Corrective Action Plans

Finding 1226305 (2023-001)

Material Weakness 2023

Kiowa County Hospital Authority D/B/A Elkview General Hospital

OK

Internal Control / Segregation of Duties Questioned Costs Procurement, Suspension & Debarment

Finding Reference Number 2023-001 Finding The Hospital’s internal control processes regarding usage of funds received under the Provider Relief Fund allocation within the American Rescue Plan Act, 2021, did not provide for adequate segregation of duties. Internal controls around approving, tracking,...

Finding Reference Number 2023-001 Finding The Hospital’s internal control processes regarding usage of funds received under the Provider Relief Fund allocation within the American Rescue Plan Act, 2021, did not provide for adequate segregation of duties. Internal controls around approving, tracking, and reporting expenses were not sufficient. Management agrees with the finding. Corrective Action Plan In September 2023, the Hospital implemented a policy regarding the usage of grant funding received through HRSA. This policy includes review of program guidelines, education of responsible staff, maintenance of separate general ledger accounts for program expenditures, approval of purchase orders by appropriate levels of management, and establishment of logs for program expenditures. It also provides for review of general ledger accounts and review of reports submitted to granting agencies. These changes were implemented to ensure allowable costs are properly approved, tracked, reviewed, and reported in accordance with federal requirements and to provide for adequate segregation of duties in these responsibilities. Responsible Personnel Lisa Hart, former Chief Executive Officer (responsible for implementation of corrective action). Megan Corbin, Chief Executive Officer (current contact for any follow-up regarding corrective action). Completion Date Corrective action was completed in September 2023.

View Audit 408962

Finding 1226287 (2023-010)

Material Weakness 2023

Cobre Consolidated School District

NM

Reporting Internal Control / Segregation of Duties § 200.512

Recommendation We recommend that Management enhance its internal control structure, including financial close and reporting, to ensure timely filing of future federal Uniform Grant Guidance reporting packages. Management Response Corrective Action The District acknowledges the finding. The FY23 Sing...

Recommendation We recommend that Management enhance its internal control structure, including financial close and reporting, to ensure timely filing of future federal Uniform Grant Guidance reporting packages. Management Response Corrective Action The District acknowledges the finding. The FY23 Single Audit reporting package was not timely filed due to the delayed audit, prior-year close issues, turnover, and incomplete audit preparation. Corrective action includes implementing an audit calendar, preparing the SEFA timely and on the required basis, tracking audit requests, assigning responsibility for federal reporting items, and monitoring the Federal Audit Clearinghouse filing deadline. The District will submit future Single Audit reporting packages within the required timeframe. Due Date of Completion: In progress; procedures to be implemented for the FY26 audit cycle and ongoing thereafter. Responsible Party(ies) Superintendent, Director of Finance/Business Office, and contracted finance support.

View Audit 408952

Finding 1224640 (2023-009)

Material Weakness 2023

Serenity House of Clallam County

WA

Procurement, Suspension & Debarment Internal Control / Segregation of Duties Significant Deficiency § 200.317 § 200.318 § 200.327

Procurement Recommendation: We recommend that management develop, adopt, and implement written procurement and conflict-of-interest policies that comply with Uniform Guidance requirements. These policies should address procurement standards, including methods of procurement and oversight, and establ...

Procurement Recommendation: We recommend that management develop, adopt, and implement written procurement and conflict-of-interest policies that comply with Uniform Guidance requirements. These policies should address procurement standards, including methods of procurement and oversight, and establish standards of conduct governing conflicts of interest for employees, officers, and agents involved in the administration of federal awards. Management should also ensure that these policies are communicated to relevant personnel and applied consistently. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: In 2024 new maintenance staff was employed 3 bids are required for capital projects. If one contractor has personal relationship with employee conflict of interest form is filed. Name(s) of the contact person(s) responsible for corrective action: Kristin Cowan Planned completion date for corrective action plan: July 2024

View Audit 407897

Finding 1224639 (2023-008)

Material Weakness 2023

Serenity House of Clallam County

WA

Internal Control / Segregation of Duties Questioned Costs Allowable Costs / Cost Principles § 200.302 § 200.303

Reporting Recommendation: We recommend that the auditee implement procedures to ensure that Form 19-lA reimbursement requests are reviewed prior to submission to confirm that expenditures are charged to the correct approved budget line items. This may include maintaining a reconciliation between the...

