Corrective Action Plans

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Finding 2022-018 Eligibility Individual(s) Responsible: Michelle Cadue, Tribal Treasurer and Jonnah McKinney, KTIK IHS Director. Action:Complete patient files will be maintained to document eligibility in accordance with program requirements. Records will be made available for audit review while mai...
Finding 2022-018 Eligibility Individual(s) Responsible: Michelle Cadue, Tribal Treasurer and Jonnah McKinney, KTIK IHS Director. Action:Complete patient files will be maintained to document eligibility in accordance with program requirements. Records will be made available for audit review while maintaining confidentiality, i.e., HIPPA. Anticipated Completion Date: March 2026.
Finding 2022-016 Program Income Individual(s) Responsible: Tribal Council; Rona Johnson-Murillo, Accounting Director; Program Directors; Enterprise Managers; and Tyce Martin, HR Generalist. Action: Ensure that documentation is available for every item purchased or run through payroll. Anticipated Co...
Finding 2022-016 Program Income Individual(s) Responsible: Tribal Council; Rona Johnson-Murillo, Accounting Director; Program Directors; Enterprise Managers; and Tyce Martin, HR Generalist. Action: Ensure that documentation is available for every item purchased or run through payroll. Anticipated Completion Date: March 2026.
Finding 2022-014 Special Tests and Provisions Individual(s) Responsible: Michelle Cadue, Tribal Treasurer; Paula Vann, Grants Compliance Officer; and Cheryl DuBois, Head Start Director. Action: Review annual and quarterly reporting to ensure timely filing. Implementation of procedures to ensure all ...
Finding 2022-014 Special Tests and Provisions Individual(s) Responsible: Michelle Cadue, Tribal Treasurer; Paula Vann, Grants Compliance Officer; and Cheryl DuBois, Head Start Director. Action: Review annual and quarterly reporting to ensure timely filing. Implementation of procedures to ensure all required Head Start facilities documentation is obtained, accurately completed, retained, and readily accessible for review. Resources will be allocated to develop, implement, and monitor policies and procedures that support effective operations, timely reporting, and full compliance with Head Start facilities requirements. Anticipated Completion Date: March 2026.
Finding 2022-012 Matching, Level of Effort and Earmarking Individual(s) Responsible: Cheryl DuBois, Head Start Director and Paula Vann, Grants Compliance Officer. Action: Make sure all reporting requirements are met. Maintain enrollment documentation and provide information upon request. Anticipated...
Finding 2022-012 Matching, Level of Effort and Earmarking Individual(s) Responsible: Cheryl DuBois, Head Start Director and Paula Vann, Grants Compliance Officer. Action: Make sure all reporting requirements are met. Maintain enrollment documentation and provide information upon request. Anticipated Completion Date: March 2026.
Finding: The Company was not able to evidence the review and approval of non-payroll expenses incurred in connection with the Coronavirus State and Local Fiscal Recovery Funds grant program. Corrective Actions Taken or Planned: During the testing there was one invoice Insight was not able to documen...
Finding: The Company was not able to evidence the review and approval of non-payroll expenses incurred in connection with the Coronavirus State and Local Fiscal Recovery Funds grant program. Corrective Actions Taken or Planned: During the testing there was one invoice Insight was not able to document that it had been approved by management to pay. During this period of 2022 we were on a manual accounts payable system. Invoices were approved before payment was made by email and the email was to be printed and attached. In September of 2022 we implemented a new ERP system. This system requires electronic approval by management for the invoice to be paid. Ferrick Jones, Controller, is responsible for ensuring this is remediated.
Condition: Costs charged to ALN 97.036 – Disaster Grants: Public Assistance were also charged to ALN 93.498, U.S. Department of Health and Human Services, Provider Relief Fund in a prior fiscal year, as reported in the Period 1 submission to the Provider Relief Fund portal. Planned Corrective Action...
