Corrective Action Plans

Finding 1168916 (2022-003)

Material Weakness 2022

Weld Seattle

WA

Procurement, Suspension & Debarment Subrecipient Monitoring Material Weakness § 200.320

Management agrees with the finding presented by the audit. Management has taken corrective actions to meet this standard. The Organization has taken corrective actions to meet this standard for FY23. These actions include the Organization's implementation of a procurement policy with multiple levels...

Management agrees with the finding presented by the audit. Management has taken corrective actions to meet this standard. The Organization has taken corrective actions to meet this standard for FY23. These actions include the Organization's implementation of a procurement policy with multiple levels of review. All purchases greater than or equal to $30,000 must receive three separate bids from outside vendors. Once the bids are received, the Executive Director will review and present the bids to the Board. The Board will approve the bid that is the most favorable purchase option for the Organization. The finance department will retain all bids received. Additionally, all purchases less than $30,000 that are consistent with the budgeted expenses for the year may require review and signature approval at the discretion of the Executive Director. Employees at the Director level have purchasing authority up to $5,000 and are authorized credit card holders. Employees who are below the Director level and are authorized card holders have purchasing authority up to $1,000. Any purchases greater than the $1,000 limit are required to have approval by their immediate supervisor before the purchase can be made. Once a purchase is made, regardless of the dollar amount, the procurement form must be submitted, with the respective receipt or invoice, to the finance department for processing.

View Audit 381373

Finding 1168834 (2022-005)

Material Weakness 2022

Snohomish County Food Bank Coalition

WA

Subrecipient Monitoring § 200.334

Corrective Action: Snohomish County Food Bank Coalition will implement a formal document retention policy to ensure source documents are retained in accordance with the requirements of the Uniform Guidance. Anticipated Completion Date: December 31, 2025

View Audit 381040

Finding 1168524 (2022-002)

Material Weakness 2022

The County of Butler

MO

Subrecipient Monitoring Allowable Costs / Cost Principles Material Weakness

U.S. Department of Treasury - Coronavirus State and Local Fiscal Recovery Effort Recommendation: We recommend the County review federal guidelines to ensure that reports are identified to allow proper and timely submission. Explanation of disagreement with audit finding: There is no disagreement wit...

U.S. Department of Treasury - Coronavirus State and Local Fiscal Recovery Effort Recommendation: We recommend the County review federal guidelines to ensure that reports are identified to allow proper and timely submission. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County agrees and is developing a process to ensure reports are prepared and submitted. Name(s) of the contact person(s) responsible for corrective action: Donna Hillis, County Clerk Planned completion date for corrective action plan: December 31, 2025

View Audit 380345

Finding 1166164 (2022-001)

Material Weakness 2022

City of Watertown

MA

Procurement, Suspension & Debarment Subrecipient Monitoring Allowable Costs / Cost Principles

Re: Corrective Action Plan - Audit Finding 2022-01 -Documentation of Policies and Procedures over Federal Awards Planned Corrective Action: The District will develop and formally adopt comprehensive written policies and procedures compliant with 2 CFR Part 200, including allowability of costs, procu...

Re: Corrective Action Plan - Audit Finding 2022-01 -Documentation of Policies and Procedures over Federal Awards Planned Corrective Action: The District will develop and formally adopt comprehensive written policies and procedures compliant with 2 CFR Part 200, including allowability of costs, procurement, conflicts of interest, cash management, travel, time and effort, inventory management, and record retention. All procedures will be consolidated into a Federal Grants Procedures Manual, approved by leadership, and reviewed annually. Relevant staff will receive training. Planned Implementation Date of Corrective Action: Already following corrective action Person Responsible for Corrective Action: Lisa Gibbons; Director of Finance & Operations ___Lisa Gibbons__________________________ Signature

View Audit 377065

Finding 1165300 (2022-003)

Material Weakness 2022

Spatial Informatics Group Natural Assets Laboratory

CA

Allowable Costs / Cost Principles Procurement, Suspension & Debarment Subrecipient Monitoring § 200.318 § 200.319

2022-003 – Procurement Documentation Planned Corrective Action(s): SIG-NAL will strengthen its procurement controls by fully implementing the updated Procurement Policy and Standard Operating Procedure adopted in 2025. Standardized procurement documentation templates will be developed, including che...

