Corrective Action Plans

Finding 1227816 (2023-005)

Material Weakness 2023

Commonwealth of the Northern Mariana Islands Public School System

MP

Reporting Subrecipient Monitoring Allowable Costs / Cost Principles

Finding No.: 2023-005 AL Program: 10.555 National School Lunch Program (NSLP) Area: Reporting Questioned Costs: $-0- Views of Auditee and Corrective Action Plan: Management’s Position: PSS Management concurs with the findings. Financial and Grants Management procedures were promulgated in a SOP on S...

Finding No.: 2023-005 AL Program: 10.555 National School Lunch Program (NSLP) Area: Reporting Questioned Costs: $-0- Views of Auditee and Corrective Action Plan: Management’s Position: PSS Management concurs with the findings. Financial and Grants Management procedures were promulgated in a SOP on September 18, 2024. The financial management system was subsequently changed to Tyler Munis to conform with CNMI central government requirements which will enhance capabilities. The SOPs and the Tyler Munis implementation are under review by an external consultant and recommendations made to improve coding of grant details and expenditures, increased frequency of reconciliations, and a specific SOP for report preparation. Corrective Action Plan: I. Implementation of a Comprehensive Grant Tracker: PSS will develop and implement a centralized Grant Lifecycle Tracker for all active federal awards. This tool will serve as the primary monitoring mechanism for compliance by recording all financial and programmatic reporting due dates, assigning specific preparers for each report, and establishing automated milestones to ensure sufficient lead time for both the preparation phase and the subsequent supervisory review. II. Deployment of Enhanced Data Analysis Tools: To ensure that quarterly program reporting is both consistent and timely, PSS will develop and implement specialized data analysis tools. these tools will streamline the aggregation of program data, reducing manual entry errors and allowing for more efficient evaluation of program performance against federal benchmarks. Proposed Completion Date: In progress for FY 2024 with completion by August 2026. Name of Contact Person and Title: Contact: Jacqueline Che, Federal Programs Officer Email Address: jacqueline.che@cnmipss.org

View Audit 409786

Finding 1227715 (2023-001)

Material Weakness 2023

SOUTHWEST INDIGENOUS WOMENS COALITION

AZ

Reporting Significant Deficiency

Management Response: Management concurs with the finding. During the FY2023 audit period, the Organization experienced significant administrative and staffing challenges that affected the timely organization and retention of audit documentation necessary to complete the Single Audit within the requi...

Management Response: Management concurs with the finding. During the FY2023 audit period, the Organization experienced significant administrative and staffing challenges that affected the timely organization and retention of audit documentation necessary to complete the Single Audit within the required timeframe. While management recognizes the importance of timely audit completion, there was no intent to delay compliance with federal reporting requirements. Since FY2023, SWIWC has substantially strengthened its financial management and audit readiness processes. The Organization has substantially revised its financial policies and procedures, centralized audit documentation, established standardized record retention practices, enhanced grant-specific compliance files, and implemented audit preparation checklists and tracking systems designed to support timely completion of future audits. Management believes these improvements significantly reduce the likelihood of similar delays occurring in future audit periods. Anticipated Completion Date: Planned Implementation completion by 9/30/2026; ongoing monitoring. Responsible Party: Executive Director and Chief Financial Officer.

View Audit 409697

Finding 1227614 (2023-006)

Material Weakness 2023

Village of Maywood

IL

Reporting Subrecipient Monitoring Internal Control / Segregation of Duties § 200.303

The Village acknowledges the recommendation and will continue to strengthen its procedures for identifying and tracking grant activity. Management plans to implement additional review procedures over grant funding sources and related expenditures for purposes of SEFA reporting. The Village will also...

The Village acknowledges the recommendation and will continue to strengthen its procedures for identifying and tracking grant activity. Management plans to implement additional review procedures over grant funding sources and related expenditures for purposes of SEFA reporting. The Village will also consider providing the SEFA and supporting expenditure information to its external engineering consultants for review to help ensure all grant activity administered on behalf of the Village is properly identified and reported.

