Corrective Action Plans

Finding 478606 (2024-001)

Significant Deficiency 2024

Presidio Gate Apartments 121-Eh 132-Np-Wah-L8

CA

HUD Housing Programs Reporting Questioned Costs

Corrective action plan for finding 2024-001 The company recognizes that the audit for Presidio Gate Apartments missed its official filing date in 2023. The delay in submitting the reports was due to a system conversion, staffing shortages and a delay in the auditor filing the financial statements in...

Corrective action plan for finding 2024-001 The company recognizes that the audit for Presidio Gate Apartments missed its official filing date in 2023. The delay in submitting the reports was due to a system conversion, staffing shortages and a delay in the auditor filing the financial statements in a timely manner. We have now been on our new system for a year and have staff allocated to working on timely and accurate financial reporting. We will work with new auditors to make sure late filings are not repeated. This corrective plan has resulted in the timely filing of the 2024 reports. Any questions on our corrective action you can contact: Joseph Miller, Director of Finance jomiller@frontporch.net (818) 254-1414

View Audit 315230

Finding 478604 (2024-001)

Significant Deficiency 2024

Lytton IV Housing Corporation 121-Ee 012-Np-Wah

CA

Questioned Costs Special Tests & Provisions HUD Housing Programs

Corrective action plan for finding 2024-001 The company recognizes that this underfunding was inadvertently missed for one month during the transition to a new financial institution. Upon recognizing the missed deposit, a transfer of $2,750 was made to the Replacement Reserve on 6/26/2024. The task ...

Corrective action plan for finding 2024-001 The company recognizes that this underfunding was inadvertently missed for one month during the transition to a new financial institution. Upon recognizing the missed deposit, a transfer of $2,750 was made to the Replacement Reserve on 6/26/2024. The task of Replacement Reserve monthly funding is now on a checklist and reviewed by multiple team members verifying that the payments are made. Any questions on our corrective action you can contact: Joseph Miller, Director of Finance jomiller@frontporch.net (818) 254-1414

View Audit 315229

Finding 477896 (2024-001)

Significant Deficiency 2024

Clinica Campesina Family Health Services

CO

Questioned Costs Significant Deficiency Matching / Level of Effort / Earmarking

Federal Program: Consolidated Health Centers Grant Assistance Listing No. 93.224 & 93.527 Recommendation: Our auditors recommended the Organization to review internal controls in regards to retaining the completed sliding fee applications in the patients record to support the sliding fee discount p...

Federal Program: Consolidated Health Centers Grant Assistance Listing No. 93.224 & 93.527 Recommendation: Our auditors recommended the Organization to review internal controls in regards to retaining the completed sliding fee applications in the patients record to support the sliding fee discount provided to the patient. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization is aware of the importance of properly applying the sliding fee scale to all eligible patients. We feel that we have strong policies and procedures to ensure this is performed accurately. However, the process is dependent on many individuals and is susceptible to human error. We will implement the following process to mitigate this risk. We will increase our internal audit procedures to audit sliding fee applications on a more frequent basis for any Enrollment Specialist who fails to maintain a 5% error rate. We will increase the number of Sliding Fee Discount applications to 5 every month. We will also conduct a retraining with the team to ensure all documents are uploaded into the document management system correctly for each patient. If the U.S. Department of Health and Human Services has questions regarding this plan, please call Brian Johnston, CFO at 303-665-3036.

View Audit 314530

Finding 404818 (2024-001)

None 2024

Prairie Estates

MO

Questioned Costs HUD Housing Programs

The deposit was delayed due to cash flow issues from service coordinator funding not being allocated for two years, and therefore, eleven monthly deposits were made in a lump sum in March, 2024. Since the end of the fiscal year, monthly deposits have been made and management is committed to ensuring...

The deposit was delayed due to cash flow issues from service coordinator funding not being allocated for two years, and therefore, eleven monthly deposits were made in a lump sum in March, 2024. Since the end of the fiscal year, monthly deposits have been made and management is committed to ensuring the required deposits are made monthly going forward. Person(s) Responsible: Aaron Franklin, Karen Webber Timing for Implementation: Completed 04/01/2024

View Audit 311203

Finding 403896 (2024-001)

Material Weakness 2024

Uncompahgre Combined Clinics Dba Uncompahgre Medical Center

CO

Internal Control / Segregation of Duties Questioned Costs Subrecipient Monitoring

Recommendation: Our auditors recommended the Organization to review internal controls in regards to the determination, recording, and monitoring of the sliding fee process to ensure that appropriate sliding fee rates/categories are utilized for each sliding fee encounter and that the support for the...