2022-003 – Procurement Documentation Planned Corrective Action(s): SIG-NAL will strengthen its procurement controls by fully implementing the updated Procurement Policy and Standard Operating Procedure adopted in 2025. Standardized procurement documentation templates will be developed, including checklists for method of procurement, contractor selection, cost/price analysis, and justification, and will be used for all purchasing actions. The organization will require that all procurement records are completed and retained in accordance with 2 CFR §§ 200.318–320. Anticipated Completion Date ● April 2026 Responsible Party ● Director of Operations, with support from the Finance Team and Executive Director

View Audit 375849

Finding 1165299 (2022-002)

Material Weakness 2022

Spatial Informatics Group Natural Assets Laboratory

CA

Subrecipient Monitoring Allowable Costs / Cost Principles Material Weakness § 200.303 § 200.328 § 200.400 § 200.430

Planned Corrective Action(s): SIG-NAL will enhance internal controls by implementing formal review and approval processes for payroll, expenses, and financial reporting. The organization will require documented evidence (digital or written) of all reviews and approvals and will maintain these record...

Planned Corrective Action(s): SIG-NAL will enhance internal controls by implementing formal review and approval processes for payroll, expenses, and financial reporting. The organization will require documented evidence (digital or written) of all reviews and approvals and will maintain these records in a standardized, centralized system. The Finance Team will ensure that all controls are performed and documented in accordance with 2 CFR Part 200 requirements. Updated internal control policies and procedures adopted in 2025 address these requirements and are being fully implemented. Anticipated Completion Date ● March 2026 Responsible Party ● Director of Operations, with support from the Finance Team and Executive Director

View Audit 375849

Finding 1164212 (2022-001)

Material Weakness 2022

County of Belknap, New Hampshire

NH

Subrecipient Monitoring Allowable Costs / Cost Principles Procurement, Suspension & Debarment

Planned Corrective Action: A Uniform Guidance policy and Procedure document has been adopted. Planned Implementation Date of Corrective Action: The policy was effective 03/21/2025. Person Responsible for Corrective Action: Finance Director

View Audit 373506

Finding 1162282 (2022-006)

Material Weakness 2022

Round Valley Indian Tribes

CA

Questioned Costs Cash Management Subrecipient Monitoring

The Tribes, in collaboration with the Interim CFO, will review cash flow projection and monitoring processes to strengthen management of operating and grant funds. The Tribes will obtain external funding, as needed, to meet general fund and reimbursement grant cash needs and to reimburse advance-fun...

The Tribes, in collaboration with the Interim CFO, will review cash flow projection and monitoring processes to strengthen management of operating and grant funds. The Tribes will obtain external funding, as needed, to meet general fund and reimbursement grant cash needs and to reimburse advance-funded grants for any interfund borrowing incurred. General fund budgets will be evaluated to ensure adequate cash is available for planned expenditures, and procedures will be enhanced to improve the timeliness of billing and collection for reimbursement-based grants. James Russ, Tribal Business Administrator, Wendy Wilson, Interim CFO and Sonia Horne, Grants and Contracts Accountant December 31, 2025

View Audit 372097 Questioned Costs: $1

Finding 1162223 (2022-005)

Material Weakness 2022

Northeast Iowa Workforce Development Board

IA

Subrecipient Monitoring

Policies have already been updated, and risk assessments have been completed for subsequent years.

View Audit 372030

Finding 1162222 (2022-004)

Material Weakness 2022

Northeast Iowa Workforce Development Board

IA

Subrecipient Monitoring

Going forward, new subawards and pass thru grant agreements will have elements specified in the respective agreement as required by Uniform Guidance, Part 200.332 and WIOA. We plan to implement these changes January 1, 2026.

View Audit 372030

Finding 1162220 (2022-002)

Material Weakness 2022

Northeast Iowa Workforce Development Board

IA

Allowable Costs / Cost Principles Eligibility Internal Control / Segregation of Duties

The Northeast Iowa Workforce Development Area acknowledges the finding. Since the period under review, a new Title I service provider has been implemented, and multiple corrective measures have been established to strengthen eligibility determination and documentation. Eligibility checklists and sta...

