Corrective Action Plans

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Statement of condition #2024-001: The Corporation did not furnish HUD with a complete Management Occupancy Review response within 30 days. Comments on the Finding and Each Recommendation: Management should submit a plan to resolve all deficiencies within 30 calendar days of the date of the receipt ...
Statement of condition #2024-001: The Corporation did not furnish HUD with a complete Management Occupancy Review response within 30 days. Comments on the Finding and Each Recommendation: Management should submit a plan to resolve all deficiencies within 30 calendar days of the date of the receipt of the report. Action(s) taken or planned on the finding: No further action is necessary. Management's response was submitted on October 27, 2023.
Statement of condition #2024-001: The Corporation used reserve for replacements funds for a non-approved purpose. Comments on the Finding and Each Recommendation: Management should reimburse the reserve for replacements fund all excess funds withdrew. Action(s) taken or planned on the finding: Man...
Statement of condition #2024-001: The Corporation used reserve for replacements funds for a non-approved purpose. Comments on the Finding and Each Recommendation: Management should reimburse the reserve for replacements fund all excess funds withdrew. Action(s) taken or planned on the finding: Management refunded $2,717 to reserve for replacement account on August 13, 2024.
View Audit 319175 Questioned Costs: $1
Statement of condition #2024-001: The Corporation did not furnish HUD with a complete Management Occupancy Review response within 30 days. Comments on the Finding and Each Recommendation: Management should submit a plan to resolve all deficiencies within 30 calendar days of the date of the receipt ...
Statement of condition #2024-001: The Corporation did not furnish HUD with a complete Management Occupancy Review response within 30 days. Comments on the Finding and Each Recommendation: Management should submit a plan to resolve all deficiencies within 30 calendar days of the date of the receipt of the report. Action(s) taken or planned on the finding: No further action is necessary. Management's response was submitted on October 31, 2023.
Statement of condition #2024-001: The Corporation did not furnish HUD with a complete Management Occupancy Review response within 30 days. Comments on the Finding and Each Recommendation: Management should submit a plan to resolve all deficiencies within 30 calendar days of the date of the receipt ...
Statement of condition #2024-001: The Corporation did not furnish HUD with a complete Management Occupancy Review response within 30 days. Comments on the Finding and Each Recommendation: Management should submit a plan to resolve all deficiencies within 30 calendar days of the date of the receipt of the report. Action(s) taken or planned on the finding: No further action is necessary. Management's response was submitted on October 30, 2023.
Corrective Action Plan: Management will review the required procedures for pass-through entities as listed in 2 CFR 200.332 and implement the procedures accordingly. This will include documented risk assessment and monitoring procedures for all subrecipient of federal awards.
Corrective Action Plan: Management will review the required procedures for pass-through entities as listed in 2 CFR 200.332 and implement the procedures accordingly. This will include documented risk assessment and monitoring procedures for all subrecipient of federal awards.
Federal Program: Coronavirus State and Local Recovery Funds Assistance Listing No. 21.027 Recommendation: Our auditors recommended that the Organization create an internal policy over sub-grant recipient procedures and create effective internal controls and procedures over subrecipient monitoring an...
Federal Program: Coronavirus State and Local Recovery Funds Assistance Listing No. 21.027 Recommendation: Our auditors recommended that the Organization create an internal policy over sub-grant recipient procedures and create effective internal controls and procedures over subrecipient monitoring and tracking that allow for compliance with all applicable Federal laws, regulations, and compliance requirements of various Federal grants Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization has accepted the recommendation and will add language to the existing Grant Funds Tracking Policy and Procedure outlining the Organization’s responsibilities for establishing effective internal controls and procedures over subrecipient monitoring. The updated policy will also include reference to the Information to Provide to Every Subrecipient for Each Subaward form. This form outlines details of the pass-through grant, and subrecipient responsibilities, and will be signed by each subrecipient prior to any pass-through fund disbursement. Also, the Organization will educate supervisors on this policy update at an upcoming training meeting no later than October 31, 2024.
