policy guidelines. The above corrective actions are currently being implemented.

View Audit 367389

Finding 574043 (2022-002)

Material Weakness 2022

County of Rockingham

NH

Questioned Costs Allowable Costs / Cost Principles Eligibility § 200.303 § 200.334

Audit Finding Reference: 2022-002 Corrective Action Taken or Planned: 1. Formalized Record Retention Policies: A formal record retention policy specific to federal grant programs will be implemented to ensure full compliance with 2 CFR 200.334. This policy will apply regardless of whether documentat...

Audit Finding Reference: 2022-002 Corrective Action Taken or Planned: 1. Formalized Record Retention Policies: A formal record retention policy specific to federal grant programs will be implemented to ensure full compliance with 2 CFR 200.334. This policy will apply regardless of whether documentation is stored internally or by third-party systems. Any documentation downloaded or transferred from third-party systems will be subject to a review process to verify completeness and accuracy before being finalized for County retention. The County shall also take steps to ensure that information downloads and exports from third-party systems represent omplete and accurate records. 2. Audit Timing Advocacy and Preparedness: The County will continue to maintain timely documentation and preparedness for audits and will also advocate for timely initiation and completion of future audits. Significant delays in the audit process, through no fault of the County, as observed during the FY2022 audit, substantially impacted the County's ability to access necessary documentation and demonstrate compliance. Although the County made every effort to retain records in accordance with federal requirements, the timing of the audit fieldwork occurred well after the program had concluded in May 2023. Had the audit been conducted in a timely manner, full access to the third-party platform used for program administration would have been available, along with all supporting documentation. However, by the time the audit took place, the program had been closed for over 18 months, and access to the external software system had lapsed in accordance with the expiration of the service agreement. 3. Internal Audit Readiness Reviews: Beginning with FY2025, the County will conduct internal audit readiness reviews shortly after fiscal year-end to ensure all documentation for closed federal programs is centralized, archived, and accessible for future audit purposes, even if conducted years later. Anticipated Completion Date: October 15, 2025 Contact Person Responsible for Corrective Action: Charles Nickerson, Senior Director of Finance

View Audit 364627 Questioned Costs: $1

Finding 570442 (2022-008)

Material Weakness 2022

Consortium of Universities for the Advancement of Hydrologic Science, Inc.

MA

Cash Management Allowable Costs / Cost Principles Eligibility § 200.307

Finding Reference Number: MW2022-008 Statement of Concurrence or Nonconcurrence: CUAHSI agrees with the finding and recommendation. CUAHSI Corrective Action: Action by CUAHSI impacting audit year 2022: External contract accounting staff in place during audit year 2022 failed to declare program incom...

Finding Reference Number: MW2022-008 Statement of Concurrence or Nonconcurrence: CUAHSI agrees with the finding and recommendation. CUAHSI Corrective Action: Action by CUAHSI impacting audit year 2022: External contract accounting staff in place during audit year 2022 failed to declare program income in advance of the deadline specified by NSF. Program income for 2022 was filed was filed on 3 December 2022, approximately three weeks late. Corrective actions to processes and responsibilities impacting subsequent years: CUAHSI continues to use a single payment gateway for events and registration fees which supports segregation of payments per event and per grant. Program income has been reported to NSF accurately and on time as of audit year 2023 and appropriate staff and policies are in place to ensure continued future compliance. Name of Contact Person: • Maureen S. Ako, Director of Finance • Telephone: (339)221-5400 • Email: msabino@cuahsi.org Projected Completion Date: NA; is complete

View Audit 361411

Corrective Action Plans

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