Reporting Recommendation: We recommend that the auditee implement procedures to ensure that Form 19-lA reimbursement requests are reviewed prior to submission to confirm that expenditures are charged to the correct approved budget line items. This may include maintaining a reconciliation between the general ledger, the approved grant budget, and the Form 19-lA, as well as implementing supervisory review and approval of reimbursement submissions. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. 2026 Action taken in response to finding: Reoccurring bills such as utilities, loan payments, contract services and credit card payments do not require an expense request to be included for on going bills. We will review our procedures and update our financial policy. 2023 Our financial process includes at least two reviews prior to creating a bill in our accounting system, payments are reviewed by the director or the Deputy Director when signed. We do not use a auto signature all checks are reviewed. 2023 The Grantor billing is a P&L detailed report for that grant and provides reconciliation monthly This is sorted into grant line items designated billable and non-billable for compliance. Total program cost and billable to grant are tracked every month, by the grant finance manager for compliance prior to billing any grants. Timecards are reviewed, expense requests are reviewed and payments are reviewed. Prior to submission of the invoice to grantor. 2023 Grant finance manager pulls copy of timecards, bills and checks to ensure compliance with reimbursements are accurate. Name(s) of the contact person(s) responsible for corrective action: Cora Alyea Planned completion date for corrective action plan: July 2023

View Audit 407897

Finding 1224638 (2023-007)

Material Weakness 2023

Serenity House of Clallam County

WA

Allowable Costs / Cost Principles Significant Deficiency Internal Control / Segregation of Duties § 200.303 § 200.430

Allowable Costs/Payroll Disbursements Recommendation: We recommend that the auditee implement procedures to ensure that: all employee pay rates charged to Federal awards are appropriately approved and documented, and complete and accurate timesheets or equivalent time-and-effort records are maintain...

Allowable Costs/Payroll Disbursements Recommendation: We recommend that the auditee implement procedures to ensure that: all employee pay rates charged to Federal awards are appropriately approved and documented, and complete and accurate timesheets or equivalent time-and-effort records are maintained for all payroll costs charged to Federal awards. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Most Federal grants are renewed annually and have not requested any salary rate adjustments. Payroll line items are a lump sum. Serenity House since 2020 performs annually in May a market rate survey for all job positions to ensure wage rates are equitable to fair market for our County and Non-Profit job type. The sources are documented in the workbook that the annual raise percentages; wage adjustments are calculated for board approval. Our annual performance raises and adjustments is a pool of 1 to 5%, and 3 to 6 employees are below market rate each year. People with a market adjustment do not receive a merit increase. 2023 Merit increase is% that is allocated based on performance scores and management team comparison to everyone in that job category. People are scored by manager this score is reviewed by all managers that have employees in that grouped job class. The reviewing managers agreed highest performer with a 5% and lowest performer 1% Raise distribution is based on the performance review score. 2022 Employees are hired for a specific job when they are given their first time card grant line items for the grant they work on are on the time sheet. That time sheet is reviewed and corrected by the immediate supervisor then reviewed by the operations manager. Turned into the main office receptionist who checks submission against the employee list. Checks math and signatures, initials the times card takes up to payroll. 2023 Payroll double checks each time card when entering time into the payroll module. After all time is enter another employee checks the system addition to timecard. 2020 When Checks are manually signed the time is on the timecard and each check is reviewed. Each employee Name(s) of the contact person(s) responsible for corrective action: Kristin Cowan Planned completion date for corrective action plan: July 1 2023

View Audit 407897

Finding 1224626 (2023-001)

Material Weakness 2023

City of Echo

OR

Internal Control / Segregation of Duties

The City has elected to have the auditors draft the financial statements and related notes, as they do not believe the risk of material misstatement outweighs the cost of implementing additional controls.

View Audit 407885

Finding 1224456 (2023-047)

Material Weakness 2023

Commonwealth of the Northern Mariana Islands

MP

Questioned Costs Special Tests & Provisions Subrecipient Monitoring

Finding No.: 2023-047 AL Program: 93.778 – Medical Assistance Program (Medicaid; Title XIX) Area: Special Tests and Provisions – Provider Eligibility (Screening and Enrollment) Questioned Costs: $28,448,121 Contact Person(s): George J. Cruz, Medicaid Director Corrective Action Plan: The Commonwealth...

Finding No.: 2023-047 AL Program: 93.778 – Medical Assistance Program (Medicaid; Title XIX) Area: Special Tests and Provisions – Provider Eligibility (Screening and Enrollment) Questioned Costs: $28,448,121 Contact Person(s): George J. Cruz, Medicaid Director Corrective Action Plan: The Commonwealth Medicaid Agency (CMA) respectfully disagrees with the auditor’s finding. CMA does not believe the finding fully reflects the Agency's efforts to comply with provider screening and exclusion requirements during the audit period. While documentation supporting certain screening activities was not readily available for auditor review, the Agency has historically performed provider eligibility and exclusion reviews as part of its enrollment and oversight processes. To further strengthen compliance and documentation practices, CMA has developed provider enrollment and screening procedures, conducted retrospective exclusion reviews where documentation was unavailable, and continues to enhance monitoring activities. In addition, the Agency has expanded staffing resources and continues to recruit and assign personnel dedicated Finding No.: 2023-047, continued AL Program: 93.778 – Medical Assistance Program (Medicaid; Title XIX) Area: Special Tests and Provisions – Provider Eligibility (Screening and Enrollment) Questioned Costs: $28,448,121 Contact Person(s): George J. Cruz, Medicaid Director Corrective Action Plan: to provider enrollment, compliance, and program integrity functions to ensure federal screening requirements are consistently performed, documented, and monitored. Proposed Completion Date: Ongoing

View Audit 407734

Finding 1224454 (2023-045)

Material Weakness 2023

Commonwealth of the Northern Mariana Islands

MP

Material Weakness Reporting Internal Control / Segregation of Duties

Finding No.: 2023-045 AL Program: 93.778 – Medical Assistance Program (Medicaid; Title XIX) Area: Reporting Questioned Costs: $-0- Contact Person(s): George J. Cruz, Medicaid Director Corrective Action Plan: The Commonwealth Medicaid Agency (CMA) respectfully disagrees with the auditor’s finding. Wh...