View Audit 409628

Finding 1227508 (2023-001)

Material Weakness 2023

Missoula County Public School District No. 1

MT

Procurement, Suspension & Debarment Reporting School Nutrition Programs § 200.512

July 28, 2026 Business Services Missoula County Public Schools 909 South Avenue West Missoula, MT 59801 Phone 406-728-2400 Ext 3021 business@mcpsmt.org Management’s Response to Auditor’s Findings and Corrective Action Plan June 30, 2023 Prepared by Management of Missoula County Public Schools Contac...

July 28, 2026 Business Services Missoula County Public Schools 909 South Avenue West Missoula, MT 59801 Phone 406-728-2400 Ext 3021 business@mcpsmt.org Management’s Response to Auditor’s Findings and Corrective Action Plan June 30, 2023 Prepared by Management of Missoula County Public Schools Contact: Denise Williams, Executive Director of Business Operations 2023-001 Internal Controls Over Student Activity Expenditures Criteria or Specific Requirement: The State of Montana Student Activity Fund Accounting Manual requires all expenditure of funds have proper documentation. Condition: During review of student activity expenditures it was noted that documentation was not retained for all expenses. Context: We selected 50 total expenditures for testing and noted that 2 of the expenditures did not have documentation of the expense. Effect: We selected 50 total expenditures for testing and noted that 2 of the expenditures did not have documentation of the expense. Cause: The District is not in compliance with State requirements for the accounting for student activity expenditures. Auditor's Recommendation: We recommend that the District review its policies and procedures pertaining to student activity expenditures and receipts and ensure that is up to date and that it can be easily followed and replicated in case of personnel turnover. View of Responsible Officials and Corrective Action Plan: We concur with this finding. It is an on-going issue. Our policies and procedures concerning student activity funds are up to date. We have held meetings with the school bookkeepers to review the MASBO Student Activity Fund Accounting Manual and have provided electronic and paper copies to the principals, activities/athletic directors and bookkeepers. Our next meeting with this group is August 6, 2026. 2023-002 Late Submission Federal Program Information: Funding agency: U.S Department of Education U.S Department of Agriculture Title: Elementary and Secondary School Emergency Relief ESSER) Fund, American Rescue Plan - Elementary and Secondary School Emergency Relief (ARP ESSER), American Rescue Plan Elementary and Secondary School Emergency Relief - Homeless Children and Youth and Special Education Cluster Child Nutrition Cluster CFDA number: 84.425D, 84.425U, 84.425W, 84.027, 84.173 10.553, 10.555, 10.559 Award year and number: 32-0583-912020, 32-0584-922021, 32-0583-972021, 32-0583- 932021, 32-0584-772021, 32-0584-772022, 32-0584-79-2022 Criteria or Specific Requirement: 2 CFR section 200.512(a) requires the reporting package and data collection form be submitted to the Federal Audit Clearinghouse the earlier of 30 calendar days after the reports are received from auditors or nine months after the end of the audit period. Condition: The fiscal year audit and reporting package is being submitted after the required due date. Context: We reviewed the audit submission date in comparison to the required due date. Questioned Costs: To be determined by grantor Effect: There is a potential for suspension or cessation of federal and/or state funding. Cause: The ongoing Covid-19 pandemic caused a delay in the audit and as such the required deadline could not be met. Repeat: Yes Auditor's Recommendations: The District should take steps to ensure that its financial records are maintained on a current basis, reconciled timely, and audited within nine months after year end. View of Responsible Officials and Corrective Action Plan: In November 2022, the District was informed by its then auditor that they could not complete the audit for FY2022. By that time, most audit firms were booked solid and the District had a difficult time contracting with a new firm. Wipfli, LLC entered into a 3-year contract with the District with the understanding that the FY2022 audit would likely not be filed on time. The FY2022 audit was issued on May 7, 2024. The District committed to having financial information ready for the FY2023 audit by the end of June 2024, which was already twelve months after the end of the audit period. Unfortunately, the financial information for FY2023 was not ready as promised and this had an adverse effect on Wipfli LLC's ability to perform its work as scheduled. To further complicate matters, key accounting personnel left the District in August 2024 and June 2025. These individuals had 30 years and 20 years’ experience, respectively, in the District. Even though this will be a repeat finding for the FY2024 and FY2025 audits, the current accounting personnel and their staff are committed to maintaining the District's financial records on a current basis, reconciling accounts timely and will work to have them audited within the required deadlines.