Recommendation: Our auditors recommended the Organization to review internal controls in regards to the determination, recording, and monitoring of the sliding fee process to ensure that appropriate sliding fee rates/categories are utilized for each sliding fee encounter and that the support for the sliding fee discounts is retained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization recognizes the deficiency of internal controls regarding determination, recording, and monitoring of the sliding fee process from application through adjustment. The Organization has acknowledged that along with our Finance Team being new to the position for all of 2023 along with the realization that our electronic medical record was making an automatic adjustment on the Federal Poverty Level. This automatic adjustment issue has been resolved. We also reviewed the monthly adjustments and have implemented a monthly oversight process to review adjustments made to patient accounts. If the U.S. Department of Health and Human Services has questions regarding this plan, please call Tricia Lippert, Comptroller at 970-327-0537.

View Audit 310773

Finding 403361 (2024-001)

Significant Deficiency 2024

Ott's Branch Elderly Housing, Inc.

SC

Questioned Costs Subrecipient Monitoring HUD Housing Programs

Finding #2024-001 Comments on Findings and Recommendation: During the year ended March 31, 2024, deposits to the reserve for replacements account were $236 less than the required amount. Management should transfer $236 from the operating account to the reserve for replacements account. Action(s) tak...

Finding #2024-001 Comments on Findings and Recommendation: During the year ended March 31, 2024, deposits to the reserve for replacements account were $236 less than the required amount. Management should transfer $236 from the operating account to the reserve for replacements account. Action(s) taken or planned on the finding: Management concurs with the finding and recommendation.

View Audit 310491 Questioned Costs: $1

Finding 403260 (2024-001)

Significant Deficiency 2024

Realife Cooperative of Bloomington

MN

Questioned Costs Reporting Internal Control / Segregation of Duties

Recommendation: We recommend that the Cooperative continue to review the auditor prepared adjusting journal entries and financial statements with the intention of understanding and acceptance of responsibility for reporting under generally accepted accounting principles. Action Taken: The Cooperati...

Recommendation: We recommend that the Cooperative continue to review the auditor prepared adjusting journal entries and financial statements with the intention of understanding and acceptance of responsibility for reporting under generally accepted accounting principles. Action Taken: The Cooperative will continue to review the auditor prepared adjusting journal entries and financial statements with the intention of understanding and acceptance of responsibility for reporting under generally accepted accounting principles. Planned Completion Date: Not Applicable

View Audit 310433

Finding 395120 (2024-002)

None 2024

Church Street Estates Corp.

RI

Questioned Costs HUD Housing Programs Internal Control / Segregation of Duties

Management will correct the next voucher

View Audit 305045 Questioned Costs: $1

Finding 1226320 (2023-006)

Material Weakness 2023

Humboldt Park Health, Inc.

IL

HUD Housing Programs Reporting Internal Control / Segregation of Duties

Condition: The Organization did not submit the budget to HUD within 30 days of the start of its fiscal year. Planned Corrective Action: Management has implemented a new review and oversight process related to the process for the documentation submissions to HUD to ensure timely submissions of items ...

Condition: The Organization did not submit the budget to HUD within 30 days of the start of its fiscal year. Planned Corrective Action: Management has implemented a new review and oversight process related to the process for the documentation submissions to HUD to ensure timely submissions of items and to ensure documentation of review of submitted information is retained on a goforward basis. Contact person responsible for corrective action: Louise Arzu, Vice President, Finance Anticipated Completion Date: 9/30/2026

View Audit 408969

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 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 1224637 (2023-006)

Material Weakness 2023

Serenity House of Clallam County

WA

Questioned Costs Allowable Costs / Cost Principles § 200.303 § 200.403

Allowable Costs/General Disbursements Recommendation: We recommend that management reinforce the consistent execution and documentation of existing disbursement approval and documentation procedures. This should include ensuring that all expenditure charged to federal awards are appropriately approv...