Finding No.: 2023-045 AL Program: 93.778 – Medical Assistance Program (Medicaid; Title XIX) Area: Reporting Questioned Costs: $-0- Contact Person(s): George J. Cruz, Medicaid Director Corrective Action Plan: The Commonwealth Medicaid Agency (CMA) respectfully disagrees with the auditor’s finding. While the Agency acknowledges that certain supporting documentation was not provided within the timeframe requested during the audit, CMA does not agree that the reported expenditures were unsupported. The Agency experienced resource and staffing constraints that affected its ability to compile and produce all requested documentation within the audit timeline. However, the office maintains all relevant supporting documentation and is prepared to provide it upon request from the Grantor. To strengthen reporting processes and ensure timely availability of supporting records, CMA has developed reporting procedures and is currently recruiting a Fiscal Analyst position that will be responsible for CMS-64 reporting, reconciliations, documentation retention, and related federal reporting requirements. The Agency continues to improve its reporting processes and internal controls to ensure supporting documentation is maintained and readily available for future audits and reviews. Proposed Completion Date: Ongoing

View Audit 407734

Finding 1224453 (2023-044)

Material Weakness 2023

Commonwealth of the Northern Mariana Islands

MP

Questioned Costs Special Tests & Provisions Eligibility

Finding No.: 2023-044 AL Program: 93.767 – Children’s Health Insurance Program (CHIP) Area: Special Tests and Provisions – Provider Eligibility Questioned Costs: $7,808,322 Contact Person(s): George J. Cruz, Medicaid Director Corrective Action Plan: The Commonwealth Medicaid Agency (CMA) respectfull...

Finding No.: 2023-044 AL Program: 93.767 – Children’s Health Insurance Program (CHIP) Area: Special Tests and Provisions – Provider Eligibility Questioned Costs: $7,808,322 Contact Person(s): George J. Cruz, Medicaid Director Corrective Action Plan: The Commonwealth Medicaid Agency (CMA) respectfully disagrees with the auditor’s finding. CMA does not believe the finding fully reflects the Agency's efforts to comply with provider screening and exclusion requirements during the audit period. While documentation supporting certain screening activities was not readily available for auditor review, the Agency has historically performed provider eligibility and exclusion reviews as part of its enrollment and oversight processes. To further strengthen compliance and documentation practices, CMA has developed provider enrollment and screening procedures, conducted retrospective exclusion reviews where documentation was unavailable, and continues to enhance monitoring activities. In addition, the Finding No.: 2023-044, continued AL Program: 93.767 – Children’s Health Insurance Program (CHIP) Area: Special Tests and Provisions – Provider Eligibility Questioned Costs: $7,808,322 Contact Person(s): George J. Cruz, Medicaid Director Corrective Action Plan: Agency has expanded staffing resources and continues to recruit and assign personnel dedicated to provider enrollment, compliance, and program integrity functions to ensure federal screening requirements are consistently performed, documented, and monitored. Proposed Completion Date: Ongoing

View Audit 407734

Finding 1224451 (2023-042)

Material Weakness 2023

Commonwealth of the Northern Mariana Islands

MP

Internal Control / Segregation of Duties Special Tests & Provisions Questioned Costs § 200.303

Finding No.: 2023-042 AL Program: 93.489/93.575/93.596 – CCDF Cluster COVID-19 93.489/93.575/93.596 CCDF Cluster Area: Special Tests and Provisions – Health and Safety Requirements Questioned Costs: $-0- Contact Person(s): Roselle Teregeyo, CCDF Co-Administrator/Accountant Corrective Action Plan: Th...