View Audit 409535

Finding 1227175 (2023-001)

Material Weakness 2023

Hazlehurst City School District

MS

Subrecipient Monitoring Reporting Internal Control / Segregation of Duties § 200.512

AUDITEE’S CORRECTIVE ACTION PLAN As required by Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost principles, and Audit Requirements for Federal Awards (UG), the Hazlehurst City School District has prepared and hereby submits the following corrective ...

AUDITEE’S CORRECTIVE ACTION PLAN As required by Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost principles, and Audit Requirements for Federal Awards (UG), the Hazlehurst City School District has prepared and hereby submits the following corrective action plan for the findings included in the Schedule of Findings and Questioned Cost for the year ended June 30, 2023: Finding 2023-001 Corrective Action Plan Details A. Contact person responsible for corrective action: Name: Sherry Terry Title: Chief Financial Officer B. Description of corrective action planned: The district will strengthen its internal control systems over reporting to ensure single audit reporting package and data collection form are submitted to the Federal Audit Clearinghouse within established timeframe and financial statements are prepared timely. C. Anticipated completion date of corrective action: Immediately

View Audit 409337

Finding 1227161 (2023-002)

Material Weakness 2023

County of Rockingham

NH

Reporting § 200.303

Corrective Action Taken or Planned: 1. Formal documentation and retention procedures: Going forward, all report submissions will be accompanied by time and date-stamped confirmation of submissions (e.g., email confirmations, screenshots from federal submission portal, etc.). These confirmations will...

Corrective Action Taken or Planned: 1. Formal documentation and retention procedures: Going forward, all report submissions will be accompanied by time and date-stamped confirmation of submissions (e.g., email confirmations, screenshots from federal submission portal, etc.). These confirmations will be retained in a designated compliance folder for each program. Submitted reports, if available, will be downloaded immediately or as soon as possible from the respective Federal or State agency portal/site and saved to an appropriate County network folder. 2. Contingency plan for system errors: The County will develop a written contingency plan to address delays caused by system outages or data access issues. This plan will include communication protocols with software vendors, documentation of incidents, and immediate outreach to the granting agency when delays are anticipated. 3. Documenting extensions and agency communication: In any case where a reporting deadline cannot be met, staff will immediately request written approval for extensions from the granting agency, and this correspondence will be retained as part of the official reporting record, as applicable and permitted. 4. Training for program and compliance staff: Staff invovled in federal reporting will receive training on reporting deadlines, documentation standards, and escalation protocols for delays. This training will be updated annually to reflect current guidance and program requirements. Implementation date of corrective action: October 24, 2025 Person responsible for corrective action: Charles Nickerson, Senior Director of Finance

View Audit 409334

Finding 1227058 (2023-001)

Material Weakness 2023

GREAT NORTHWEST WHOLESALE WATER COMMISSION

MO

Reporting Eligibility § 200.501 § 200.512

Reference Numbers: 2023-001 and 2022-001 Federal Program: Direct - USDA Rural Utilities Service award; ALN 10.760, 'Water and Waste Disposal Systems for Rural Communities' (Single Audit / Uniform Guidance).Condition: The Great Northwest Wholesale Water Commission did not complete and submit its repo...

