Corrective Action Plans

Finding 1161222 (2022-021)

Material Weakness 2022

Commonwealth of the Northern Mariana Islands

MP

Questioned Costs Special Tests & Provisions

Finding No.: 2022-021 AL Program: 17.225 - Unemployment Insurance Area: Special Tests and Provisions - UI Program Integrity - Overpayments Questioned Costs: $13,152 Contact Person(s): Zachary Taitano, PUA Program Manager, DOL Corrective Action Plan: Condition 1: The CNMI agrees with this finding, as...

Finding No.: 2022-021 AL Program: 17.225 - Unemployment Insurance Area: Special Tests and Provisions - UI Program Integrity - Overpayments Questioned Costs: $13,152 Contact Person(s): Zachary Taitano, PUA Program Manager, DOL Corrective Action Plan: Condition 1: The CNMI agrees with this finding, as the CNMI DOL did not forward the case to the OIG and did not charge 15% against the overpayment amounts for the respective benefit types. The CNMI is currently in communication with its grantor to determine the appropriate course of action, considering the last action on this claim was in 2022, The CNMI has sought grantor clarification on how to proceed with this matter and is pending further guidance. Further corrective action items, along with a proposed completion date, will be prepared once clarification is received. Proposed Completion Date: Ongoing

View Audit 371187 Questioned Costs: $1

Finding 1161221 (2022-020)

Material Weakness 2022

Commonwealth of the Northern Mariana Islands

MP

Questioned Costs Matching / Level of Effort / Earmarking Subrecipient Monitoring

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

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

View Audit 371187 Questioned Costs: $1

Finding 1161220 (2022-019)

Material Weakness 2022

Commonwealth of the Northern Mariana Islands

MP

Questioned Costs Subrecipient Monitoring § 200.1 § 200.331 § 200.332

Finding No.: 2022-019 AL Program: 15.875 - Economic, Social, and Political Development of the Territories Area: Subrecipient Monitoring Questioned Costs: $549,849 Contact Person(s): Nerissa B. Karakaya, CIP COTR / Angelina Phillips, Office of Management and Budget (OMB) Corrective Action Plan: Condi...

Finding No.: 2022-019 AL Program: 15.875 - Economic, Social, and Political Development of the Territories Area: Subrecipient Monitoring Questioned Costs: $549,849 Contact Person(s): Nerissa B. Karakaya, CIP COTR / Angelina Phillips, Office of Management and Budget (OMB) Corrective Action Plan: Condition 1 (N. Karakaya): CIP agrees with this finding. The address this finding, CIP will implement the following: 1. Establish Written Procedures: CNMI has developed and will initiate the implementation of formal written procedures requiring that all potential subrecipients be checked in SAM.gov prior to award and that verification is documented and retained in the official files. 2. Standardized Documentation: A standardized risk assessment checklist will be used for all subrecipients to confirm they are not suspended, debarred, or excluded under 2 CFR §180.300. 3. Staff Training: All staff responsible for subrecipient monitoring will receive training on federal requirements for exclusion checks and proper documentation procedures. 4. Monitoring and Review: CIP will conduct periodic reviews to ensure that SAM.gov checks are consistently performed and documented for all new and existing subrecipients. Condition 2 (N. Karakaya): CIP respectfully disagrees with this finding. The subrecipient was not required to submit the required project narrative report; instead, the report was prepared and submitted by the project manager responsible for managing the project as assigned by the Capital Improvement Program. In accordance with 2 CFR §200.328 – Monitoring and Reporting Program Performance, subrecipients are required to provide performance reports to the pass-through entity that document the status and progress of activities in accordance with the approved scope of work. To correct this issue, the subrecipient will implement a formal internal procedure designating the Program Coordinator as responsible for preparing, reviewing, and submitting all project narrative reports. Additionally, mandatory training will be conducted for all relevant subrecipient staff on federal reporting requirements and proper submission procedures, and all future narrative reports will include a certification by the authorized subrecipient representative confirming proper submission. The Capital Improvement Program will monitor submissions quarterly for the next 12 months to ensure full compliance. Corrective Actions: 1. Implement a formal internal reporting procedure requiring the subrecipient’s Program Coordinator to prepare, review, and submit all project narrative reports. 2. Conduct mandatory training for subrecipient staff on federal reporting requirements, documentation standards, and submission procedures. 3. Include a certification statement on all future narrative reports, signed by the subrecipient’s authorized representative, confirming proper submission. 4. Conduct quarterly monitoring of subrecipient submissions for the next 12 months to ensure compliance with reporting requirements. Proposed Completion Date: December 31, 2025 Condition 3 (N. Karakaya): We acknowledge the finding that documentation was not provided to verify whether eight subrecipients were subject to the audit requirements. The Capital Improvement Program will strengthen its subrecipient monitoring procedures to ensure compliance with 2 CFR 200.331(f) and related audit requirements. Corrective actions will include: 1. Policy Implementation: Adopt and disseminate the newly established Subrecipient Monitoring Policy and Procedures, which specify verification of subrecipients’ audit requirements. 2. Training: Provide training for program and grants management staff on the updated procedures and audit verification process. 3. Documentation: Maintain written evidence of audit requirement verifications for all subrecipients as part of the grant administration files. 4. Ongoing Monitoring: Incorporate periodic review of subrecipient audit status into the regular monitoring schedule to ensure continued compliance. These steps will be implemented immediately and will be applied to all current and future awards to prevent recurrence of this issue. Proposed Completion Date: December 31, 2025