Auditee Response: The Authority will not pay any invoices until the proper documentation of Davis Bacon wages being paid is received from the contractor. The Authority will then be ensured that future payments have the proper certified payroll.
Auditee Response: The Authority will not pay any invoices until the proper documentation of Davis Bacon wages being paid is received from the contractor. The Authority will then be ensured that future payments have the proper certified payroll.
Response and Corrective Action Plan: The District will review current processes for identifying, coding and reporting federal expenditures and implement processes to ensure amounts reported are supported by the District’s general ledger.
Response and Corrective Action Plan: The District will review current processes for identifying, coding and reporting federal expenditures and implement processes to ensure amounts reported are supported by the District’s general ledger.
This finding is due to the Village not having control procedures in place to submit the annual Project and Expenditure Report for the reporting period ended March 31, 2024, accurately or within 30 days of the close of the reporting period. In the future, the Village will have controls in place to en...
This finding is due to the Village not having control procedures in place to submit the annual Project and Expenditure Report for the reporting period ended March 31, 2024, accurately or within 30 days of the close of the reporting period. In the future, the Village will have controls in place to ensure accurate and timely filing of the report. The person responsible for the corrective action is the Village Manager. The anticipated completion date of the corrective action plan is before the end of the 2025 fiscal year. The plan for adherence is the Council will build a timeline for preparation and completion of the report to ensure timely and accurate filing.
This finding is due to the Village not having formal written policies in place required by Uniform Guidance. The Village is now aware that these policies are required and will adopt all necessary policies. The Village does not believe that there were any actual nonallowable costs or transactions bec...
This finding is due to the Village not having formal written policies in place required by Uniform Guidance. The Village is now aware that these policies are required and will adopt all necessary policies. The Village does not believe that there were any actual nonallowable costs or transactions because of the lack of written policies as required by Uniform Guidance. The Village will adopt all necessary policies to be in compliance. The person responsible for the corrective action is the Village President. The anticipated completion date of the corrective action plan is before the end of the 2025 fiscal year. The plan for adherence is the Council will review all proposed policies and adopt them, the Council will also monitor any changes to policy requirements to ensure that they are in compliance in the future.
Finding 485172 (2024-002)
Significant Deficiency 2024
Finding 2024-002 Personnel Responsible for Corrective Action: Cathy Gorrell, Registrar Anticipated Completion Date: September 30, 2024 Corrective Action Plan: The Office of the Registrar recognizes the systematic programming of a pseudo academic program after a pseudo course has been added with a ...
Finding 2024-002 Personnel Responsible for Corrective Action: Cathy Gorrell, Registrar Anticipated Completion Date: September 30, 2024 Corrective Action Plan: The Office of the Registrar recognizes the systematic programming of a pseudo academic program after a pseudo course has been added with a future date after the student’s current program has been inactivated or graduated. This process has been at the request of the Office of Student Accounts for the graduation fee. The Office of the Registrar will work with the Office of Student Accounts to move to the system Graduation Application process rather than the customized and manual process of pseudo courses. Further, the Office of the Registrar has increased its data quality checks on the pseudo programs and courses. In conjunction, this should eliminate the reporting of active programs when the student has graduated.
Recommendation: Our auditors recommended the Organization to review internal controls in regards to the determination, recording, and monitoring of the sliding fee process to ensure that appropriate sliding fee rates/categories are utilized for each sliding fee encounter and that the support for the...
Recommendation: Our auditors recommended the Organization to review internal controls in regards to the determination, recording, and monitoring of the sliding fee process to ensure that appropriate sliding fee rates/categories are utilized for each sliding fee encounter and that the support for the sliding fee discounts is retained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization recognizes the deficiency of internal controls regarding determination, recording, and monitoring of the sliding fee process from application through adjustment. The Organization has acknowledged that along with our Finance Team being new to the position for all of 2023 along with the realization that our electronic medical record was making an automatic adjustment on the Federal Poverty Level. This automatic adjustment issue has been resolved. We also reviewed the monthly adjustments and have implemented a monthly oversight process to review adjustments made to patient accounts. If the U.S. Department of Health and Human Services has questions regarding this plan, please call Tricia Lippert, Comptroller at 970-327-0537.