Reference Numbers: 2023-001 and 2022-001 Federal Program: Direct - USDA Rural Utilities Service award; ALN 10.760, 'Water and Waste Disposal Systems for Rural Communities' (Single Audit / Uniform Guidance).Condition: The Great Northwest Wholesale Water Commission did not complete and submit its reporting package, including the SEFA and the single audit report, to the Federal Audit Clearinghouse within nine months of the fiscal year end. Criteria: Under 2 CFR §200.512, the audit must be completed, and the data collection form and reporting package must be submitted within 30 calendar days after receipt of the auditor's report, or nine months after the fiscal year end, whichever is earlier. Corrective Action Plan: Management acknowledges the finding and has implemented procedures to improve the timely completion and submission of the data collection form to the Federal Audit Clearinghouse. Management has engaged an audit firm to complete the December 31, 2022, 2023, and 2024 audits and will submit the reporting package to the Federal Audit Clearinghouse upon completion. Management will coordinate with the auditors throughout the audit process, monitor applicable reporting deadlines, and establish internal timelines to ensure the audit report and data collection form are submitted within the required time frame prescribed by 2 CFR 200.512(a). Personnel responsible for Corrective Action: Jerri Dearmont, Executive Director Anticipated Completion Date: August 18, 2026

View Audit 409233

Finding 1226463 (2023-001)

Material Weakness 2023

Educate Maine

ME

Reporting Subrecipient Monitoring

Finding 2023-001: The audit reporting package for the year ended December 31, 2023 has not yet been submitted to the Federal Audit Clearinghouse. Name of contact person responsible for corrective action: Amanda Peterson, Director of Operations and Jason Judd, Ed.D., Executive Director Anticipated co...

Finding 2023-001: The audit reporting package for the year ended December 31, 2023 has not yet been submitted to the Federal Audit Clearinghouse. Name of contact person responsible for corrective action: Amanda Peterson, Director of Operations and Jason Judd, Ed.D., Executive Director Anticipated completion date: September 30, 2025. Corrective Action Plan: Management agrees with the finding and is working on submission of the federal reporting package for the year ended December 31, 2023. The submission of the December 31, 2024 federal reporting package was completed prior to its due date.

View Audit 409098

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 1226318 (2023-004)

Material Weakness 2023

Humboldt Park Health, Inc.

IL

Allowable Costs / Cost Principles Subrecipient Monitoring Reporting § 200.303 § 200.328 § 200.403 § 200.502 § 200.510

Condition: Management lacked adequate controls at the transaction level to ensure compliance with activities allowed or unallowed, allowable cost principles, and period of performance, which resulted in the improper inclusion of duplicate costs and costs from a prior fiscal period. Further, a lack o...

Condition: Management lacked adequate controls at the transaction level to ensure compliance with activities allowed or unallowed, allowable cost principles, and period of performance, which resulted in the improper inclusion of duplicate costs and costs from a prior fiscal period. Further, a lack of effective controls over financial reporting and over preparation of the SEFA resulted in management reporting activity on a cash basis, inconsistent with the basis of reporting established in Note 1 and with requirements established by the passthrough funding agency. Planned Corrective Action: Management will implement a new review, reconciliation and oversight process to ensure that compliance with activities allowed or unallowed, allowable cost principles, and period of performance standards are followed for future grant submissions. Contact person responsible for corrective action: Louise Arzu, Vice President, Finance Anticipated Completion Date: 9/30/2024

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 1226287 (2023-010)

Material Weakness 2023

Cobre Consolidated School District

NM

Reporting Internal Control / Segregation of Duties § 200.512

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

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

View Audit 408952

Finding 1226240 (2023-009)

Material Weakness 2023

Mississippi County, Missouri

MO

Subrecipient Monitoring Reporting Cash Management

The Treasurer has reviewed the corrected SEFA and understands the errors. Funds will be reported accurately in the future.

View Audit 408896

Finding 1225996 (2023-001)

Material Weakness 2023

Universal Family Connection, Inc.