Condition: Costs charged to ALN 97.036 – Disaster Grants: Public Assistance were also charged to ALN 93.498, U.S. Department of Health and Human Services, Provider Relief Fund in a prior fiscal year, as reported in the Period 1 submission to the Provider Relief Fund portal. Planned Corrective Action: Management agrees and has revised existing internal control processes and policies to implement review and approval procedures to ensure expenditures submitted were not already reimbursed under a separate grant. Contact person responsible for corrective action: Kevin Riley Anticipated Completion Date: 12/31/2025
CMSU WILL SUBMIT YEARLY AUDITS WITHIN THE NIN MONTH REQUIREMENT UPON THE COMPLETION OF THE FISCAL YEAR
CMSU WILL SUBMIT YEARLY AUDITS WITHIN THE NIN MONTH REQUIREMENT UPON THE COMPLETION OF THE FISCAL YEAR
Recommendation: We recommend the College review the reporting requirements and implement procedures to ensure that all required reports are issued/posted in an accurate and timely manner. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in...
Recommendation: We recommend the College review the reporting requirements and implement procedures to ensure that all required reports are issued/posted in an accurate and timely manner. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Collaborative workflow was developed between Grant PI's and IS department personnel to ensure that all reports are posted to the website in a timely manner. Name of the contact person responsible for corrective action: Clarissa Salhus, Finance Manager, Duane VanderGriend, CFO Planned completion date for corrective action plan: Completed as of January 14, 2026
Recommendation: We recommend the College enhance their controls around payroll disbursements to ensure employees are paid properly. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The College has recognized the cha...
Recommendation: We recommend the College enhance their controls around payroll disbursements to ensure employees are paid properly. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The College has recognized the challenge of hiring a Payroll Specialist. In September 2022, the College outsourced “Payroll” to Paycom. We continue to develop and communicate the unique needs of our College Payroll structure and Federal and private funding sources with Paycom and the College Human Resources to ensure that employees are paid properly. As such, the Business Office is undergoing a restructure and we have identified an internal candidate to take the lead on Payroll. Name of the contact person responsible for corrective action: Clarissa Salhus, Finance Manager, Reatha Tom, Accounts Payable Specialist, Michelle Ferron-Guppy, Director – Human Resources, and Zoy Zamudio-Lane, Human Resources Generalist Planned completion date for corrective action plan: September 30, 2024
Recommendation: We recommend the college implement policies and procedures to ensure all procurement documentation is complete and retained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Procurement policies are ...
Recommendation: We recommend the college implement policies and procedures to ensure all procurement documentation is complete and retained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Procurement policies are in place and trainings have been provided for Purchasing and Accounts Payable staff to ensure that all Procurement documentation is included in payment packets. Name of the contact person responsible for corrective action: Clarissa Salhus, Finance Manager, Duane VanderGriend, CFO Planned completion date for corrective action plan: Completed as of January 14, 2026
HOMECorp will make use of Yardi Breeze Premier Affordable Property Management CRM feature which allows both HOMECorp and our tenants to track their program compliance, maintenance requests, leases, lease renewals and annual recertifications. This information will be saved/stored in the cloud. This w...
HOMECorp will make use of Yardi Breeze Premier Affordable Property Management CRM feature which allows both HOMECorp and our tenants to track their program compliance, maintenance requests, leases, lease renewals and annual recertifications. This information will be saved/stored in the cloud. This was implemented on 05/01/23 through coordination of the Yardi Implementation Team and the executive director. During 2021 – 2022, HOMECorp’s management team was significantly impacted by COVID and despite PPP loan retention efforts we lost all our staff and transitioned our HUD Certified Housing Counselor to Property Manager. During this time, the executive Director left as well as two (2) interim Executive Directors, who responsibilities were general management. They lacked the training and experience in Affordable Housing Management to help our property manager to maintain our program compliance procedures. Since the new Executive Director, onboarded in April 2023, the property manager has been trained on our policy and procedure for verifying tenant eligibility and calculating rent amounts in compliance with HOME program requirements, tenant intake, income verification, and rent calculations to ensure compliance with federal regulations. This is done in Yardi Affordable compliance worksheet. Quarterly periodic reviews and audits of tenant files and rent schedules are performed to ensure ongoing compliance.