Finding #2024-001 Comments on Findings and Recommendation: During the year ended March 31, 2024, deposits to the reserve for replacements account were $236 less than the required amount. Management should transfer $236 from the operating account to the reserve for replacements account. Action(s) tak...
Finding #2024-001 Comments on Findings and Recommendation: During the year ended March 31, 2024, deposits to the reserve for replacements account were $236 less than the required amount. Management should transfer $236 from the operating account to the reserve for replacements account. Action(s) taken or planned on the finding: Management concurs with the finding and recommendation.
View Audit 310491 Questioned Costs: $1
Criteria: Regulations require that the Organization must minimize the time elapsing between the transfer of funds from the Federal agency or the pass-through entity and the disbursement of funds by the recipient or subrecipient, to comply with 2 CFR § 200.305(b). Condition: The 93.493 grant is a rei...
Criteria: Regulations require that the Organization must minimize the time elapsing between the transfer of funds from the Federal agency or the pass-through entity and the disbursement of funds by the recipient or subrecipient, to comply with 2 CFR § 200.305(b). Condition: The 93.493 grant is a reimbursement type grant, subject to an approved preliminary expense budget, as the grant agreement does not specifically indicate that it is an advance-type grant. As such, all supported expenses should be recognized before applying for funding or expended within a “reasonable” period subsequent to receipt of funds. Effect: A portion of reimbursement funds were received prior to supporting expenditures being recognized, and funds were not subsequently expended within a “reasonable” period. Questioned Costs: No questioned costs were identified as a result of our procedures. Cause: The Organization applied for grant drawdowns based on projections and expended funds greater than 30 days beyond receipt, resulting in expenditures occurring prior to being identified as qualified expenditures. Recommendation: The Organization should review internal policies related to drawdowns to ensure that drawdowns occur in compliance with Uniform Guidance. Views of Responsible Officials: We agree with finding and will follow prescribed recommendation
Finding No.: 2023-050 AL Program: 97.036 – Disaster Grants – Public Assistance (Presidentially Declared Disasters) COVID-19 97.036 Disaster Grants – Public Assistance (Presidentially Declared Disasters) Area: Subrecipient Monitoring Questioned Costs: $7,350,898 Contact Person(s): Patrick Guerrero, G...
Finding No.: 2023-050 AL Program: 97.036 – Disaster Grants – Public Assistance (Presidentially Declared Disasters) COVID-19 97.036 Disaster Grants – Public Assistance (Presidentially Declared Disasters) Area: Subrecipient Monitoring Questioned Costs: $7,350,898 Contact Person(s): Patrick Guerrero, Governor’s Authorized Rep., PAO Corrective Action Plan: Condition 1-2: The CNMI Public Assistance Office (PAO) acknowledges and agrees with the compliance deficiencies identified regarding subrecipient monitoring and documentation requirements under 2 CFR §200.332 and has developed corrective actions to address these weaknesses. However, PAO respectfully disagrees with the questioned cost determination. The finding relates to deficiencies in monitoring procedures and documentation rather than the allowability, eligibility, or support for the underlying expenditures. The expenditures identified were associated Finding No.: 2023-050, continued AL Program: 97.036 – Disaster Grants – Public Assistance (Presidentially Declared Disasters) COVID-19 97.036 Disaster Grants – Public Assistance (Presidentially Declared Disasters) Area: Subrecipient Monitoring Questioned Costs: $7,350,898 Contact Person(s): Patrick Guerrero, Governor’s Authorized Rep., PAO Corrective Action Plan: with FEMA-approved projects and no specific costs were identified as unallowable, unsupported, outside the approved scope of work, or otherwise ineligible for federal participation. While PAO recognizes that monitoring documentation was insufficient to demonstrate compliance with subrecipient monitoring requirements, PAO believes the appropriate classification is a compliance finding without questioned costs. Accordingly, PAO respectfully requests consideration that questioned costs associated with this finding be reduced to $0. Subrecipient monitoring activities were historically performed alongside project management responsibilities and were not supported by a centralized tracking system. As the number and complexity of Public Assistance projects increased, monitoring activities, documentation, and audit follow-up procedures were not