IL

Reporting

Corrective Action Management concurs with the auditor’s finding and will 1) hire personnel within the accounting and finance department so that all defined tasks can be performed in a more timely manner and 2) evaluate current processes to determine how to make them more efficient so that the curren...

Corrective Action Management concurs with the auditor’s finding and will 1) hire personnel within the accounting and finance department so that all defined tasks can be performed in a more timely manner and 2) evaluate current processes to determine how to make them more efficient so that the current personnel within the accounting and finance department are able to complete their tasks in a more timely manner. Persons Responsible: Marlin Bryant, CFO Date of Implementation: September 2024

View Audit 408663

Finding 1225855 (2023-002)

Material Weakness 2023

City of Dover

DE

Reporting

Staff review of Finance internal policy numbers F317 and F317A last updated November 7, 2014 and May 15, 2015 for changes pertaining to current year requirements. Additionally, training has been sought through GFOA for updated grant training for new staff. FSRS and SAM.gov training was completed in ...

Staff review of Finance internal policy numbers F317 and F317A last updated November 7, 2014 and May 15, 2015 for changes pertaining to current year requirements. Additionally, training has been sought through GFOA for updated grant training for new staff. FSRS and SAM.gov training was completed in December 2024. Lastly, an opening for Accountant II is being reconsidered for an Accountant III role to be used specifically for project and grant accounting purposes.

View Audit 408549

Finding 1224898 (2023-001)

Material Weakness 2023

Clearfield County

PA

Reporting

Finding 2023 -01 Pennsylvania Department of Human Services – Child Support Enforcement – Pennsylvania Automated Child Support Enforcement System (PACSES) Data Reliability Validation Criteria: Per the PACSES Office of Child Support Enforcement (OCSE) 157 Data Reliability Validation:  Line 5 should b...

Finding 2023 -01 Pennsylvania Department of Human Services – Child Support Enforcement – Pennsylvania Automated Child Support Enforcement System (PACSES) Data Reliability Validation Criteria: Per the PACSES Office of Child Support Enforcement (OCSE) 157 Data Reliability Validation:  Line 5 should be reporting children in IV-D cases open at the end of the current federal fiscal year who were born out-of-wedlock;  Line 6 should be reporting children in IV-D cases open during or at the end of the fiscal year with paternity established or acknowledged;  Line 24 should be reporting the total amount of current support due for the fiscal year; and  Line 25 should be reporting the total amount of support distributed and disbursed as current support during the fiscal year. Condition: During the audit, it was determined that several of the PACSES cases sampled from the Line-Item Reports did not match the PACSES case data in the County’s system. Cause: The County is inaccurately inputting case information into PACSES causes cases to be improperly included to be reflected on the Line-Item Reports generated from PACSES. Effect: The County is not in compliance with OCSE-157 requirements. This is causing inaccurate information to be presented on its reports to OCSE from the PACSES system. Recommendation: We recommend the County develop and adhere to controls to ensure correct information is being inputted and reported on these PACSES reports for accurate reporting. Management Response: The County will implement controls to sufficiently verify the accuracy of the information being input within PACSES in accordance with applicable criteria as outlined by OCSE.

View Audit 408135

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 1224635 (2023-004)

Material Weakness 2023

Serenity House of Clallam County

WA

Reporting § 200.303 § 200.508

SEFA Preparation Recommendation: We recommend that management design and implement effective internal controls over compliance related to SEFA preparation, including assigning responsibility to personnel with appropriate training in federal award requirements. Management should also implement a docu...