The Northeast Iowa Workforce Development Area acknowledges the finding. Since the period under review, a new Title I service provider has been implemented, and multiple corrective measures have been established to strengthen eligibility determination and documentation. Eligibility checklists and standardized enrollment packets are now required for each program. In addition, the new service provider has instituted a quality assurance process, with two directors conducting case file reviews across the local area. The NEIWDB has hired a compliance specialist to provide oversight, including ongoing, quarterly, and annual monitoring of eligibility and documentation. Title I staff utilize IowaWORKS reports and alerts to support compliance, and regular monthly technical assistance sessions, statewide trainings, and structured onboarding were provided to the new service provider. These measures were implemented beginning July 1, 2024 and are ongoing. The compliance specialist will report monitoring results to the NEIWDB to ensure accountability and corrective follow-up where needed. The Northeast Iowa Local Area believe these actions fully address the issue and will prevent recurrence in future program years.

View Audit 372030

Finding 1162219 (2022-001)

Material Weakness 2022

Northeast Iowa Workforce Development Board

IA

Matching / Level of Effort / Earmarking Subrecipient Monitoring Reporting

The Northeast Iowa Workforce Development Area acknowledges the finding. Since the program year was reviewed, the State of Iowa has received a waiver allowing a 50% Out-of-School Youth and 50% In-School Youth expenditure split, which the Northeast Iowa LWDA has adopted. In addition, a new Title I ser...

The Northeast Iowa Workforce Development Area acknowledges the finding. Since the program year was reviewed, the State of Iowa has received a waiver allowing a 50% Out-of-School Youth and 50% In-School Youth expenditure split, which the Northeast Iowa LWDA has adopted. In addition, a new Title I service provider is in place, and procedures are being implemented to ensure compliance with the current expenditure requirements. LWDA staff will conduct quarterly reviews of youth expenditures and require regular reporting from the service provider to verify adherence.

View Audit 372030

Finding 1161329 (2022-003)

Material Weakness 2022

COUNTY OF NEWTON

TX

Internal Control / Segregation of Duties Subrecipient Monitoring Reporting § 200.512

The Commissioner’s of the County of Newton, Texas has reviewed the finding indicated as 2022-003 and agree with the finding. The Commissioner’s have adopted controls, and employed external accounting support, to insure that the County will comply in all material respects with its reporting requireme...

The Commissioner’s of the County of Newton, Texas has reviewed the finding indicated as 2022-003 and agree with the finding. The Commissioner’s have adopted controls, and employed external accounting support, to insure that the County will comply in all material respects with its reporting requirements as per the Uniform Guidance 2 CFR 200. Anticipated Completion Date: September 30, 2025 Responsible Parties: Sherry Moore, County Auditor and Commissioners

View Audit 371223

Finding 1161328 (2022-002)

Material Weakness 2022

COUNTY OF NEWTON

TX

Subrecipient Monitoring Cash Management Internal Control / Segregation of Duties § 200.512

The County will implement procedures and coordinate with outside grant management sources to ensure all grant documentation is received, approved, and reconciled to the general ledger prior to submitting requests for reimbursement. The Commissioners will ensure adequate training is provided. Anticip...

The County will implement procedures and coordinate with outside grant management sources to ensure all grant documentation is received, approved, and reconciled to the general ledger prior to submitting requests for reimbursement. The Commissioners will ensure adequate training is provided. Anticipated Completion Date: Full implementation should be accomplished by fiscal year 2026. Responsible Parties: Sherry Moore, County Auditor and Commissioners

View Audit 371223

Finding 1161261 (2022-047)

Material Weakness 2022

Commonwealth of the Northern Mariana Islands

MP

Subrecipient Monitoring Reporting

Finding No.: 2022-047 AL Program: 97.039 - Hazard Mitigation Grant Program Area: Reporting Questioned Costs: $-0- Contact Person(s): Patrick Guerrero, Governor’s Authorized Rep., PAO Corrective Action Plan: Condition 1: HMGP agrees with this finding. HMGP acknowledges that this FFATA reporting condi...