Allowable Costs/General Disbursements Recommendation: We recommend that management reinforce the consistent execution and documentation of existing disbursement approval and documentation procedures. This should include ensuring that all expenditure charged to federal awards are appropriately approved and supported by sufficient documentation prior to payment, and that management periodically monitors compliance with these procedures to confirm they are operating as designed. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. 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. 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. The Grantor billing is a P&L detailed report for that grant. 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. Name(s) of the contact person(s) responsible for corrective action: Cora Alyea Planned completion date for corrective action plan: Completed in 2023

View Audit 407897

Finding 1224541 (2023-001)

Material Weakness 2023

New York State YMCA Foundation, Inc.

NY

Questioned Costs Reporting § 200.512

Management agrees with this finding and will review updated policies and procedures as adopted by bookkeepers. •Management will engage in consistent reviews and reconciliations to ensure that updated documentation is provided to auditors in a timely manner.•Executive Director Kyle Stewart will work ...

Management agrees with this finding and will review updated policies and procedures as adopted by bookkeepers. •Management will engage in consistent reviews and reconciliations to ensure that updated documentation is provided to auditors in a timely manner.•Executive Director Kyle Stewart will work in conjunction with the organization’s bookkeepers.•Action will be completed consistently and end of each fiscal year. Documentation and financial reports will be provided to auditors subsequent to execution of annual engagement. Annual audit requirements will be completed on time.

View Audit 407784

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 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 1224429 (2023-028)

Material Weakness 2023

Commonwealth of the Northern Mariana Islands

MP

Eligibility Questioned Costs

Finding No.: 2023-028 AL Program: COVID-19 21.023 – Emergency Rental Assistance Program Area: Eligibility Questioned Costs: $99,935 Contact Person(s): Epiphanio Cabrera, Jr., Grants Administrator, OGM-SC Corrective Action Plan: Condition 1a: The Office of Grants Management (OGM) respectfully disagre...

Finding No.: 2023-028 AL Program: COVID-19 21.023 – Emergency Rental Assistance Program Area: Eligibility Questioned Costs: $99,935 Contact Person(s): Epiphanio Cabrera, Jr., Grants Administrator, OGM-SC Corrective Action Plan: Condition 1a: The Office of Grants Management (OGM) respectfully disagrees with the finding and questioned cost of $8,337.00 because assigned personnel were not made aware to supply supporting documents for the following questioned costs. Possible communication breakdown may exist as per OGM staff, and OGM staffer reported a different request list was furnished at different times. However, OGM is pleased to provide you with copies of the documents for these questioned costs items. I believe that the timing played a major role with the release of this draft document, but OGM should not be penalized. We are requesting this finding be removed based on the explanation provided above. Finding No.: 2023-028, continued AL Program: COVID-19 21.023 – Emergency Rental Assistance Program Area: Eligibility Questioned Costs: $99,935 Contact Person(s): Epiphanio Cabrera, Jr., Grants Administrator, OGM-SC Corrective Action Plan: Condition 1b: The Office of Grants Management respectfully disagrees with the finding and questioned cost of $91,598.00 because assigned personnel were not made aware to supply supporting documents for the following questioned costs. Possible communication breakdown may exist as per OGM staff, and OGM staffer reported a different request list was furnished at different times. However, OGM is pleased to provide you with copies of the documents for these questioned costs items. I believe that the timing played a major role with the release of this draft document, but OGM should not be penalized. We are requesting this finding be removed based on the explanation provided above. Proposed Completion Date: Ongoing Condition 1c: The Office of Grants Management disagrees with the finding and questioned cost of $68,181.00 because assigned personnel were not made aware to supply supporting documents for the following questioned costs. Possible communication breakdown may exist as per OGM staff, and OGM staffer reported a different request list was furnished at different times. However, OGM is pleased to provide you with copies of the documents for these questioned costs items. I believe that the timing played a major role with the release of this draft document, but OGM should not be penalized. We are requesting this finding be removed based on the explanation provided above. Proposed Completion Date: Ongoing Condition 1d: The Office of Grants Management disagrees with the finding and questioned cost of $4,500.00 because assigned personnel were not made aware to supply supporting documents for the following questioned costs. Possible communication breakdown may exist as per OGM staff, and OGM staffer reported a different request list was furnished at different times. For this particular finding, the client was unemployed and thus could not provide an employment verification. Finding No.: 2023-028, continued AL Program: COVID-19 21.023 – Emergency Rental Assistance Program Area: Eligibility Questioned Costs: $99,935 Contact Person(s): Epiphanio Cabrera, Jr., Grants Administrator, OGM-SC Corrective Action Plan: However, OGM is pleased to provide you with copies of the documents for these questioned costs items. I believe that the timing played a major role with the release of this draft document, but OGM should not be penalized. We are requesting this finding be removed based on the explanation provided above. Proposed Completion Date: Ongoing Condition 1e: The Office of Grants Management disagrees with the finding and questioned cost of $19,614.00 because assigned personnel were not made aware to supply supporting documents for the following questioned costs. Possible communication breakdown may exist as per OGM staff, and OGM staffer reported a different request list was furnished at different times. However, OGM is pleased to provide you with copies of the documents for these questioned costs items. I believe that the timing played a major role with the release of this draft document, but OGM should not be penalized. We are requesting this finding be removed based on the explanation provided above. Proposed Completion Date: Ongoing