SEFA Preparation Recommendation: We recommend that management design and implement effective internal controls over compliance related to SEFA preparation, including assigning responsibility to personnel with appropriate training in federal award requirements. Management should also implement a documented review process, performed by a knowledgeable individual, to ensure the SEFA is complete, accurate, and compliant with Uniform Guidance prior to submission for audit. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Reached out to HUD Granter, Third Party Accounting Firm and in 2023. Followed up with a briefing from Auditor in 2025 for this audit. Name(s) of the contact person(s) responsible for corrective action: Sharon Maggard Planned completion date for corrective action plan: Completed

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 1224461 (2023-049)

Material Weakness 2023

Commonwealth of the Northern Mariana Islands

MP

Subrecipient Monitoring Procurement, Suspension & Debarment Reporting

Finding No.: 2023-049 AL Program: 97.036 – Disaster Grants – Public Assistance (Presidentially Declared Disasters) COVID-19 97.036 Disaster Grants – Public Assistance (Presidentially Declared Disasters) Area: Reporting Questioned Costs: $-0- Contact Person(s): Patrick Guerrero, Governor’s Authorized...

Finding No.: 2023-049 AL Program: 97.036 – Disaster Grants – Public Assistance (Presidentially Declared Disasters) COVID-19 97.036 Disaster Grants – Public Assistance (Presidentially Declared Disasters) Area: Reporting Questioned Costs: $-0- Contact Person(s): Patrick Guerrero, Governor’s Authorized Rep., PAO Corrective Action Plan: CNMI Public Assistance Office (PAO) agrees with the auditor's finding and conclusion. PAO acknowledges that required FFATA first-tier subaward reports were not submitted to the FFATA Subaward Reporting System (SAM.gov) for FEMA Public Assistance disasters DR-4235-MP, DR-4396-MP, DR-4404-MP, and DR-4511-MP during Fiscal Year 2023. The issue occurred because PAO did not have direct access to the FFATA reporting system and had not established formal written procedures to identify reportable subawards, track reporting deadlines, and ensure timely submission of required reports. In addition, monitoring controls over FFATA reporting requirements were not sufficiently developed to detect and prevent noncompliance. As a result, required reports were not submitted within the prescribed reporting period. The CNMI Public Assistance Office will implement the following corrective actions: • Develop and implement written FFATA reporting policies and procedures that establish responsibilities for identifying reportable subawards, preparing required reports, maintaining supporting documentation, obtaining supervisory review and approval, and documenting report submission. • Establish a centralized tracking log for all FEMA Public Assistance subawards to identify FFATA-reportable awards and monitor reporting deadlines. • Continue coordinating with the appropriate federal and CNMI agencies to obtain access to the FFATA Subaward Reporting System (SAM.gov) or identify an authorized entity responsible for submitting FFATA reports on behalf of the CNMI Public Assistance Office. • Conduct periodic management reviews of subaward activities and reporting requirements to ensure compliance with FFATA reporting deadlines and documentation requirements. PAO has made multiple requests for access to the FFATA reporting system and continues to follow up with the appropriate agencies regarding access and reporting responsibilities. Management has reviewed the audit finding and begun evaluating procedures needed to identify reportable Finding No.: 2023-049, continued AL Program: 97.036 – Disaster Grants – Public Assistance (Presidentially Declared Disasters) COVID-19 97.036 Disaster Grants – Public Assistance (Presidentially Declared Disasters) Area: Reporting Questioned Costs: $-0- Contact Person(s): Patrick Guerrero, Governor’s Authorized Rep., PAO Corrective Action Plan: subawards and track reporting requirements. PAO has initiated efforts to improve grant file organization and documentation management to support future compliance activities. Upon obtaining access to the appropriate reporting system or confirmation of the responsible reporting entity, PAO will review all current and future FEMA Public Assistance subawards for FFATA applicability and ensure required reports are submitted within established deadlines. The implementation of written procedures, supervisory review, and a subaward tracking system will provide ongoing monitoring and accountability to prevent future instances of noncompliance. The proposed completion date reflects the time necessary to obtain system access or establish reporting responsibilities, develop, and implement formal procedures, train responsible personnel, and fully integrate FFATA compliance monitoring into PAO's grant management processes. Proposed Completion Date: September 30, 2027

View Audit 407734

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 1224452 (2023-043)

Material Weakness 2023

Commonwealth of the Northern Mariana Islands

MP

Reporting § 200.303

Finding No.: 2023-043 AL Program: 93.767 – Children’s Health Insurance Program (CHIP) 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 th...