Finding No.: 2022-047 AL Program: 97.039 - Hazard Mitigation Grant Program Area: Reporting Questioned Costs: $-0- Contact Person(s): Patrick Guerrero, Governor’s Authorized Rep., PAO Corrective Action Plan: Condition 1: HMGP agrees with this finding. HMGP acknowledges that this FFATA reporting condition was not addressed during the time period under review. However, HMGP became aware of the issue during a previous audit and have since been working to implement corrective measures. An action already taken for HMGP includes reaching out to the Public Assistance Office who had already begun the process of obtaining the necessary permissions on the FFATA Subaward Reporting System (FSRS) online submission portal to assign a designated administrator for our programs. The next action steps are: o To continue to work with the Governor’s office staff at to gain access through SAM.gov to ensure timely reporting of all subawards to FFATA/SAM.gov. o To establish adequate policies and procedures within HMGP’s standard operating procedures for the preparation and submission of FFATA reports to the FSRS. Once HMGP is provided with the necessary guidance and submission access on the FSRS, HMGP will promptly establish written internal controls to prevent any future non-compliance. HMGP understands that although the action steps taken to meet FFATA reporting compliance is actively underway, each subsequent Fiscal Year will unfortunately reflect a lack of FFATA submissions until the process is resolved and implemented. Proposed Completion Date: September 30, 2026

View Audit 371187

Finding 1161260 (2022-046)

Material Weakness 2022

Commonwealth of the Northern Mariana Islands

MP

Questioned Costs Cash Management Subrecipient Monitoring

Finding No.: 2022-046 AL Program: 97.039 - Hazard Mitigation Grant Program Area: Cash Management Questioned Costs: $2,687,277 Contact Person(s): Patrick Guerrero, Governor’s Authorized Rep., PAO Corrective Action Plan: Condition 1: HMGP respectfully disagrees with this finding. According to 31 CFR p...

Finding No.: 2022-046 AL Program: 97.039 - Hazard Mitigation Grant Program Area: Cash Management Questioned Costs: $2,687,277 Contact Person(s): Patrick Guerrero, Governor’s Authorized Rep., PAO Corrective Action Plan: Condition 1: HMGP respectfully disagrees with this finding. According to 31 CFR part 205, which is the default procedure if a Treasury-State Agreement (TSA) is not formally in effect, it is permissible and standard practice for a reimbursement check to clear after the disbursement request date, provided the subrecipient has submitted proof of prior payment with local funds. All checks in the samples tested are from local funds and all documents attached verified the expenses. Reimbursable funding is a recognized funding technique under 31 CFR 205.12(b)(e). This technique means that a Federal Program Agency transfers federal funds to a state after that state has already paid out the funds for Federal assistance program purposes and provided all necessary documentation. HMGP’s process operates under this reimbursement methodology: subrecipients incur costs using local funds first, then submit required documentation to HMGP for reimbursement. Consequently, the timing of reimbursement payments clearing after the request date is an inherent and necessary characteristic of this system. In absence of the TSA, the CNMI adheres to this prescribed default and the reimbursement method procedures are acceptable under the default. All expenses were processed, recorded, and supported by documentation and shows that the expense has initially been paid by non-federal, local government funds, had been processed through Munis on a reimbursement basis, and was processed no later than 30 calendar days after the reimbursement request was received. The finding suggests a deficiency, HMGP’s procedures are standard and compliant practice when operating under a reimbursement system and the default procedure. Although HMGP does believe that the current process meets federal and FEMA requirements, HMGP will develop and document a formal written procedure clearly outlining the expenditure timing process under the reimbursement system. This procedure will explain how costs are verified as incurred and demonstrate compliance with applicable federal and FEMA standards for fund control and accountability. Provide additional clarification and support documents to the auditor, if requested. Proposed Completion Date: September 30, 2025.

View Audit 371187 Questioned Costs: $1

Finding 1161259 (2022-045)

Material Weakness 2022

Commonwealth of the Northern Mariana Islands

MP

Questioned Costs Allowable Costs / Cost Principles Cash Management § 200.1

Finding No.: 2022-045 AL Program: 97.039 - Hazard Mitigation Grant Program Area: Allowable Costs/Cost Principles Questioned Costs: $99,924 Contact Person(s): Patrick Guerrero, Governor’s Authorized Rep., PAO Corrective Action Plan: The Hazard Mitigation Grant Program (HMGP) agrees with this finding....