View Audit 371187 Questioned Costs: $1

Finding 1161219 (2022-018)

Material Weakness 2022

Commonwealth of the Northern Mariana Islands

MP

Questioned Costs Subrecipient Monitoring Reporting

Finding No.: 2022-018 AL Program: 15.875 - Economic, Social, and Political Development of the Territories Area: Reporting Questioned Costs: $-0- Contact Person(s): Nerissa B. Karakaya, CIP COTR Corrective Action Plan: CIP agrees with this finding. A documentation checklist exists; however, it was no...

Finding No.: 2022-018 AL Program: 15.875 - Economic, Social, and Political Development of the Territories Area: Reporting Questioned Costs: $-0- Contact Person(s): Nerissa B. Karakaya, CIP COTR Corrective Action Plan: CIP agrees with this finding. A documentation checklist exists; however, it was not consistently fully extended to program administration records. Monitoring controls focused primarily on project completion, resulting in less attention to verifying that supporting documentation for administrative expenses was fully compiled and properly reconciled. In addition, segregation-of-duties constraints were evident, as the same staff oversaw both the preparation of reports and the maintenance of program administration records, which limited independent verification and delayed the retrieval of required documentation. The following steps will be implemented to address this finding. 1. Implement Formal Monitoring Procedures • Develop and document a standardized review checklist to verify that all data in financial and operational reports is supported by source documentation and reconciled to the accounting records. • Require periodic management sign-off (e.g., monthly or quarterly) to confirm that reconciliations are performed and retained. 2. Strengthen Segregation of Duties • Reassign key tasks so that data preparation, reconciliation, and approval are performed by separate individuals or units whenever possible. • Where staffing constraints prevent full segregation, implement compensating controls (e.g., independent supervisory review, dual sign-off). 3. Training and Capacity Building • Provide targeted training to finance and program staff on proper documentation, reconciliation procedures, and the importance of segregation of duties. 4. Periodic Internal Reviews • Establish periodic internal audits or spot checks by an independent unit (e.g., internal audit or compliance team) to verify adherence to the new monitoring controls and segregation requirements. 5. Timeline for Implementation • Within 30 days: Draft and approve written monitoring and reconciliation procedures. • Within 60 days: Reassign tasks to strengthen segregation of duties or document compensating controls. • Within 90 days: Conduct staff training and begin periodic internal reviews. 6. Monitoring & Reporting • Quarterly management reports to track completion of reconciliations and internal review results. • Annual evaluation of control design and effectiveness by internal audit or an independent reviewer. These actions will ensure reported data is consistently supported by accurate underlying accounting records and controls are suitably designed and effective, reducing the risk of misstatement or undetected errors due to inadequate segregation of duties. Proposed Completion Date: December 31, 2025

View Audit 371187

Finding 1161218 (2022-017)

Material Weakness 2022

Commonwealth of the Northern Mariana Islands

MP

Questioned Costs Procurement, Suspension & Debarment § 200.317

Finding No.: 2022-017 AL Program: 15.875 - Economic, Social, and Political Development of the Territories Area: Procurement and Suspension and Debarment Questioned Costs: $770,427 Contact Person(s): Epiphanio Cabrera, Jr., Grants Administrator, OGM-SC / Gerladine Cruz, Procurement Services Director ...