Finding No.: 2023-043 AL Program: 93.767 – Children’s Health Insurance Program (CHIP) 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

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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)

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Finding 1224430 (2023-029)

Material Weakness 2023

Commonwealth of the Northern Mariana Islands

MP

Reporting

Finding No.: 2023-029, continued AL Program: COVID-19 21.023 – Emergency Rental Assistance Program Area: Reporting Questioned Costs: $-0- Contact Person(s): Epiphanio Cabrera, Jr., Grants Administrator, OGM-SC Corrective Action Plan: months after the closing of the fiscal year whereby the expenses s...

Finding No.: 2023-029, continued AL Program: COVID-19 21.023 – Emergency Rental Assistance Program Area: Reporting Questioned Costs: $-0- Contact Person(s): Epiphanio Cabrera, Jr., Grants Administrator, OGM-SC Corrective Action Plan: months after the closing of the fiscal year whereby the expenses stabilized. As such, OGM should not be penalized for the difference in the SF425. OGM did provide the narrative report to EY for that reporting period. Furthermore, the Department of Finance had the responsibility in reporting of this program’s activities; OGM did not have access to the US Treasury portal. This further made it more difficult to catch-up with the reporting of items. Subsequently, US Treasury started requesting for different metrics or evidence to which our office was not prepared because we were operating under a set of understood deliverables, making it again difficult to report succinctly and accurately for the program. OGM was tasked by the former Governor last minute to handle this program because the state housing program did not want to manage this emergency rental assistance program due to the overload in workload brought on by the CDBG-Disaster program. Furthermore, OGM did provide EY with complete listing of expenses that matched the FMIS generated ending fund balance for this business unit. Regarding ERA1, US Treasury accepted the full report inclusive of SF425. For ERA2, a final report has been provided and is under full review. OGM will need to hire more financial analysts to meet the increased demand from programs such as CCERA-type programs. Furthermore, US Treasury has closed and accepted ERA1 reports. CCERA did return $1,746.41, inclusive of 5% interest to US Treasury under invoice # OCAERA0411A under the Collect Delinquent Indebtedness. Proposed Completion Date: Ongoing Condition 2a: The Office of Grants Management (OGM) disagrees with this finding. For ERA1 reports, US Treasury has accepted the final report and has closed all matters pertaining to this grant and this is substantiated by the return of funds amounting to $1,746.41. As noted, reports are very difficult to generate without full access to real-time data and the lack of software. The immense load and pressure to execute welfare assistance can be very overwhelming. I ask that this finding be removed as all reports have been accepted by US Treasury for ERA 1. Proposed Completion Date: Ongoing Finding No.: 2023-029, continued AL Program: COVID-19 21.023 – Emergency Rental Assistance Program Area: Reporting Questioned Costs: $-0- Contact Person(s): Epiphanio Cabrera, Jr., Grants Administrator, OGM-SC Corrective Action Plan: Condition 2b: The Office of Grants Management (OGM) disagrees with this finding. For ERA 2, reports are very difficult to generate without full access to real-time data and the lack of software. The immense load and pressure to execute welfare assistance can be very overwhelming. OGM will need to hire more financial analysts in the future to meet the increased demand from programs such as CCERA-type programs. Additional monitoring controls and systematic filing will need to exist in the future related work to improve reporting requirements. Proposed Completion Date: Ongoing Condition 2c: The Office of Grants Management (OGM) disagrees with this finding. We believe this condition is substantially related to the reporting concerns identified under Condition 2b and reflects the same underlying reporting and documentation challenges. Because the supporting accounting records and narrative reporting requirements are interconnected, the Office respectfully requests consideration of consolidating this condition with Condition 2b to avoid duplication of findings addressing the same underlying issue. Proposed Completion Date: Ongoing

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