Finding No.: 2022-045 AL Program: 97.039 - Hazard Mitigation Grant Program Area: Allowable Costs/Cost Principles Questioned Costs: $99,924 Contact Person(s): Patrick Guerrero, Governor’s Authorized Rep., PAO Corrective Action Plan: The Hazard Mitigation Grant Program (HMGP) agrees with this finding. During the audit submission process, HMGP provided the support documents for the journal entries and reversals associated with the $99,923.27 to the auditor, as requested. However, it was only upon receiving this audit finding # 2022-049, that the discrepancy of a duplicate audit drawdown was called into question. HMGP’s ledger for this project as well as the Munis drawdown history does not indicate a remaining balance of $99,923.73 and the project related to this finding has already been closed out. To address this audit finding that HMGP received this last week on September 17th, HMGP reached out to the Department of Finance to provide related documents for the drawdowns. Based on the documents provided by DOF, the questioned cost was not a direct result of the duplicate drawdown but as a result of the reverse journal entries made by Tyler Munis staff in an effort to correct the duplicate drawdown. HMGP accurately completed all required steps to process and provided the necessary justification to process a total of $99,923.73 for professional services and submitted it to DOF. Based on the supporting documents, the $99,923.73 was comprised of: • $53,451.01- under Request for Payment Application #11, letter reference # GAR22-HM-005 received by DOF on 10/18/2021 and requested to be charged to M142352.62060. • $46,472.72- under Request for Payment Application #12, letter reference # GAR22-HM-031 received by DOF on 11/05/2021 and requested to be charged to M142352.62060. Both HMGP payment application requests show the project string was meant to be charged to 62060 which stands for Professional Services and was submitted to DOF for processing. Since the new Munis financial system portal was launch in the CNMI a month prior, HMGP personnel were not able to enter transactions directly, unlike the current process. However, when the transaction was processed on Munis, it was entered in by a Tyler Munis representative, as identified by the staff initials SMD, who was assigned to assist DOF employees with data input during the transition period and, according to the Munis transaction history, accidentally entered the debit for the $99,923.27 under the Construction project string instead of Professional Services on 12/2/2021. On 12/13/2021, SMD credited the $99,923.27 back to Construction and debited $99,923.27 to Professional Services with Journal entry # 2125. The Munis transaction history also shows various entries and reversals made under the project account that serve to correct the same journal error. HMGP personnel would not be able to review the transactions entered prior to posting, and based on the transaction logs, even after the transactions were posted, HMGP would see that those involved in processing the transactions corrected their errors. Additionally, the supporting documents associated with the drawdowns on Munis display a bank statement with a lumpsum total of various project accounts. Furthermore, most of the journal entries during the time in question either contained the same supporting documents or indicated “access denied” when selected by HMGP personnel with Munis access. The document provided to HMGP on 9/24/2025 indicated the final two transactions related to this expense was entered by Tyler Munis staff on August of 2022. In an effort to reverse the duplicate drawdowns that occurred in Professional Services, SMD reversed the $99,923.27 from professional services labeled as "REV JE 2125 DONE IN ERROR". Journal Entry (JE) 2125 refers to the debit they initially made on 12/13/2021. This credit effectively canceled out and corrected one of the two drawdowns that occurred within the Professional Services Project String. However, on the same day, SMD made a second journal entry reversal under the Construction project string with an identical PA journal comment ""REV JE 2125 DONE IN ERROR."" It is unclear as to why this transaction occurred given that original error under construction was made and corrected on December 2021. Since this incorrect journal entry was made as a debit to construction and the correct journal entry was made as a credit to professional services, the net draw would have been $0. Since $0 worth of funds were paid out and no check was cut as a result, this additional debit would not have been conspicuous to HMGP or the DOF staff. HMGP is prepared to provide the additional documentation upon request. Additionally, acknowledging that the second debit to construction in August of 2022 for $99,923.73 was recorded and was not corrected for this project, HMGP will work with DOF to correct the journal entry and return the funds to FEMA. To address the finding, a significant action step already taken is the transition that occurred in 2024 for agencies to initiate their own drawdowns. This drawdown process ensures HMGP’s direct oversight of all expenditures moving forward to reduce the risk of future duplications. HMGP created an internal drawdown tracker upon DOF’s transition to agency-initiated drawdown requests for 2024 expenses to present. HMGP will work with DOF to correct the journal entry on Munis in relation to the questioned cost and process the return of funds to FEMA. HMGP will create a tracker for all requested transactions made to DOF, such as reversals or corrections if needed as that function cannot be completed on Munis by HMGP. HMGP will review the tracker on a bi-weekly basis to ensure that all MUNIS journal entries and transfers related to HMGP to ensure expenditures are completed accurately and on a timely basis to avoid future misclassifications or duplications. HMGP will continue to ensure that all payments are correctly coded and submitted into Munis with the appropriate documentation and supporting details. HMGP will update the financial management portion of the HMGP standard operating procedures to reflect these action items. Proposed Completion Date: September 30, 2026