Finding No.: 2022-017 AL Program: 15.875 - Economic, Social, and Political Development of the Territories Area: Procurement and Suspension and Debarment Questioned Costs: $770,427 Contact Person(s): Epiphanio Cabrera, Jr., Grants Administrator, OGM-SC / Gerladine Cruz, Procurement Services Director / Nerissa B. Karakaya, CIP COTR Corrective Action Plan: Condition 1 (G. Cruz): The Procurement Services Division agrees with this finding. The Division will revise CNMI’s procurement regulations to ensure alignment with federal procurement standards as outlined in 2 CFR Part 200, particularly the small purchase threshold requirements and competitive procurement procedures. Proposed Completion Date: Policy updates drafted by December 31, 2025 and adopted by March 31, 2026. Condition 2 (G. Cruz): The Procurement Services Division agrees with this finding. To address the lack of consistent verification of vendor eligibility under federal debarment and suspension requirements (2 CFR §180.300), a policy will be implemented requiring all agencies to submit debarment verification documentation at the time of vendor selection. Acceptable documentation may include (1) a printout or screenshot from the SAM.gov Exclusions database, confirming that the vendor is not debarred or suspended, (2) a signed certification from the vendor attesting to their eligibility, or (3) a signed contract clause or provision that explicitly states the vendor is not excluded from federal transactions and complies with applicable debarment regulations. Procurement procedures and standard forms will be revised to include debarment verification as a mandatory step prior to any purchase approval involving federal funds. Procurement Services will ensure that debarment verification documents are maintained in the official procurement file for each transaction involving federal funds. Proposed Completion Date: June 30, 2026 Condition 3(a) (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. For Project Code 2701210042, a purchase order (PO 22202856) totaling $48,000 was executed in accordance with procurement requirements, supported by the solicitation and evaluation of three independent quotations to ensure competitiveness and compliance with applicable procurement regulations. For Project Code 1901210064, a purchase order (PO 22216403) totaling $22,881 was processed following the initial Invitation to Bid (ITB21-OGM/RDCCA-046). After the originally awarded contractor defaulted, procurement guidance was sought, resulting in direction to obtain and evaluate three independent quotations before issuing a purchase order. This approach ensured continued adherence to competitive procurement standards while addressing the unforeseen contractor default and maintaining project continuity. Proposed Completion Date: Ongoing Condition 3(b) (N. Karakaya): Capital Improvement Program agrees with this finding. CIP acknowledges the need to maintain sufficient and appropriate audit evidence demonstrating compliance with federal procurement standards. We recognize that our current recordkeeping for bid submissions and ITB publication can be improved to ensure that auditors can readily verify compliance. Corrective Actions: 1. Standardize Procurement Documentation Checklist • Develop a Bid Documentation Checklist that must be completed and signed for each procurement action. • Checklist will confirm inclusion of: - Copy of ITB and required documents - Copy of any addendums issued by Procurement Services - Proof of ITB publication (e.g., newspaper ad tear sheets, online postings with date/time stamps, screenshots). - Bid opening records (bid tabulation sheet, attendance log, time-stamped submissions). - Copies of all bids received, with date/time of receipt. - Documentation of evaluation committee scoring and award recommendation. 2. Centralized Digital Repository • Establish a secure electronic folder in the organization’s shared drive or document management system for every procurement project. • Require that all supporting documents—bid advertisements, bid submissions, evaluation forms, and award notifications—be uploaded within five business days after bid opening. 3. Policy and Procedure Update • Revise the Procurement Manual to incorporate the checklist and digital repository requirements. • Reference 2 CFR 200.508(d) explicitly, ensuring staff understand the federal mandate for “sufficient and appropriate audit evidence.” 4. Staff Training and Awareness • Conduct a mandatory training session for all staff involved in procurement on proper documentation and the use of the checklist and repository. • Provide annual refresher training to maintain compliance 5. Monitoring & Verification • The CIP staff will conduct a semi-annual review of procurement files to verify that all required evidence is consistently documented and readily accessible for future audits. Proposed Completion Date: December 31, 2025

View Audit 371187 Questioned Costs: $1

Finding 1161217 (2022-016)

Material Weakness 2022

Commonwealth of the Northern Mariana Islands

MP

Questioned Costs Procurement, Suspension & Debarment Subrecipient Monitoring § 200.308 § 200.309 § 200.344 § 200.403

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

Finding 1161215 (2022-014)

Material Weakness 2022

Commonwealth of the Northern Mariana Islands

MP

Cash Management Questioned Costs Subrecipient Monitoring

Finding No.: 2022-014 AL Program: 15.875 - Economic, Social, and Political Development of the Territories Area: Cash Management Questioned Costs: $482,041 Contact Person(s): Tracy B. Norita, Secretary of Finance / Nerissa B. Karakaya, CIP COTR Corrective Action Plan: Condition 1 (N. Karakaya): CIP a...