consistently performed or documented. In addition, delays in the completion of CNMI-wide Single Audits and limited responsiveness from certain subrecipients affected PAO's ability to obtain timely financial reports, audit reports, and supporting documentation. PAO is implementing corrective actions in phases to establish a sustainable and documented subrecipient monitoring framework. Phase I – Immediate Actions (Completed/In Progress) • Responsibility for subrecipient monitoring activities has been assigned to the Compliance Manager and Risk Officer to provide dedicated oversight independent of project management functions. • PAO has begun conducting biannual subrecipient risk assessments and documenting risk ratings for active subrecipients. • For nonresponsive subrecipients, PAO will maintain documentation of all attempts to obtain required information and will perform additional follow-up as appropriate. These records will be maintained as evidence of monitoring activities and due diligence. • Standardized monitoring checklists, risk assessment forms, audit review checklists, and follow-up procedures are being developed to improve consistency and documentation. Finding No.: 2023-050, continued AL Program: 97.036 – Disaster Grants – Public Assistance (Presidentially Declared Disasters) COVID-19 97.036 Disaster Grants – Public Assistance (Presidentially Declared Disasters) Area: Subrecipient Monitoring Questioned Costs: $7,350,898 Contact Person(s): Patrick Guerrero, Governor’s Authorized Rep., PAO Corrective Action Plan: • PAO will initiate a centralized tracking process using existing tools, including Excel spreadsheets and shared electronic files, to monitor: o Subrecipient risk assessments. o Financial and performance report submissions. o Single Audit report status. o Monitoring activities performed. o Corrective actions and follow-up requirements. o PAO will continue to document requests for financial reports, audit reports, risk assessment information, and other monitoring documentation. Supporting records, including request emails, follow-up correspondence, meeting invitations, telephone call logs, and responses received from subrecipients, will be retained to demonstrate monitoring efforts and follow-up actions. Phase II – Process Formalization • PAO will finalize written updates to the Subrecipient Monitoring Procedures establishing requirements for: o Risk assessments. o Monitoring frequency. o Financial and performance report reviews. o Single Audit follow-up. o Documentation retention. o Escalation procedures for nonresponsive subrecipients; and o Management review. • PAO will establish a formal Subrecipient Monitoring Register that consolidates monitoring activities, risk ratings, audit status, corrective actions, compliance deadlines, and follow-up actions. • Quarterly management reviews will be implemented to monitor completion of required monitoring activities, assess high-risk subrecipients, and address outstanding compliance issues. • PAO will establish formal procedures to review subrecipient Single Audit reports, verify reporting of FEMA-funded expenditures on the SEFA, document audit reviews, and track corrective actions resulting from audit findings. Finding No.: 2023-050, continued AL Program: 97.036 – Disaster Grants – Public Assistance (Presidentially Declared Disasters) COVID-19 97.036 Disaster Grants – Public Assistance (Presidentially Declared Disasters) Area: Subrecipient Monitoring Questioned Costs: $7,350,898 Contact Person(s): Patrick Guerrero, Governor’s Authorized Rep., PAO Corrective Action Plan: Phase III – Compliance & Monitoring Portal (Future Implementation) • Upon acquisition and implementation of Microsoft 365 resources, PAO will develop a centralized Compliance & Monitoring Portal to serve as the official repository for subrecipient monitoring records. • The portal will include electronic tracking of risk assessments, monitoring activities, audit findings, corrective actions, reporting deadlines, communication logs, and supporting documentation. • Automated reminders, management dashboards, workflow tracking, and document retention controls will be incorporated to strengthen oversight and improve monitoring documentation. These corrective actions will establish a documented, risk-based monitoring framework that improves oversight of subrecipients, strengthens documentation and audit trails, formalizes monitoring procedures, enhances accountability through dedicated compliance personnel, and improves compliance with the requirements of 2 CFR §200.332. Phase I – Ongoing Phase II – June 30, 2027 Phase III – Upon acquisition and implementation of Microsoft 365 resources and completion of staff training. Proposed Completion Date: June 30, 2027 (For Phase II). Phase I & II is Ongoing.