View Audit 371187 Questioned Costs: $1

Finding 1161258 (2022-044)

Material Weakness 2022

Commonwealth of the Northern Mariana Islands

MP

Questioned Costs Subrecipient Monitoring § 200.332 § 200.501

Finding No.: 2022-044 AL Program: 97.036 - Disaster Grants - Public Assistance (Presidentially Declared Disasters) Area: Subrecipient Monitoring Questioned Costs: $1,540,330 Contact Person(s): Patrick Guerrero, Governor’s Authorized Rep., PAO Corrective Action Plan: Condition 1: The Public Assistanc...

Finding No.: 2022-044 AL Program: 97.036 - Disaster Grants - Public Assistance (Presidentially Declared Disasters) Area: Subrecipient Monitoring Questioned Costs: $1,540,330 Contact Person(s): Patrick Guerrero, Governor’s Authorized Rep., PAO Corrective Action Plan: Condition 1: The Public Assistance Office agrees with this finding and acknowledges that, as the pass-through entity, we are responsible for monitoring subrecipients. The Public Assistance Office will strengthen monitoring procedures to ensure compliance with 2 CFR 200.332(e). Beginning September 2025, PAO has begun conducting biannual risk assessments. The PAO will also strengthen documentation and audit trails by maintaining monitoring checklists, review notes, and communications in subrecipient files. Proposed Completion Date: Ongoing Condition 2: The Public Assistance Office agrees with this finding and acknowledges that, as the pass-through entity, we are responsible for monitoring subrecipients. The Public Assistance Office will strengthen monitoring procedures to ensure compliance with 2 CFR 200.332(g). Beginning September 2025, PAO has begun conducting biannual risk assessments. Proposed Completion Date: Ongoing

View Audit 371187 Questioned Costs: $1

Finding 1161257 (2022-043)

Material Weakness 2022

Commonwealth of the Northern Mariana Islands

MP

Subrecipient Monitoring Reporting

Finding No.: 2022-043 AL Program: 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: Condition 1: The Public Assistance Office agrees with...

Finding No.: 2022-043 AL Program: 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: Condition 1: The Public Assistance Office agrees with this finding and is aware of the need to submit the Federal Funding Accountability and Transparency Act (“FFATA”) reports. The Public Assistance Office will continue to work on gaining access through SAM.gov to ensure timely reporting of all subawards to FFATA/SAM.gov. As of September 2025, the Public Assistance Office has continued to attempt to gain access to enter these reports. Should the Public Assistance Office be granted access and necessary permissions to FFATA/SAM.gov, the Compliance and Audit Manager will input all previously unreported FFATA subaward data. Proposed Completion Date: December 31, 2025

View Audit 371187

Finding 1161256 (2022-042)

Material Weakness 2022

Commonwealth of the Northern Mariana Islands

MP

Questioned Costs Subrecipient Monitoring Period of Performance § 200.344

Finding No.: 2022-042 AL Program: 97.036 - Disaster Grants - Public Assistance (Presidentially Declared Disasters) Area: Period of Performance Questioned Costs: $423,234 Contact Person(s): Patrick Guerrero, Governor’s Authorized Rep., PAO Corrective Action Plan: Condition 1: 1. Regarding the finding...