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

View Audit 371187 Questioned Costs: $1

Finding 1161214 (2022-013)

Material Weakness 2022

Commonwealth of the Northern Mariana Islands

MP

Questioned Costs Allowable Costs / Cost Principles

Finding No.: 2022-013 AL Program: 15.875 - Economic, Social, and Political Development of the Territories Area: Allowable Costs/Cost Principles Questioned Costs: $1,828,733 Contact Person(s): Epiphanio Cabrera, Jr., Grants Administrator, OGM-SC / Nerissa B. Karakaya, CIP COTR Corrective Action Plan:...

Finding No.: 2022-013 AL Program: 15.875 - Economic, Social, and Political Development of the Territories Area: Allowable Costs/Cost Principles Questioned Costs: $1,828,733 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. Furthermore, based on our documentation, the Authority to Proceed (ATP) requirement was not fully communicated or operationalized with the relevant agencies until late 2021. During this period, the National Environmental Policy Act (NEPA) compliance processes were nascent for both OGM and the partner agencies, and subsequently required coordination with the U.S. Army Corps of Engineers for proper implementation. Given that these procedural requirements were still in the initial stages of establishment and integration, the CNMI Government should not be deemed liable for noncompliance with obligations that were not yet fully defined or operationalized. Proposed Completion Date: Ongoing Condition 2 (N. Karakaya): We respectfully disagree with this finding. Our office has obtained an Authorization to Proceed (ATP) for all projects funded by the Office of Insular Affairs under the 702 Capital Improvement Project (CIP) grants. It appears that supporting documents may not have been provided to the assigned auditor within the required timeframe; however, our office has maintained all ATPs associated with the projects listed in Condition 2. In addition, the Capital Improvement Program has implemented a process to include the Authorization to Proceed when routing contracts for projects procured through sealed bid procurement and sealed proposals. Corrective Action Plan: 1. Centralized Record Submission: - Designate a staff member responsible for ensuring that all ATP supporting documents are submitted to the auditors during scheduled audits. - Create a checklist to confirm that all required ATP documentation is included in audit packets. 2. Process Improvement: - Incorporate a mandatory step in the contract routing process to attach the Authorization to Proceed for all projects procured through sealed bid procurement and sealed proposals. - Update internal procedures to reflect this requirement. Training & Awareness: - Conduct a briefing for CIP staff on the importance of timely submission of ATP documentation to auditors. - Provide refresher training annually to ensure continued compliance. 4. Timeline for Implementation: - Checklist & Process Update: By October 15, 2025 - Staff Training: By October 31, 2025 Proposed Completion Date: December 31, 2025

View Audit 371187 Questioned Costs: $1

Finding 1161192 (2022-012)

Material Weakness 2022

Commonwealth of the Northern Mariana Islands

MP

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

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

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

View Audit 371187 Questioned Costs: $1

Finding 1161191 (2022-011)

Material Weakness 2022

Commonwealth of the Northern Mariana Islands

MP

Subrecipient Monitoring School Nutrition Programs Questioned Costs § 200.334

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

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

View Audit 371187

Finding 1160584 (2022-002)

Material Weakness 2022

Summitview Child & Family Services

CA

Allowable Costs / Cost Principles Questioned Costs Subrecipient Monitoring § 200.302

Planned Corrective Action: The Organization will implement and reinforce a comprehensive system for retaining all invoices, payment records, and supporting documentation associated with federal awards. Additionally, the Organization will create and maintain a clear record retention policy. Invoice a...