Finding No.: 2023-042 AL Program: 93.489/93.575/93.596 – CCDF Cluster COVID-19 93.489/93.575/93.596 CCDF Cluster Area: Special Tests and Provisions – Health and Safety Requirements Questioned Costs: $-0- Contact Person(s): Roselle Teregeyo, CCDF Co-Administrator/Accountant Corrective Action Plan: The CNMI CCDF Program agrees with this finding. Two types of providers were tested, Licensed center-based programs and license-exempt home-based programs. Finding No.: 2023-042, continued AL Program: 93.489/93.575/93.596 – CCDF Cluster COVID-19 93.489/93.575/93.596 CCDF Cluster Area: Special Tests and Provisions – Health and Safety Requirements Questioned Costs: $-0- Contact Person(s): Roselle Teregeyo, CCDF Co-Administrator/Accountant Corrective Action Plan: For the Licensed center-based program, the Unannounced visit was conducted on December 27, 2022, and the renewal (announced) visit was conducted on May 17, 2023. Prior to the May visit, the CCDF program was in a transition period in the full implementation of the Reach Higher CNMI Monitoring Check In visits. Before May 2023, visits were conducted but the reports were not reviewed nor signed off by the CCDF Director. Beginning May, as evidenced by the May 17, 2023 visit, all check in visits were submitted to the CCDF Office and these are reviewed and signed off by the CCDF Director. Similarly, for home-based programs, prior to October 2023, all check in visits were not submitted to the CCDF Director for reviewed and signature. However, beginning October 1, 2023, home based programs check in visits reports are now submitted to the CCDF Office for the Director’s review and sign off. The following corrective actions have been implemented by the CNMI CCDF Program to prevent recurrence: • The CCDF Director or designee will review and affix his/her signature on all CCDF provider check in visit reports to ensure oversight, accuracy, and compliance with CCDF monitoring requirements. • All check in visit reports have been submitted to the CCDF Office for review and signature by the CCDF Director beginning May 17, 2023 for licensed center-based programs and October 1, 2023 for license-exempt home-based programs. This process has been consistently followed since those dates. • Monthly meetings will include reminders to all consultants regarding the required submission and review procedure to ensure continued adherence. Procedure fully implemented since May 2023 and October 1, 2023, for licensed center-based programs and licensed-exempt home-based programs respectively. Proposed Completion Date: Completed

View Audit 407734

Finding 1224450 (2023-041)

Material Weakness 2023

Commonwealth of the Northern Mariana Islands

MP

Subrecipient Monitoring Internal Control / Segregation of Duties § 200.303 § 200.308 § 200.309 § 200.403

Finding No.: 2023-041 AL Program: 93.489/93.575/93.596 – CCDF Cluster COVID-19 93.489/93.575/93.596 CCDF Cluster Area: Period of Performance Questioned Costs: $95,367 Contact Person(s): Roselle Teregeyo, CCDF Co-Administrator/Accountant Corrective Action Plan: Condition 1 & 3a: The CNMI CCDF Program...

Finding No.: 2023-041 AL Program: 93.489/93.575/93.596 – CCDF Cluster COVID-19 93.489/93.575/93.596 CCDF Cluster Area: Period of Performance Questioned Costs: $95,367 Contact Person(s): Roselle Teregeyo, CCDF Co-Administrator/Accountant Corrective Action Plan: Condition 1 & 3a: The CNMI CCDF Program agrees with this finding. To strengthen oversight and ensure adequate accountability over Federal awards, the CNMI CCDF Program has implemented a filing system Finding No.: 2023-041, continued AL Program: 93.489/93.575/93.596 – CCDF Cluster COVID-19 93.489/93.575/93.596 CCDF Cluster Area: Period of Performance Questioned Costs: $95,367 Contact Person(s): Roselle Teregeyo, CCDF Co-Administrator/Accountant Corrective Action Plan: where all documents relating to a federal award are properly maintained and labeled for accessibility. This system became effective on October 1, 2025. Proposed Completion Date: Completed Condition 2 & 3b: The CNMI CCDF Program agrees with this finding and acknowledges the need to strengthen internal controls to ensure that all expenditures are cleared by the bank before the end of the liquidation period. The CCDF Program will coordinate with the Department of Finance (DOF) Financial Services Division regarding the establishment of a monitoring log that tracks all checks issued and cleared by vendor and office. Once this log is implemented, the CCDF Program will request regular copies to allow responsible staff to verify whether payments have cleared and to follow up with vendors as needed to ensure timely bank reconciliation. To streamline payment processing and enhance compliance with federal cash management requirements, the CCDF Program is exploring a transition to a fully ACH based payment system. Moving to electronic payments will reduce delays associated with paper checks, improve tracking and reconciliation, and strengthen internal controls over disbursements. This corrective action is currently in progress. The CCDF Program anticipates full implementation of the monitoring process and/or ACH transition by October 1, 2026. Proposed Completion Date: October 1, 2026

View Audit 407734

Finding 1224449 (2023-040)

Material Weakness 2023

Commonwealth of the Northern Mariana Islands

MP

Subrecipient Monitoring Eligibility Internal Control / Segregation of Duties

Finding No.: 2023-040 AL Program: 93.489/93.575/93.596 – CCDF Cluster COVID-19 93.489/93.575/93.596 CCDF Cluster Area: Eligibility Questioned Costs: $12,490 Contact Person(s): Roselle Teregeyo, CCDF Co-Administrator/Accountant Corrective Action Plan: Condition 1: The CNMI CCDF Program respectfully d...