Finding No.: 2022-042 AL Program: 97.036 - Disaster Grants - Public Assistance (Presidentially Declared Disasters) Area: Period of Performance Questioned Costs: $423,234 Contact Person(s): Patrick Guerrero, Governor’s Authorized Rep., PAO Corrective Action Plan: Condition 1: 1. Regarding the finding related to DR4235MP, PW 95, the Public Assistance Office agrees that the liquidation was processed after the liquidation deadline. 2. Regarding the finding related to DR4396MP, PW 4, the Public Assistance Office disagrees with this finding. Liquidation was done prior to the closeout deadline of December 31, 2022. 3. Regarding the finding related to DR4511MP, PW 27, the Public Assistance Office disagrees with this finding. Liquidation was done prior to the closeout deadline of June 30, 2025. 4. Regarding the finding related to DR4511MP, PW 8, the Public Assistance Office disagrees with this finding. Liquidation was done prior to the closeout deadline of June 30, 2025. As of Fiscal Year 2024, the Public Assistance Office initiates drawdown requests, allowing for more timely processing. The office will implement better financial monitoring procedures to ensure obligations are liquidated within the required liquidation period. Staff will also be refreshed on liquidation requirements to ensure compliance. When delays are anticipated, the office will coordinate with subrecipients and promptly request necessary time extension approvals from Grantor to maintain compliance. Proposed Completion Date: Ongoing Condition 2: The Public Assistance Office respectfully disagrees with this finding. • Regarding the finding related to DR4235MP, PW 49, the Public Assistance Office disagrees with this finding. The invoice was dated and recorded after the period of performance (June 30, 2022), but date of actual work completed as shown on the Megger Test was May 20, 2022. The Public Assistance Office acknowledges that the record of the Megger Test had not been submitted to the auditors when submitting documentation. The Public Assistance Office will continue to exercise diligence in reviewing project documentation to ensure that all work is verified and completed prior to payment/reimbursement. The office will continue to monitor performance timelines to confirm that work is completed on or before the established period of performance deadlines. This process will include periodic internal reviews and coordination with subrecipients to ensure compliance. When delays are anticipated, the office will coordinate with subrecipients and promptly request necessary time extension approvals from Grantor to maintain compliance. Proposed Completion Date: Ongoing

View Audit 371187 Questioned Costs: $1

Finding 1161252 (2022-041)

Material Weakness 2022

Commonwealth of the Northern Mariana Islands

MP

Questioned Costs Special Tests & Provisions Subrecipient Monitoring

Finding No.: 2022-041 AL Program: 93.778 - Medical Assistance Program Area: Special Tests and Provisions - Provider Eligibility (Screening and Enrollment) Questioned Costs: $3,640,189 Contact Person(s): Geroge J. Cruz, Medicaid Director Corrective Action Plan: The CNMI Medicaid Office respectfully d...

Finding No.: 2022-041 AL Program: 93.778 - Medical Assistance Program Area: Special Tests and Provisions - Provider Eligibility (Screening and Enrollment) Questioned Costs: $3,640,189 Contact Person(s): Geroge J. Cruz, Medicaid Director Corrective Action Plan: The CNMI Medicaid Office respectfully disagrees with the finding. While the office did perform OIG exclusion list validation, screenshots were not captured for each individual check. It is important to note that the OIG Exclusion List portal’s search function is limited to on-screen viewing and does not provide a built-in option to print or export search results. Additionally, the CMS access process for exclusion checks involves a rigorous background clearance, and only one personnel of three total successfully gained access. The CNMI Medicaid Office acknowledges that historically, limited personnel capacity has hindered full compliance with this requirement. However, efforts are currently underway to streamline and strengthen the exclusion verification process. The office is actively developing a fully functional Program Integrity Division that will be responsible for conducting and documenting OIG exclusion checks in a consistent and compliant manner moving forward. Proposed Completion Date: January 1, 2027

View Audit 371187 Questioned Costs: $1

Finding 1161251 (2022-040)

Material Weakness 2022

Commonwealth of the Northern Mariana Islands

MP

Special Tests & Provisions Subrecipient Monitoring

Finding No.: 2022-040 AL Program: 93.778 - Medical Assistance Program Area: Special Tests and Provisions - ADP Risk Analysis and System Security Review Questioned Costs: $-0- Contact Person(s): Geroge J. Cruz, Medicaid Director Corrective Action Plan: The CNMI Medicaid Office respectfully disagrees ...