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
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
Finding No.: 2023-046 AL Program: 93.778 – Medical Assistance Program (Medicaid; Title XIX) Area: Special Tests and Provisions – ADP Risk Analysis and System Security Review Questioned Costs: Undeterminable Contact Person(s): George J. Cruz, Medicaid Director Corrective Action Plan: The Commonwealth...
Finding No.: 2023-046 AL Program: 93.778 – Medical Assistance Program (Medicaid; Title XIX) Area: Special Tests and Provisions – ADP Risk Analysis and System Security Review Questioned Costs: Undeterminable Contact Person(s): George J. Cruz, Medicaid Director Corrective Action Plan: The Commonwealth Medicaid Agency (CMA) respectfully disagrees with the auditor’s finding. CMA provided documentation supporting its ADP security and risk management activities and does not believe the finding fully reflects the Agency's efforts to comply with applicable requirements. CMA maintains policies and procedures governing ADP security and risk management and has dedicated personnel responsible for conducting and overseeing security assessments. To further strengthen compliance and documentation practices, CMA continues to evaluate and enhance its policies, procedures, and internal controls related to ADP security reviews, risk assessments, and record retention. The Agency has completed an ADP security assessment and maintains supporting policies and procedures, which are available upon request. Proposed Completion Date: Completed
Finding No.: 2023-042 AL Program: 93.489/93.575/93.596 – CCDF Cluster COVID-19 93.489/93.575/93.596 CCDF Cluster Area: Special Tests and Provisions – Health and Safety Requirements Questioned Costs: $-0- Contact Person(s): Roselle Teregeyo, CCDF Co-Administrator/Accountant Corrective Action Plan: Th...
Finding No.: 2023-042 AL Program: 93.489/93.575/93.596 – CCDF Cluster COVID-19 93.489/93.575/93.596 CCDF Cluster Area: Special Tests and Provisions – Health and Safety Requirements Questioned Costs: $-0- Contact Person(s): Roselle Teregeyo, CCDF Co-Administrator/Accountant Corrective Action Plan: The CNMI CCDF Program agrees with this finding. Two types of providers were tested, Licensed center-based programs and license-exempt home-based programs. Finding No.: 2023-042, continued AL Program: 93.489/93.575/93.596 – CCDF Cluster COVID-19 93.489/93.575/93.596 CCDF Cluster Area: Special Tests and Provisions – Health and Safety Requirements Questioned Costs: $-0- Contact Person(s): Roselle Teregeyo, CCDF Co-Administrator/Accountant Corrective Action Plan: For the Licensed center-based program, the Unannounced visit was conducted on December 27, 2022, and the renewal (announced) visit was conducted on May 17, 2023. Prior to the May visit, the CCDF program was in a transition period in the full implementation of the Reach Higher CNMI Monitoring Check In visits. Before May 2023, visits were conducted but the reports were not reviewed nor signed off by the CCDF Director. Beginning May, as evidenced by the May 17, 2023 visit, all check in visits were submitted to the CCDF Office and these are reviewed and signed off by the CCDF Director. Similarly, for home-based programs, prior to October 2023, all check in visits were not submitted to the CCDF Director for reviewed and signature. However, beginning October 1, 2023, home based programs check in visits reports are now submitted to the CCDF Office for the Director’s review and sign off. The following corrective actions have been implemented by the CNMI CCDF Program to prevent recurrence: • The CCDF Director or designee will review and affix his/her signature on all CCDF provider check in visit reports to ensure oversight, accuracy, and compliance with CCDF monitoring requirements. • All check in visit reports have been submitted to the CCDF Office for review and signature by the CCDF Director beginning May 17, 2023 for licensed center-based programs and October 1, 2023 for license-exempt home-based programs. This process has been consistently followed since those dates. • Monthly meetings will include reminders to all consultants regarding the required submission and review procedure to ensure continued adherence. Procedure fully implemented since May 2023 and October 1, 2023, for licensed center-based programs and licensed-exempt home-based programs respectively. Proposed Completion Date: Completed
Finding No.: 2023-041 AL Program: 93.489/93.575/93.596 – CCDF Cluster COVID-19 93.489/93.575/93.596 CCDF Cluster Area: Period of Performance Questioned Costs: $95,367 Contact Person(s): Roselle Teregeyo, CCDF Co-Administrator/Accountant Corrective Action Plan: Condition 1 & 3a: The CNMI CCDF Program...