Finding No.: 2023-040 AL Program: 93.489/93.575/93.596 – CCDF Cluster COVID-19 93.489/93.575/93.596 CCDF Cluster Area: Eligibility Questioned Costs: $12,490 Contact Person(s): Roselle Teregeyo, CCDF Co-Administrator/Accountant Corrective Action Plan: Condition 1: The CNMI CCDF Program respectfully disagrees with this finding. During the audit period, the CNMI CCDF State Plan for FY 2022–2024, Section 3.1.8, Employment Requirements, permitted the acceptance of a USCIS receipt notice (WAC receipt number) as documentation of employment authorization when applicable. Specifically, the State Plan states that a USCIS receipt indicating a WAC number may be requested when necessary and that additional documentation may be requested to identify applicants who meet the long-term employment criteria. Based on the policies in effect during the certification periods cited above, the CCDF Program determined eligibility using the documentation requirements established in the approved CCDF State Plan. Therefore, the questioned costs associated with these cases were incurred in accordance with the Program's established eligibility policies at that time. The issue occurred during a period of increased application volume when eligibility determinations and document reviews were processed manually. In addition, the State Plan language did not explicitly state that USCIS receipt notices would not be accepted as evidence of employment authorization, which contributed to differing interpretations of acceptable documentation requirements. Although the Program maintains that the cited cases were processed in accordance with the policies in effect during the audit period, the CCDF Program has strengthened its documentation requirements to address concerns raised in prior audits. Effective February 1, 2026, the CCDF Program no longer accepts USCIS employment authorization receipt notices as proof of work authorization. This policy change was implemented through CCDF Memorandum Subsidy FY26 No. 1 and serves as a corrective action to ensure consistency and strengthen compliance with employment verification requirements. Program staff have been notified of the revised policy and eligibility determinations will now require approved work authorization documentation rather than receipt notices. Proposed Completion Date: Completed Finding No.: 2023-040, continued AL Program: 93.489/93.575/93.596 – CCDF Cluster COVID-19 93.489/93.575/93.596 CCDF Cluster Area: Eligibility Questioned Costs: $12,490 Contact Person(s): Roselle Teregeyo, CCDF Co-Administrator/Accountant Corrective Action Plan: Condition 2: The CNMI CCDF Program agrees with this finding. During the audit period, provider payments were processed manually for approximately 1,101 children each month. The manual calculation and entry of subsidy amounts increased the risk of human error, resulting in isolated instances of overpayments and underpayments. To strengthen internal controls and reduce the risk of payment errors, the CCDF Program has been working with a contracted system developer since late 2025 to implement an automated subsidy management system. Once operational, the system will automatically calculate and assign payment amounts based on eligibility factors, including the child's age and approved level of care, thereby reducing reliance on manual calculations. The CCDF Program will continue monitoring payment processes and implementing automated controls to improve payment accuracy and strengthen compliance with program requirements. The Program will initiate recovery of the $390 overpayment identified in Case ID 3040 B through adjustments to provider payments scheduled for August and September 2026. For the underpayments identified in Case IDs 3275 B, 3275 C, and 3600 C, the Program will process payment adjustments and issue the respective amounts owed through the August 2026 provider payment cycle. Proposed Completion Date: September 2026

View Audit 407734

Finding 1224434 (2023-033)

Material Weakness 2023

Commonwealth of the Northern Mariana Islands

MP

Subrecipient Monitoring Allowable Costs / Cost Principles Reporting

Finding No.: 2023-033 AL Program: COVID-19 21.027 - Coronavirus State and Local Fiscal Recovery Funds Area: Reporting Questioned Costs: $-0- Contact Person(s): Tracy B. Norita, Secretary of Finance Corrective Action Plan: Condition 1-3: The CNMI Department of Finance agrees with this finding. Requir...

Finding No.: 2023-033 AL Program: COVID-19 21.027 - Coronavirus State and Local Fiscal Recovery Funds Area: Reporting Questioned Costs: $-0- Contact Person(s): Tracy B. Norita, Secretary of Finance Corrective Action Plan: Condition 1-3: The CNMI Department of Finance agrees with this finding. Required Project and Expenditure Reports were not submitted for certain periods and supporting documentation and revenue loss calculations were unavailable for audit review. The primary cause was staff turnover and reorganization following a change in administration in FY 2023, which highlighted gaps in reporting capacity. This occurred alongside issues identified in the finding, including insufficient processes following CNMI’s transition from JD Edwards to Tyler Munis, missing supporting documentation, and lack of structured reporting controls. The proposed corrective actions are described below: a. Cross Training of Personnel (Implemented) CNMI DOF has cross trained multiple staff to ensure continuity and eliminate dependency on any single employee for revenue loss analysis and reporting and documentation retention. This improves data accuracy and prevents operational disruptions. b. Strengthening Data Extraction & Documentation Processes (In Progress) DOF is developing processes to reliably extract revenue related data from Tyler Munis to support timely revenue loss calculations, as recommended by auditors. Finding No.: 2023-033, continued AL Program: COVID-19 21.027 - Coronavirus State and Local Fiscal Recovery Funds Area: Reporting Questioned Costs: $-0- Contact Person(s): Tracy B. Norita, Secretary of Finance Corrective Action Plan: c. Municipal Training and Oversight Clarification (In Progress) CNMI will work closely with municipalities—particularly Rota, which is less familiar with federal grant requirements—to: • Clarify who is responsible for SLFRF reporting oversight • Verify the municipality’s elected option under the Final Rule • Provide training and technical assistance to ensure full compliance d. Development of reports DOF will formalize a written SOP establishing: • Required timelines • Documentation standards • Review procedures • Data retention requirements Proposed Completion Date: October 31, 2026 (Some actions already implemented; others underway)