Planned Corrective Action: The Organization will implement and reinforce a comprehensive system for retaining all invoices, payment records, and supporting documentation associated with federal awards. Additionally, the Organization will create and maintain a clear record retention policy. Invoice and Payment Documentation: • All invoices related to the federal program will be promptly reviewed and approved by the appropriate personnel to ensure they reflect allowable costs under the specific terms and conditions of the award. • Management will establish clear procedures for the proper recording and classification of payments, ensuring that they are linked directly to the corresponding federal program expenses. • All supporting documentation (e.g., purchase orders, contracts, receipts) will be retained in electronic formats within the accounting system, in accordance with the Organization’s record retention policy, ensuring availability for future audits or reviews. Retention and Accessibility: • The Organization will maintain a secure, organized filing system for all invoices and payments, ensuring that each record is easily accessible for audit purposes. This system will include electronic records that are stored in a centralized database, with restricted access to authorized personnel. • Retained invoices and payment documentation will be kept for the full duration required by federal regulations, typically for a period of at least seven years after the final expenditure report for the federal award has been submitted, or as otherwise required by the specific federal agency. Periodic Reviews and Monitoring: • To ensure ongoing compliance, Management will perform periodic reviews of federal program expenditures and documentation. This will include random sampling of invoices and payment records to confirm that they are complete, accurate, and in compliance with federal regulations. • In the event of any discrepancies or issues identified during these reviews, Management will take immediate corrective action to address the issue and prevent recurrence. By maintaining thorough records of all invoices and payments, the Organization aims to not only comply with federal audit requirements but also to ensure transparency, accountability, and sound financial management of federal funds.

View Audit 370890 Questioned Costs: $1

Finding 1160244 (2022-001)

Material Weakness 2022

Cheyenne-Eagle Butte Airport Association, Inc.

SD

Questioned Costs Reporting

Finding 2022-001: Uniform Guidance Audit Requirement Responsible Individuals: Jeannie Walters, Finance Officer Corrective Action Plan: The Association will work to complete future audits timely. Anticipated Completion Date: Future federal programs

View Audit 370631

Finding 1160197 (2022-015)

Material Weakness 2022

Fremont County School District No. 21

WY

Subrecipient Monitoring Reporting Questioned Costs

Unsupported Expenditures – Education Stabilization Funds INDIVIDUAL RESPONSIBLE: Business Manager and Federal Grants Director ANTICIPATED COMPLETION DATE: FY2026 CORRECTIVE ACTION PLAN: At this point in time the ESSR funds are no longer available, so there will not be any other documentation going f...

Unsupported Expenditures – Education Stabilization Funds INDIVIDUAL RESPONSIBLE: Business Manager and Federal Grants Director ANTICIPATED COMPLETION DATE: FY2026 CORRECTIVE ACTION PLAN: At this point in time the ESSR funds are no longer available, so there will not be any other documentation going forward. However, with other grants the processes have changed. Since FY2022 an accounting firm was hired to catch the school district up on grant requests. This accountant requested funds on a quarterly basis. On July 1, 2025, the District hired a Federal Grants Director to work with the Business Manager to complete the grant catch up process and to create a system that documents each expenditure and the timing of the requests. Once the system is in place cash requests will be completed monthly.

View Audit 370564 Questioned Costs: $1

Finding 1160144 (2022-022)

Material Weakness 2022

College of the Marshall Islands

MH

Questioned Costs Procurement, Suspension & Debarment § 200.214 § 200.303 § 200.318 § 200.319 § 200.320

Procurement and Suspension and Debarment: The College agrees with the finding and takes note of the previous corrective actions that did not fully resolve the issue. The College will update its Purchasing and Accounts Payable Policy to require SAM.gov verification prior to awarding contracts. The Co...

Procurement and Suspension and Debarment: The College agrees with the finding and takes note of the previous corrective actions that did not fully resolve the issue. The College will update its Purchasing and Accounts Payable Policy to require SAM.gov verification prior to awarding contracts. The College will conduct mandatory procurement training to strengthen compliance with federal requirements.

View Audit 370531 Questioned Costs: $1

Finding 1160142 (2022-021)

Material Weakness 2022

College of the Marshall Islands

MH

Subrecipient Monitoring Cash Management Questioned Costs § 200.303 § 200.305

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

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

View Audit 370531

Finding 1160138 (2022-019)

Material Weakness 2022

College of the Marshall Islands

MH

Questioned Costs Allowable Costs / Cost Principles Equipment & Real Property Management § 200.303

Activities Allowed or Unallowed/ Allowable Costs/Cost Principles: The College agrees with the finding. We take note previous corrective actions did not fully resolve the issue. The College will implement monthly/quarterly budget-to-actual reconciliations as a new agenda item during its monthly grant...