View Audit 407734

Finding 1224423 (2023-022)

Material Weakness 2023

Commonwealth of the Northern Mariana Islands

MP

Eligibility Matching / Level of Effort / Earmarking Questioned Costs

Finding No.: 2023-022 AL Program: COVID-19 17.225 – Unemployment Insurance (UI) Area: Eligibility Questioned Costs: $-0- Contact Person(s): Zachary Taitano, PUA Program Manager, DOL Corrective Action Plan: The CNMI agrees with this finding and acknowledges that a variance exists between the expendit...

Finding No.: 2023-022 AL Program: COVID-19 17.225 – Unemployment Insurance (UI) Area: Eligibility Questioned Costs: $-0- Contact Person(s): Zachary Taitano, PUA Program Manager, DOL Corrective Action Plan: The CNMI agrees with this finding and acknowledges that a variance exists between the expenditure report details and the listing of payments from the HireMarianas Portal. We are currently reviewing and reconciling both records to determine the cause of the variance. The Expenditure Detail Listing totals $3,057,097.02, while the HireMarianas benefit listing totals $4,112,291.03. During this review, we identified that the HireMarianas benefit listing total includes benefit tax withholdings and child support deductions. However, these amounts are not included in the Expenditure Detail Listing. Therefore, the variance is attributable to PUA tax withholdings ($169,283), FPUC tax withholdings ($150,054), and child support deductions ($202). After excluding these amounts, the adjusted HireMarianas Portal total is $3,792,752.03. Additionally, a review of the MUNIS system identified 19 late entries not reflected in the original Expenditure Detail Listing of $3,057,092.02. These entries represent FY23 expenditures recorded in FY24 and consist of 10 PUA benefit payments totaling $108,937.63 and 9 FPUC benefit payments totaling $110,625.00, for a combined total of $219,562.63. After incorporating these MUNIS late entries into the Expenditure Detail Listing, the adjusted expenditure total is $3,276,654.65. Based on these adjustments, the remaining variance is $516,097.37. Finding No.: 2023-022, continued AL Program: COVID-19 17.225 – Unemployment Insurance (UI) Area: Eligibility Questioned Costs: $-0- Contact Person(s): Zachary Taitano, PUA Program Manager, DOL Corrective Action Plan: CNMI DOL will continue its review and will coordinate with Geographic Solutions, Inc. (GSI), the HireMarianas Portal vendor, and the Department of Finance to further investigate and resolve any remaining discrepancies and to ensure the accuracy and completeness of reported disbursements. Proposed Completion Date: October 2026

View Audit 407734

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 1224235 (2023-013)

Material Weakness 2023

International Fertilizer Development Company

AL

Questioned Costs Reporting Significant Deficiency § 200.512

2023-013-Late filing of the data collection form Suggested Action: Enhanced internal controls and timelines around the year-end close and audit coordination to ensure timely completion of future audits and related filings. Responsible Official: Global Finance Director Completion Date: 6/30/2026

View Audit 407579

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

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