View Audit 407734

Finding 1224427 (2023-026)

Material Weakness 2023

Commonwealth of the Northern Mariana Islands

MP

Special Tests & Provisions Subrecipient Monitoring Equipment & Real Property Management § 200.303

Finding No.: 2023-026 AL Program: 20.205 – Highway Planning and Construction (Federal-Aid Highway Program) Area: Special Tests and Provisions – Quality Assurance Program Questioned Costs: $-0- Contact Person(s): Stacy Atalig, Federal Programs Coordinator, DPW Corrective Action Plan: The Department o...

Finding No.: 2023-026 AL Program: 20.205 – Highway Planning and Construction (Federal-Aid Highway Program) Area: Special Tests and Provisions – Quality Assurance Program Questioned Costs: $-0- Contact Person(s): Stacy Atalig, Federal Programs Coordinator, DPW Corrective Action Plan: The Department of Public Works (DPW), Transportation Services Division (TSD) - Highway Branch agrees with the conclusions presented in this finding. Finding No.: 2023-026, continued AL Program: 20.205 – Highway Planning and Construction (Federal-Aid Highway Program) Area: Special Tests and Provisions – Quality Assurance Program Questioned Costs: $-0- Contact Person(s): Stacy Atalig, Federal Programs Coordinator, DPW Corrective Action Plan: The Highway Branch would adhere to 2 CFR 200.303(a), which mandates the establishment, documentation, and maintenance of effective internal controls over Federal awards. This system provides reasonable assurance that such awards comply with relevant Federal statutes, regulations, and the specific terms and conditions associated with the awards. Therefore, the Highway Branch will implement the following recommendations: Condition 1: • In accordance with 23 CFR 637.207, the DPW, TSD – Highway Branch will develop a QA program, policies and procedures that is approved by FHWA; and • Train employees and assign as designated agent to perform the functions of the QA Program. Condition 2: DPW, TSD – Highway Branch will develop a log sheet to document the results of the sampling and testing performed to include contractor and sub-contractor (if applicable), project numbers, project titles, date and time, location, and the name of the Highway Inspector/Engineer monitoring the project. Proposed Completion Date: September 2026

View Audit 407734

Finding 1224396 (2023-013)

Material Weakness 2023

Commonwealth of the Northern Mariana Islands

MP

Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303 § 200.403

Finding No.: 2023-013 AL Programs: 11.307 – Economic Adjustment Assistance Area: Activities Allowed or Unallowed and Allowable Costs/Cost Principles Questioned Costs: $3,695,208 Contact Person(s): Elizabeth S. Balajadia, Office of Planning and Development Acting Director / James Kintol, Project Mana...

Finding No.: 2023-013 AL Programs: 11.307 – Economic Adjustment Assistance Area: Activities Allowed or Unallowed and Allowable Costs/Cost Principles Questioned Costs: $3,695,208 Contact Person(s): Elizabeth S. Balajadia, Office of Planning and Development Acting Director / James Kintol, Project Manager, Department of Finance Corrective Action Plan: Condition 1: The CNMI Department of Finance respectfully disagrees with this finding related to project number FG17010001 (Economic Resiliency Center). The Department acknowledges that although supporting documentation – such as journal entries, approvals of expense transfers, sole-source justification memo, and grantor approval - was submitted, copies of the related invoices and/or contract agreement were not included. This omission was an oversight and resulted in a documentation-timing deficiency. The Department maintains copies of all required documents, and they are available for review upon request. To prevent recurrence, the department will reinforce our internal review procedures to ensure that all required supporting documentation is consistently compiled, retained within the Tyler MUNIS system, and submitted as part of future audit requests. Proposed Completion Date: Ongoing Condition 2: The CNMI Department of Finance respectfully disagrees with this finding related to PA Journals 478, 360, 2137, and 335. These transactions pertain to the Department’s Economic Resiliency Center (ERC) project. Due to internal scheduling constraints and the compressed 2-day turnaround to provide supporting documentation to the auditors, the requested documents were not submitted by the specified deadline. This timing issue resulted in the finding; however, it does not reflect a Finding No.: 2023-013, continued AL Programs: 11.307 – Economic Adjustment Assistance Area: Activities Allowed or Unallowed and Allowable Costs/Cost Principles Questioned Costs: $3,695,208 Contact Person(s): Elizabeth S. Balajadia, Office of Planning and Development Acting Director / James Kintol, Project Manager, Department of Finance Corrective Action Plan: lack of documentation or inadequate recordkeeping. The Department maintains all relevant supporting documentation for these transactions and such documentation is available for review upon request from the Grantor. The Office of Planning and Development (OPD) partially agrees with the finding. OPD reviewed the questioned transactions and supporting documentation available under its custody. Payment documentation has been identified for PA Journals 186, 142, 141, 2670, 270, 4200, 556, 4180, and 913 and is maintained by OPD for review. For PA Journals 191 and 144, OPD verified that the invoice amounts are consistent with Contract No. 32200454; however, the PA Journal effective dates and journal numbers provided in the audit schedule do not correspond with the records reflected in the Munis system. For PA Journals 1585, 1862, 2219, 1138, 197, 593, and 219, additional information is required to complete verification because the PA Journal effective dates and journal numbers differ from the Munis records available to OPD. The referenced invoice amounts alone are insufficient to identify the transactions, as they may represent portions of cost shared expenditures or partial payments associated with larger transactions. Identification of the vendor would significantly assist in locating and reconciling the transactions. OPD further notes that the compilation of requested documentation occurred under significant time constraints. During the audit process, agencies were at one point provided approximately two business days to submit requested samples and supporting documentation. Given the volume of transactions and the age of some records, the limited response timeframe may have affected the ability to fully research, reconcile, and compile all supporting documentation prior to submission. Additional time for both agency response and auditor review may have facilitated a more comprehensive reconciliation and verification of the questioned items. OPD will continue coordinating with the Department of Finance and the auditors to reconcile discrepancies between the audit schedules and Munis records, provide available supporting documentation, and strengthen record-retention and transaction-tracking procedures to ensure supporting documentation is readily identifiable and accessible for future audits. Proposed Completion Date: Ongoing