Activities Allowed or Unallowed/ Allowable Costs/Cost Principles: The College agrees with the finding. We take note previous corrective actions did not fully resolve the issue. The College will implement monthly/quarterly budget-to-actual reconciliations as a new agenda item during its monthly grant meetings. The College will enforce stricter oversight by the grants office to ensure compliance with allowable cost principles.

View Audit 370531 Questioned Costs: $1

Finding 1160136 (2022-018)

Material Weakness 2022

College of the Marshall Islands

MH

Subrecipient Monitoring Eligibility Reporting § 200.303

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

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

View Audit 370531

Finding 1160135 (2022-017)

Material Weakness 2022

College of the Marshall Islands

MH

Questioned Costs Subrecipient Monitoring Eligibility § 200.303

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

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

View Audit 370531 Questioned Costs: $1

Finding 1160133 (2022-015)

Material Weakness 2022

College of the Marshall Islands

MH

Allowable Costs / Cost Principles Questioned Costs Subrecipient Monitoring § 200.303

Allowable Costs/Cost Principle The College of the Marshall Islands acknowledges the finding and agrees that some payroll and non-payroll expenditures charged to the TRIO Upward Bound program lacked sufficient supporting documentation, including missing employment contracts, timesheets, and student m...

Allowable Costs/Cost Principle The College of the Marshall Islands acknowledges the finding and agrees that some payroll and non-payroll expenditures charged to the TRIO Upward Bound program lacked sufficient supporting documentation, including missing employment contracts, timesheets, and student meal listings, as well as discrepancies between paid hours/rates and approved documentation. These gaps arose primarily from inadequate internal controls and the limitations of the previous manual filing system, which hindered timely verification during the audit fieldwork. To address this, the College has upgraded and institutionalized a cloud-based filing system to ensure complete, organized, and easily accessible documentation for all program expenditures. Internal controls have been strengthened to require proper supporting documents including signed employment contracts, verified timesheets, approval for incentive and leave payments, and student listings—before any program costs are processed or reported. With the upgraded systems and the support of newly hired skilled staff, the College is now better equipped to ensure accuracy and compliance. Staff have been trained—and will continue to be trained twice a year—on federal cost principles and documentation standards to prevent recurrence of similar issues in future audits.

View Audit 370531 Questioned Costs: $1

Finding 1160132 (2022-014)

Material Weakness 2022

College of the Marshall Islands

MH

Allowable Costs / Cost Principles Questioned Costs Subrecipient Monitoring § 200.303

Activities Allowed or Unallowed & Allowable Costs/Cost Principles College of the Marshall Islands acknowledges the finding and agrees that the noted questioned costs arose from missing supporting documentation and employment contracts due to limitations in the previous manual filing system, which ma...

Activities Allowed or Unallowed & Allowable Costs/Cost Principles College of the Marshall Islands acknowledges the finding and agrees that the noted questioned costs arose from missing supporting documentation and employment contracts due to limitations in the previous manual filing system, which made timely retrieval difficult during the audit fieldwork. The College has since upgraded and institutionalized a cloud-based filing system to improve recordkeeping, accessibility, and documentation retention for all program expenditures. Internal controls have been strengthened to ensure that all stipends, salaries, and benefits charged to the TRIO Upward Bound program are fully supported by proper documentation, verified, and reviewed before payment and reporting. With the upgraded systems and the support of newly hired skilled staff, the College is now better equipped to ensure compliance. Staff have been trained—and will continue to be trained twice a year—on federal grant cost principles and documentation requirements to prevent recurrence of similar issues in future audits.

View Audit 370531 Questioned Costs: $1

Finding 1160130 (2022-012)

Material Weakness 2022

College of the Marshall Islands

MH

Questioned Costs Procurement, Suspension & Debarment Subrecipient Monitoring § 200.214 § 200.303 § 200.318 § 200.320 § 200.323

Procurement and Suspension and Debarment College of the Marshall Islands acknowledges the finding and confirms that the gaps noted resulted mainly from the previous manual filing system and limited internal procurement controls. The College has since upgraded and institutionalized a cloud-based fili...