During 2020 – 2022, HOMECorp’s management team was significantly impacted by COVID and despite PPP loan retention efforts we lost all our staff and transitioned our HUD Certified Housing Counselor to Property Manager. Due to staffing shortages and restricted to access to apartments as a result of he...
During 2020 – 2022, HOMECorp’s management team was significantly impacted by COVID and despite PPP loan retention efforts we lost all our staff and transitioned our HUD Certified Housing Counselor to Property Manager. Due to staffing shortages and restricted to access to apartments as a result of health concerns, our property manager was unable to perform Housing Quality Standards Inspections. The new Executive Director has contracted with a General Contractor to help assist our property manager with Housing Quality Standards Inspections. These inspections are conducted annually with detailed inspection logs for HVAC, Painting, Fire Safety, and major unit renovations maintained and tracked in our digital database. These logs are reviewed and updated on a quarterly basis to ensure timeliness in compliance and maintenance requests.
HOMECorp will make use of Yardi Breeze Premier Affordable Property Management CRM feature which allows both HOMECorp and our tenants to track their program compliance, maintenance requests, leases, lease renewals and annual recertifications. This information will be saved/stored in the cloud. This w...
HOMECorp will make use of Yardi Breeze Premier Affordable Property Management CRM feature which allows both HOMECorp and our tenants to track their program compliance, maintenance requests, leases, lease renewals and annual recertifications. This information will be saved/stored in the cloud. This was implemented on 05/01/23 through coordination of the Yardi Implementation Team and the executive director. During 2021 – 2022, HOMECorp’s management team was significantly impacted by COVID and despite PPP loan retention efforts we lost all our staff and transitioned our HUD Certified Housing Counselor to Property Manager. During this time, the Executive Director, left as well as two (2) interim Executive Directors, who responsibilities were general management. They lacked the training and experience in Affordable Housing Management to help our property manager to maintain our program compliance procedures. Since the new Executive Director onboarded in April 2023, the property manager has been trained on our policy and procedure for verifying tenant eligibility and calculating rent amounts in compliance with HOME program requirements, tenant intake, income verification, and rent calculations to ensure compliance with federal regulations. This is done in Yardi Affordable compliance worksheet. Quarterly periodic reviews and audits of tenant files and rent schedules are performed to ensure ongoing compliance.
The City will enhance compliance monitoring by updating monitoring checklists, ensuring required signatures are obtained, and documenting follow-up when borrower documentation (including occupancy certifications) is incomplete. A monitoring calendar will be used to ensure timely review of HOME loans...
The City will enhance compliance monitoring by updating monitoring checklists, ensuring required signatures are obtained, and documenting follow-up when borrower documentation (including occupancy certifications) is incomplete. A monitoring calendar will be used to ensure timely review of HOME loans and collection of required annual documentation. Staff will receive refresher training on HOME requirements.
Finding 2022-004: Activities Allowed and Unallowed, Allowable Costs (Compliance; Internal Controls Over Compliance) Response: For the audit period and subsequent audit periods (FY 2022-23 and partial 2023-24) The District will not be in compliance with this finding as duties were completed by one em...
Finding 2022-004: Activities Allowed and Unallowed, Allowable Costs (Compliance; Internal Controls Over Compliance) Response: For the audit period and subsequent audit periods (FY 2022-23 and partial 2023-24) The District will not be in compliance with this finding as duties were completed by one employee (accounts payable, payroll, balancing) and many records are not able to be located. For partial 2023-24 and 2024-25 records are now fully maintained and should be accessible for audit review. Training has been provided by the District’s Financial Consultant (payroll and accounts payable). The District Financial Consultant is reviewing payroll, processing tax and retirement payments, reviewing AP and correcting coding when necessary. The Consultant is also balancing reports and submitting monthly financial reports to the Board of Trustees.