Finding No.: 2023-041 AL Program: 93.489/93.575/93.596 – CCDF Cluster COVID-19 93.489/93.575/93.596 CCDF Cluster Area: Period of Performance Questioned Costs: $95,367 Contact Person(s): Roselle Teregeyo, CCDF Co-Administrator/Accountant Corrective Action Plan: Condition 1 & 3a: The CNMI CCDF Program agrees with this finding. To strengthen oversight and ensure adequate accountability over Federal awards, the CNMI CCDF Program has implemented a filing system Finding No.: 2023-041, continued AL Program: 93.489/93.575/93.596 – CCDF Cluster COVID-19 93.489/93.575/93.596 CCDF Cluster Area: Period of Performance Questioned Costs: $95,367 Contact Person(s): Roselle Teregeyo, CCDF Co-Administrator/Accountant Corrective Action Plan: where all documents relating to a federal award are properly maintained and labeled for accessibility. This system became effective on October 1, 2025. Proposed Completion Date: Completed Condition 2 & 3b: The CNMI CCDF Program agrees with this finding and acknowledges the need to strengthen internal controls to ensure that all expenditures are cleared by the bank before the end of the liquidation period. The CCDF Program will coordinate with the Department of Finance (DOF) Financial Services Division regarding the establishment of a monitoring log that tracks all checks issued and cleared by vendor and office. Once this log is implemented, the CCDF Program will request regular copies to allow responsible staff to verify whether payments have cleared and to follow up with vendors as needed to ensure timely bank reconciliation. To streamline payment processing and enhance compliance with federal cash management requirements, the CCDF Program is exploring a transition to a fully ACH based payment system. Moving to electronic payments will reduce delays associated with paper checks, improve tracking and reconciliation, and strengthen internal controls over disbursements. This corrective action is currently in progress. The CCDF Program anticipates full implementation of the monitoring process and/or ACH transition by October 1, 2026. Proposed Completion Date: October 1, 2026
Finding No.: 2023-040 AL Program: 93.489/93.575/93.596 – CCDF Cluster COVID-19 93.489/93.575/93.596 CCDF Cluster Area: Eligibility Questioned Costs: $12,490 Contact Person(s): Roselle Teregeyo, CCDF Co-Administrator/Accountant Corrective Action Plan: Condition 1: The CNMI CCDF Program respectfully d...
Finding No.: 2023-040 AL Program: 93.489/93.575/93.596 – CCDF Cluster COVID-19 93.489/93.575/93.596 CCDF Cluster Area: Eligibility Questioned Costs: $12,490 Contact Person(s): Roselle Teregeyo, CCDF Co-Administrator/Accountant Corrective Action Plan: Condition 1: The CNMI CCDF Program respectfully disagrees with this finding. During the audit period, the CNMI CCDF State Plan for FY 2022–2024, Section 3.1.8, Employment Requirements, permitted the acceptance of a USCIS receipt notice (WAC receipt number) as documentation of employment authorization when applicable. Specifically, the State Plan states that a USCIS receipt indicating a WAC number may be requested when necessary and that additional documentation may be requested to identify applicants who meet the long-term employment criteria. Based on the policies in effect during the certification periods cited above, the CCDF Program determined eligibility using the documentation requirements established in the approved CCDF State Plan. Therefore, the questioned costs associated with these cases were incurred in accordance with the Program's established eligibility policies at that time. The issue occurred during a period of increased application volume when eligibility determinations and document reviews were processed manually. In addition, the State Plan language did not explicitly state that USCIS receipt notices would not be accepted as evidence of employment authorization, which contributed to differing interpretations of acceptable documentation requirements. Although the Program maintains that the cited cases were processed in accordance with the policies in effect during the audit period, the CCDF Program has strengthened its documentation requirements to address concerns raised in prior