Procurement and Suspension and Debarment College of the Marshall Islands acknowledges the finding and confirms that the gaps noted resulted mainly from the previous manual filing system and limited internal procurement controls. The College has since upgraded and institutionalized a cloud-based filing system to ensure complete documentation, proper retention, and easy retrieval of procurement records. Internal control policies and procedures have been strengthened to ensure compliance with the RMI Procurement Code, including vendor selection documentation, verification of suspension and debarment status, and equitable distribution of micro- purchases. In addition, newly hired staff dedicated to Procurement and Accounts Payable have been onboarded to improve oversight and compliance. With these new systems, strengthened controls, and added staffing capacity, the College is now better positioned to maintain full compliance. Staff have been trained—and will continue to be trained twice a year—on procurement requirements and federal regulations to prevent recurrence of similar issues in future audits.

View Audit 370531 Questioned Costs: $1

Finding 1160129 (2022-011)

Material Weakness 2022

College of the Marshall Islands

MH

Questioned Costs Subrecipient Monitoring § 200.303

Period of Performance College of the Marshall Islands acknowledges the finding and confirms that this resulted from gaps in the previous manual filing and monitoring system, which made it difficult to verify funding period dates during the audit fieldwork. The College has since upgraded and institut...

Period of Performance College of the Marshall Islands acknowledges the finding and confirms that this resulted from gaps in the previous manual filing and monitoring system, which made it difficult to verify funding period dates during the audit fieldwork. The College has since upgraded and institutionalized a cloud-based filing system and strengthened internal controls to ensure all costs are properly aligned with the funding periods stipulated in the grant awards. With the upgraded systems and the support of newly hired skilled staff, the College is now better equipped to maintain accurate documentation and monitoring. Staff have been trained—and will continue to be trained twice a year— on compliance with federal grant requirements, including period of performance rules. These measures will ensure timely verification and prevent similar issues from recurring in future audits.

View Audit 370531 Questioned Costs: $1

Finding 1160127 (2022-009)

Material Weakness 2022

College of the Marshall Islands

MH

Subrecipient Monitoring Allowable Costs / Cost Principles Questioned Costs § 200.303

Allowable Costs/Cost Principles College of the Marshall Islands acknowledges the finding and confirms that during the audit fieldwork, the required supporting documents could not be located due to the limitations of the previous manual filing system. The College has since upgraded and institutionali...

Allowable Costs/Cost Principles College of the Marshall Islands acknowledges the finding and confirms that during the audit fieldwork, the required supporting documents could not be located due to the limitations of the previous manual filing system. The College has since upgraded and institutionalized a cloud- based filing system to ensure accurate recordkeeping, easy retrieval, and compliance with federal documentation requirements. Internal control procedures have been strengthened, and staff have received proper training, which will continue to be conducted twice a year on compliance with federal allowable cost principles and documentation standards. These measures will prevent recurrence of similar issues and ensure that all federal expenditures are adequately supported and fully compliant going forward.

View Audit 370531 Questioned Costs: $1

Finding 1160126 (2022-008)

Material Weakness 2022

College of the Marshall Islands

MH

Subrecipient Monitoring Allowable Costs / Cost Principles Questioned Costs § 200.303

Activities Allowed or Unallowed & Allowable Costs/Cost Principles College of the Marshall Islands acknowledges the finding and agrees that certain payroll expenditures were not adequately supported by employment or overload contracts, and some salaries and related benefits charged were not clearly a...

Activities Allowed or Unallowed & Allowable Costs/Cost Principles College of the Marshall Islands acknowledges the finding and agrees that certain payroll expenditures were not adequately supported by employment or overload contracts, and some salaries and related benefits charged were not clearly aligned with the purpose of the related subgrants. These gaps occurred because of inadequate internal controls and the limitations of the previous manual filing system, which made it difficult to locate and verify supporting documents during the audit fieldwork. To address this, the College has upgraded and institutionalized a cloud-based filing system to ensure complete, accessible, and properly organized documentation for all grant-funded positions and expenditures. Internal controls have been strengthened to require signed employment and overload contracts, proper funding source verification, and supervisory review before any grant- related payroll costs are charged. With the upgraded systems and the support of newly hired skilled staff, the College is now better equipped to maintain compliance and oversight. Staff have been trained and will continue to be trained twice a year on federal allowability and cost principles to prevent recurrence of similar issues in future audits.

View Audit 370531 Questioned Costs: $1

Finding 1160034 (2022-007)

Material Weakness 2022

US Helping Us, People Into Living, Inc.

DC

Questioned Costs Eligibility

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

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

View Audit 370488

Corrective Action Plans

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