Views of Responsible Officials and Planned Corrective Actions: PRIDE agrees with the finding and recommended procedures will be implemented.
Views of Responsible Officials and Planned Corrective Actions: PRIDE agrees with the finding and recommended procedures will be implemented.
Corrective Action Plan The documentation deficiencies identified were largely due to the absence of a dedicated internal Human Resources (HR) department and the absence of formalized HR procedures. During the audit period, HR services were outsourced to a third-party provider; however, the services ...
Corrective Action Plan The documentation deficiencies identified were largely due to the absence of a dedicated internal Human Resources (HR) department and the absence of formalized HR procedures. During the audit period, HR services were outsourced to a third-party provider; however, the services provided were not comprehensive nor su􀆯iciently tailored to the agency’s operational and compliance needs. Additionally, the scope and deliverables under that contract were not clearly defined, resulting in incomplete documentation practices and potential risk exposure.
Audit Finding: Finding 2022-002: Submission of Single Audit Management’s Comments on Findings and Recommendation: We concur with the auditor's findings. Management’s Corrective Action Plan: We now are aware of the audit requirements and are committed to compliance. The Organization will engage audit...
Audit Finding: Finding 2022-002: Submission of Single Audit Management’s Comments on Findings and Recommendation: We concur with the auditor's findings. Management’s Corrective Action Plan: We now are aware of the audit requirements and are committed to compliance. The Organization will engage auditors to perform subsequent period audits, as applicable. Employee / Division Responsible for Execution: Executive Director Timeline and Estimated Completion Date: Effective Immediately
I did start reaching out to companies, even the one that completed our last audit, and no one would respond. I did reach out to the State Auditors and was put on the listing to be scheduled.
I did start reaching out to companies, even the one that completed our last audit, and no one would respond. I did reach out to the State Auditors and was put on the listing to be scheduled.
The Tribes, in collaboration with the Interim CFO, will review cash flow projection and monitoring processes to strengthen management of operating and grant funds. The Tribes will obtain external funding, as needed, to meet general fund and reimbursement grant cash needs and to reimburse advance-fun...
The Tribes, in collaboration with the Interim CFO, will review cash flow projection and monitoring processes to strengthen management of operating and grant funds. The Tribes will obtain external funding, as needed, to meet general fund and reimbursement grant cash needs and to reimburse advance-funded grants for any interfund borrowing incurred. General fund budgets will be evaluated to ensure adequate cash is available for planned expenditures, and procedures will be enhanced to improve the timeliness of billing and collection for reimbursement-based grants. James Russ, Tribal Business Administrator, Wendy Wilson, Interim CFO and Sonia Horne, Grants and Contracts Accountant December 31, 2025
View Audit 372097 Questioned Costs: $1
The Northeast Iowa Workforce Development Area acknowledges the finding. Since the program year was reviewed, the State of Iowa has received a waiver allowing a 50% Out-of-School Youth and 50% In-School Youth expenditure split, which the Northeast Iowa LWDA has adopted. In addition, a new Title I ser...
The Northeast Iowa Workforce Development Area acknowledges the finding. Since the program year was reviewed, the State of Iowa has received a waiver allowing a 50% Out-of-School Youth and 50% In-School Youth expenditure split, which the Northeast Iowa LWDA has adopted. In addition, a new Title I service provider is in place, and procedures are being implemented to ensure compliance with the current expenditure requirements. LWDA staff will conduct quarterly reviews of youth expenditures and require regular reporting from the service provider to verify adherence.
Finding Number: 2022-004 Condition: The Organization was unable to provide supporting documentation to substantiate the allowability and accuracy of the expenses and lost revenue submitted in the portal. Planned Corrective Action: Company is an emergency services (ambulance, first responder, and was...