audits. Effective February 1, 2026, the CCDF Program no longer accepts USCIS employment authorization receipt notices as proof of work authorization. This policy change was implemented through CCDF Memorandum Subsidy FY26 No. 1 and serves as a corrective action to ensure consistency and strengthen compliance with employment verification requirements. Program staff have been notified of the revised policy and eligibility determinations will now require approved work authorization documentation rather than receipt notices. Proposed Completion Date: Completed Finding No.: 2023-040, continued AL Program: 93.489/93.575/93.596 – CCDF Cluster COVID-19 93.489/93.575/93.596 CCDF Cluster Area: Eligibility Questioned Costs: $12,490 Contact Person(s): Roselle Teregeyo, CCDF Co-Administrator/Accountant Corrective Action Plan: Condition 2: The CNMI CCDF Program agrees with this finding. During the audit period, provider payments were processed manually for approximately 1,101 children each month. The manual calculation and entry of subsidy amounts increased the risk of human error, resulting in isolated instances of overpayments and underpayments. To strengthen internal controls and reduce the risk of payment errors, the CCDF Program has been working with a contracted system developer since late 2025 to implement an automated subsidy management system. Once operational, the system will automatically calculate and assign payment amounts based on eligibility factors, including the child's age and approved level of care, thereby reducing reliance on manual calculations. The CCDF Program will continue monitoring payment processes and implementing automated controls to improve payment accuracy and strengthen compliance with program requirements. The Program will initiate recovery of the $390 overpayment identified in Case ID 3040 B through adjustments to provider payments scheduled for August and September 2026. For the underpayments identified in Case IDs 3275 B, 3275 C, and 3600 C, the Program will process payment adjustments and issue the respective amounts owed through the August 2026 provider payment cycle. Proposed Completion Date: September 2026
Finding No.: 2023-038 AL Program: COVID-19 84.425H – Education Stabilization Fund – Governors (Outlying Areas) (ESF-Governor) Area: Subrecipient Monitoring Questioned Costs: $6,641,757 Contact Person(s): Tracy B. Norita, Secretary of Finance Corrective Action Plan: Condition 1-2: The CNMI Department...
Finding No.: 2023-038 AL Program: COVID-19 84.425H – Education Stabilization Fund – Governors (Outlying Areas) (ESF-Governor) Area: Subrecipient Monitoring Questioned Costs: $6,641,757 Contact Person(s): Tracy B. Norita, Secretary of Finance Corrective Action Plan: Condition 1-2: The CNMI Department of Finance agrees with this finding. CNMI submitted risk assessment and monitoring compliance documentation to the auditor on February 26, 2026, after the agreed February 19, 2026, deadline, resulting in evidence timing deficiency. CNMI established Standard Operating Procedures for subrecipient monitoring effective October 28, 2026. Management will implement standardized file labeling and retention procedures in accordance with the SOP so that each subrecipient file contains the subrecipient determination, required subaward clauses, the unique entity identifier, documented SAM.gov exclusion checks, and verification of audit requirements. In alignment with 2 CFR §200.332, CNMI will review financial and performance reports quarterly, conduct an annual performance assessment using a standardized checklist (updated annually or upon project completion), maintain documentation of all monitoring activities, and verify audit status for entities subject to the Single Audit Act. The risk assessment and monitoring compliance documentation for this grant is available to the auditor upon request. Proposed Completion Date: Completed
Finding No.: 2023-037 AL Program: COVID-19 84.425H – Education Stabilization Fund – Governors (Outlying Areas) (ESF-Governor) Area: Reporting Questioned Costs: $-0- Contact Person(s): Tracy B. Norita, Secretary of Finance Corrective Action Plan: Condition 1-2: The CNMI Department of Finance agrees w...