View Audit 407734

Finding 1224308 (2023-003)

Material Weakness 2023

Santo Domingo Tribal Housing Authority

NM

Reporting Internal Control / Segregation of Duties

Management’s Response: SDTHA’s management concurs that a problem exists with financial reporting for the IHBG award. During the HUD monitoring for 2019 and the subsequent audits, issueswere noted with expenditures. These issues were brought up to management in 2020, which resulted in having to compl...

Management’s Response: SDTHA’s management concurs that a problem exists with financial reporting for the IHBG award. During the HUD monitoring for 2019 and the subsequent audits, issueswere noted with expenditures. These issues were brought up to management in 2020, which resulted in having to complete the 2018 audit. The audit reports are cumulative, ending balances from the prior year are carried over to the beginning of the next year, so this has slowed down the completion of timely filing. SDTHA developed a plan to have 2023 completed by quarter two of 2026, 2024 and 2025 audits to be completed before the end of 2026 Timeline and Estimated Completion Date: December 31, 2026 Responsible Official: Lorrie Chavez, Executive Director and Jonah Garcia, Finance Officer

View Audit 407599

Finding 1224302 (2023-002)

Material Weakness 2023

Prevent Child Abuse Utah

UT

Questioned Costs Subrecipient Monitoring Material Weakness § 200.512

Management should establish and implement a robust tracking system to monitor reporting deadlines, ensure timely financial statement preparation, and improve coordination with external auditors. Additionally, assigning a compliance officer or designated staff member responsible for tracking audit pr...

Management should establish and implement a robust tracking system to monitor reporting deadlines, ensure timely financial statement preparation, and improve coordination with external auditors. Additionally, assigning a compliance officer or designated staff member responsible for tracking audit progress and submission deadlines can help prevent future delays.

View Audit 407583

Finding 1224301 (2023-001)

Material Weakness 2023

Prevent Child Abuse Utah

UT

Questioned Costs Material Weakness Internal Control / Segregation of Duties

Prevent Child Abuse Utah should strengthen its year-end financial close process to ensure the proper closing and review of account balances. Prevent Child Abuse Utah’s internal control system does not provide for the preparation of a complete set of financial statements. We recommend that Prevent Ch...

Prevent Child Abuse Utah should strengthen its year-end financial close process to ensure the proper closing and review of account balances. Prevent Child Abuse Utah’s internal control system does not provide for the preparation of a complete set of financial statements. We recommend that Prevent Child Abuse Utah evaluate the ongoing benefits and expenses of including this element into its system of internal control.

View Audit 407583

Finding 1224170 (2023-008)

Material Weakness 2023

International Fertilizer Development Company

AL

Internal Control / Segregation of Duties

2023-008-Ineffective Control Environment Suggested Action: Management reinforcing a culture of stronger ethical conduct by reinforcing IFDC internal policies and procedures. Responsible Official: Chief Executive Officer, Chief Operations Officer, Global Finance Director Completion Date: 4/30/2026

View Audit 407579

Finding 1224020 (2023-005)

Material Weakness 2023

LAND MANOR, INC.

TX

Internal Control / Segregation of Duties Subrecipient Monitoring

Monitoring Corrective Action Plan: Each Program Director audits charts on a monthly basis and the Quality Management Coordinator audits them on a quarterly basis. Management continues to assess the need for a formal monthly compliance review checklist and has assigned its Quality Management Coordina...

Monitoring Corrective Action Plan: Each Program Director audits charts on a monthly basis and the Quality Management Coordinator audits them on a quarterly basis. Management continues to assess the need for a formal monthly compliance review checklist and has assigned its Quality Management Coordinator, a licensed counselor, to conduct Quality Assurance Reviews quarterly. Anticipated Completion Date: July 15, 2026 Responsible Party: Land Manor Executive Director, Quality Management Coordinator and Program Directors.