Finding Number: 2022-004 Condition: The Organization was unable to provide supporting documentation to substantiate the allowability and accuracy of the expenses and lost revenue submitted in the portal. Planned Corrective Action: Company is an emergency services (ambulance, first responder, and was instrumental in the administration of the monoclonal antibodies) – healthcare company and was during the pandemic. Company was able to provide general ledger information by personnel classification in aggregate monthly with percentages related to the Covid pandemic. Company changed payroll companies in June 2022 from Trion to DM Payroll – where we were unable to access the payroll registers by personnel name. Medstar has full access to payroll registers through DM Payroll. Contact person responsible for corrective action: Lalainia Budzynowski, VP of Finance Anticipated Completion Date: 06/30/2022 - Completed
View Audit 371328 Questioned Costs: $1
Finding No.: 2022-030 AL Program: 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 Department of Finance agrees with this finding. It is important to n...
Finding No.: 2022-030 AL Program: 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 Department of Finance agrees with this finding. It is important to note that the issue occurred during FY22, a period marked by the transition from the legacy financial system (JDE) to the new Tyler Munis platform. During this time, processes for retaining and reconciling supporting documents had not been standardized, resulting in inconsistencies and a heightened risk of missing or improperly uploaded records. Furthermore, the Program Manager previously responsible for overseeing this grant is no longer with the Department. 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, which contributed to this finding. Nevertheless, the Department is committed to provide relevant supporting documentation upon request from the Grantor. Proposed Completion Date: Ongoing.
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 No.: 2022-016 AL Program: 15.875 - Economic, Social, and Political Development of the Territories Area: Period of Performance Questioned Costs: $494,836 Contact Person(s): Epiphanio Cabrera, Jr., Grants Administrator, OGM-SC / Nerissa B. Karakaya, CIP COTR Corrective Action Plan: Condition 1...
Finding No.: 2022-016 AL Program: 15.875 - Economic, Social, and Political Development of the Territories Area: Period of Performance Questioned Costs: $494,836 Contact Person(s): Epiphanio Cabrera, Jr., Grants Administrator, OGM-SC / Nerissa B. Karakaya, CIP COTR Corrective Action Plan: Condition 1 (E. Cabrera): The Office of Grant Management (OGM) 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, OGM maintain all relevant supporting documentation and is prepared to provide it upon request from the Grantor. Based on our records, grant award D20AP00005 remains active with a period of performance extending through September 30, 2025, while grant award D20AP00037 was closed on September 30, 2024. Both grants remained operational well beyond the originally prescribed September 30, 2022 deadline. Given the extended period of performance authorized by the awarding agency, all associated questioned costs ($494,660.00) are supported by active grant activity and should be deemed allowable. Accordingly, OGM respectfully requests that these questioned costs be removed, as they reflect legitimate expenditures incurred within the approved grant periods. Proposed Completion Date: Ongoing Condition 2 (N. Karakaya): CIP agrees with the finding. To address the finding and prevent recurrence, CIP will: - Revise and strengthen written financial management policies to clearly define documentation requirements to substantiate expenditures and ensure costs are within the award’s period of performance. - Incorporate federal regulation references, including 2 CFR 200.303 (Internal Controls) and 2 CFR 200.344 (Closeout). - Implement a standardized checklist for technical analyst and program managers to confirm that all expenditure documentation includes dates verifying that costs were incurred within the period of performance. - Require a secondary review and sign-off by the CIP Administrator prior to submission of documentation to auditors. - Conduct mandatory annual training for program on federal period of performance requirements and required supporting documentation standards. - Provide refresher sessions before each audit cycle. - Establish a quarterly self-audit of grant files to verify that documentation is complete and properly supports expenditures. - Document results of each review and address deficiencies immediately. The responsible official will report progress on corrective actions to the CNMI leadership and maintain documentation of all implemented changes. Evidence of compliance (updated policies, training records, and self-audit reports) will be provided to the auditors upon request. Proposed Completion Date: December 31, 2025
View Audit 371187 Questioned Costs: $1
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