Finding No.: 2023-037 AL Program: COVID-19 84.425H – Education Stabilization Fund – Governors (Outlying Areas) (ESF-Governor) Area: Reporting Questioned Costs: $-0- Contact Person(s): Tracy B. Norita, Secretary of Finance Corrective Action Plan: Condition 1-2: The CNMI Department of Finance agrees with this finding. CNMI acknowledges that, while the ED annual performance report (APR) for FY2023 was submitted, the underlying accounting records supporting the reported data were not included, and CNMI was not fully aware of the FFATA subaward reporting requirement for this program. To address these deficiencies, CNMI will (1) ensure that all future APR submissions include the complete supporting accounting documentation and that such documentation is retained and made available to auditors upon request, and (2) incorporate FFATA/FSRS reporting requirements into the CNMI Internal Control SOP for federal grants and implement procedures to verify timely submission of all first tier subawards of $30,000 or more. Proposed Completion Date: Ongoing
Finding No.: 2023-035 AL Program: COVID-19 84.425H – Education Stabilization Fund – Governors (Outlying Areas) (ESF-Governor) Area: Allowable Costs/Cost Principles Questioned Costs: $-0- Contact Person(s): Tracy B. Norita, Secretary of Finance Corrective Action Plan: The CNMI Department of Finance a...
Finding No.: 2023-035 AL Program: COVID-19 84.425H – Education Stabilization Fund – Governors (Outlying Areas) (ESF-Governor) Area: Allowable Costs/Cost Principles Questioned Costs: $-0- Contact Person(s): Tracy B. Norita, Secretary of Finance Corrective Action Plan: The CNMI Department of Finance agrees with this finding. While approval controls are implemented within the Munis financial system and, since the FY2022 system migration, all federal expenditure approvals have been processed in Munis, the supporting evidence was provided to the auditors on April 9, 2026, after the agreed documentation deadline of February 19, 2026, resulting in evidence timing deficiency. CNMI established a Standard Operating Procedure for Internal Control for Federal Grants Management on May 1, 2025, to govern these processes, and management will ensure that going forward the expenditure workflow, not solely the journal entry workflow, is attached to documentation submitted with audit requests and will be included in the required documents checklist; documents of approval are available upon request. Proposed Completion Date: Completed
Finding No.: 2023-034 AL Program: COVID-19 21.027 - Coronavirus State and Local Fiscal Recovery Funds Area: Subrecipient Monitoring Questioned Costs: $15,640,541 Contact Person(s): Tracy B. Norita, Secretary of Finance Corrective Action Plan: Condition 1-3: The CNMI Department of Finance agrees with...
Finding No.: 2023-034 AL Program: COVID-19 21.027 - Coronavirus State and Local Fiscal Recovery Funds Area: Subrecipient Monitoring Questioned Costs: $15,640,541 Contact Person(s): Tracy B. Norita, Secretary of Finance Corrective Action Plan: Condition 1-3: The CNMI Department of Finance agrees with this finding. During FY 2023, the Department of Finance became aware that existing practices for subrecipient monitoring did not fully meet federal requirements under 2 CFR 200.331–200.332. DOF began implementing corrective actions in the latter part of FY 2023 and continued strengthening procedures throughout FY 2024, including improvements in documentation, SAM.gov verification, and basic risk assessment elements. In response to these identified gaps, the CNMI formally adopted comprehensive Subrecipient Monitoring Policies and Procedures effective October 28, 2025, which fully incorporate federal pass through entity requirements and include standardized processes, templates, monitoring tools, and clear definitions. These procedures were not applied retroactively; however, they are fully in place for FY 2025 and ongoing operations. Finding No.: 2023-034, continued AL Program: COVID-19 21.027 - Coronavirus State and Local Fiscal Recovery Funds Area: Subrecipient Monitoring Questioned Costs: $15,640,541 Contact Person(s): Tracy B. Norita, Secretary of Finance Corrective Action Plan: As a result, while we anticipate partial improvement and reduced findings for FY 2024 due to incremental implementation of best practices, we do not expect subrecipient monitoring findings beginning in FY 2025, as the adopted SOP directly addresses all elements identified in the FY 2023 audit finding. Proposed Completion Date: Ongoing
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