View Audit 407429

Finding 1224019 (2023-004)

Material Weakness 2023

LAND MANOR, INC.

TX

Reporting Internal Control / Segregation of Duties

Control Activities Corrective Action Plan: The Corrective Action Plan referenced at 2023-002/003 will be expanded to include internal control over program compliance. The Monitoring Program being considered at 2023-001 would enhance compliance awareness on the part of program employees. Anticipated ...

Control Activities Corrective Action Plan: The Corrective Action Plan referenced at 2023-002/003 will be expanded to include internal control over program compliance. The Monitoring Program being considered at 2023-001 would enhance compliance awareness on the part of program employees. Anticipated Completion Date: July 15, 2026 Responsible Party: Land Manor Executive Director, Quality Management Coordinator and Program Directors.

View Audit 407429

Finding 1223940 (2023-005)

Material Weakness 2023

Hope Toledo Services

OH

Questioned Costs Allowable Costs / Cost Principles HUD Housing Programs

Other Coronavirus State and Local Fiscal Recovery Funds – Assistance Listing No. 21.027 Recommendation: We recommend that the management and finance staff work on retaining documentation and training staff to ensure processes and controls are in place over provider payment calculations and payroll. ...

Other Coronavirus State and Local Fiscal Recovery Funds – Assistance Listing No. 21.027 Recommendation: We recommend that the management and finance staff work on retaining documentation and training staff to ensure processes and controls are in place over provider payment calculations and payroll. We also recommend a formal check signing process is implemented to ensure authorization of disbursement is documented appropriately. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: We will update our policies and procedures to incorporate the recommendations above. Name of the contact person responsible for corrective action: John C. Jones, President and CEO Planned completion date for corrective action plan: 9/30/2026

View Audit 407341

Finding 1223936 (2023-003)

Material Weakness 2023

Hope Toledo Services

OH

Questioned Costs HUD Housing Programs Reporting

Reporting Coronavirus State and Local Fiscal Recovery Funds – Assistance Listing No. 21.027 Recommendation: We recommend that reports are prepared and reviewed by separate individuals. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/tak...

Reporting Coronavirus State and Local Fiscal Recovery Funds – Assistance Listing No. 21.027 Recommendation: We recommend that reports are prepared and reviewed by separate individuals. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: The Organization will put a formal layer of review after preparation of the report and before submission to the grantor. Name of the contact person responsible for corrective action: John C. Jones, President and CEO Planned completion date for corrective action plan: 9/30/2026

View Audit 407341

Finding 1223925 (2023-003)

Material Weakness 2023

Municipality of Camuy

PR

Internal Control / Segregation of Duties Subrecipient Monitoring Material Weakness § 200.303

We acknowledge the finding. The Municipality will be working on scheduling the reports required by each program. It is important to note that all reports are prepared by the accountants assigned to each federal program and reviewed and approved by the Finance Department and the Mayor. This process s...

We acknowledge the finding. The Municipality will be working on scheduling the reports required by each program. It is important to note that all reports are prepared by the accountants assigned to each federal program and reviewed and approved by the Finance Department and the Mayor. This process sometimes results in late report submissions. Staff have been instructed to work on the reports before the 10th of each month to allow sufficient time for proper review and submission, ensuring they are duly reviewed and approved. The reports due on September 15, 2022, and October 15, 2022, were delayed due to Hurricane Fiona's passage through Puerto Rico on September 14, 2022. We experienced power and internet outages at the Municipality. Personnel in charge: Daiana González Hernández, Finance Office Director Projected Completion Date: August 31, 2026

View Audit 407331

Finding 1223714 (2023-004)

Material Weakness 2023

Rhode Island Disaster Medical Assistance Team, Inc.

RI

Reporting Internal Control / Segregation of Duties § 200.512

Strengthened internal controls over year-end financial reporting to ensure timely completion of the audit by establishing a comprehensive audit timeline with milestone deadlines by February 28, 2026. Implemented a detailed closing schedule and tracking process to monitor deadlines, beginning with mo...

Strengthened internal controls over year-end financial reporting to ensure timely completion of the audit by establishing a comprehensive audit timeline with milestone deadlines by February 28, 2026. Implemented a detailed closing schedule and tracking process to monitor deadlines, beginning with monthly financial close procedures and year-end close preparation by March 31, 2026. Ensured adequate staffing or external support during the financial statement preparation and audit process, including retention of qualified accounting consultant by April 30, 2026. Began conducting periodic reviews to confirm compliance with federal Single Audit submission deadlines, with Executive Director oversight of audit progress reports by May 31, 2026. In the process of prioritizing completion of the outstanding audit report for fiscal year 2024 with an aggressive timeline: 2024 audit by December 31, 2026. In the process of establishing year-round audit preparation procedures, including monthly reconciliations, quarterly financial reviews, and ongoing documentation organization to prevent delays.

View Audit 407209

Corrective Action Plans

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