Finding No.: 2022-040 AL Program: 93.778 - Medical Assistance Program Area: Special Tests and Provisions - ADP Risk Analysis and System Security Review Questioned Costs: $-0- Contact Person(s): Geroge J. Cruz, Medicaid Director Corrective Action Plan: The CNMI Medicaid Office respectfully disagrees with this finding. Due to internal scheduling constraints and the compressed timeline required to complete the FY22 audit, the requested documents were not submitted by the specified deadline, resulting in this finding. However, the office maintains all relevant supporting documentation and is prepared to provide it upon request from the Grantor. Proposed Completion Date: Ongoing

View Audit 371187

Finding 1161249 (2022-038)

Material Weakness 2022

Commonwealth of the Northern Mariana Islands

MP

Questioned Costs Allowable Costs / Cost Principles Eligibility

Finding No.: 2022-038 AL Program: 93.778 - Medical Assistance Program Area: Activities Allowed or Unallowed and Allowable Costs/Cost Principles Questioned Costs: $27,816,686 Contact Person(s): Geroge J. Cruz, Medicaid Director Corrective Action Plan: Condition 1: The CNMI Medicaid Office respectfull...

Finding No.: 2022-038 AL Program: 93.778 - Medical Assistance Program Area: Activities Allowed or Unallowed and Allowable Costs/Cost Principles Questioned Costs: $27,816,686 Contact Person(s): Geroge J. Cruz, Medicaid Director Corrective Action Plan: Condition 1: The CNMI Medicaid Office respectfully disagrees with this finding. Due to internal scheduling constraints and the compressed timeline required to complete the FY22 audit, the requested documents were not submitted by the specified deadline, resulting in this finding. However, the office maintains all relevant supporting documentation and is prepared to provide it upon request from the Grantor. Proposed Completion Date: Ongoing Condition 2: The CNMI Medicaid Office respectfully disagrees with this finding. Due to internal scheduling constraints and the compressed timeline required to complete the FY22 audit, the requested documents were not submitted by the specified deadline, resulting in this finding. However, the office maintains all relevant supporting documentation and is prepared to provide it upon request from the Grantor. Proposed Completion Date: Ongoing Condition 3: CNMI Medicaid Office respectfully disagrees with this finding. The agency currently does not have a Medicaid Management Information System (MMIS) in place to collect and accurately report comprehensive Benefits Paid data. All data processing is done manually, and information is maintained using Excel spreadsheets, which limits the ability to generate complete and reliable reports. Additionally, the "Benefits Paid" data provided to the auditor does not include services covered under the Certified Public Expenditures (CPE) payments made to CHCC. Therefore, these records should not be used as the sole basis for evaluating program eligibility, total expenditures, or compliance with eligibility requirements. However, the CNMI Medicaid Office maintains all relevant supporting documentation and is prepared to provide it upon request from the Grantor. Proposed Completion Date: Ongoing

View Audit 371187 Questioned Costs: $1

Finding 1161244 (2022-037)

Material Weakness 2022

Commonwealth of the Northern Mariana Islands

MP

Questioned Costs Special Tests & Provisions Subrecipient Monitoring

Finding No.: 2022-037 AL Program: 93.767 - Children’s Health Insurance Program Area: Special Tests and Provisions - Provider Eligibility (Screening and Enrollment) Questioned Costs: $7,932,110 Contact Person(s): Geroge J. Cruz, Medicaid Director Corrective Action Plan: CNMI Medicaid Office respectfu...

Finding No.: 2022-037 AL Program: 93.767 - Children’s Health Insurance Program Area: Special Tests and Provisions - Provider Eligibility (Screening and Enrollment) Questioned Costs: $7,932,110 Contact Person(s): Geroge J. Cruz, Medicaid Director Corrective Action Plan: CNMI Medicaid Office respectfully disagrees with the finding. While the office did perform OIG exclusion list validation, screenshots were not captured for each individual check. It is important to note that the OIG Exclusion List portal’s search function is limited to on-screen viewing and does not provide a built-in option to print or export search results. Additionally, the CMS access process for exclusion checks involves a rigorous background clearance, and only one personnel of three total successfully gained access. CNMI Medicaid Office acknowledges that historically, limited personnel capacity has hindered full compliance with this requirement. However, efforts are currently underway to streamline and strengthen the exclusion verification process. The office is actively developing a fully functional Program Integrity Division that will be responsible for conducting and documenting OIG exclusion checks in a consistent and compliant manner moving forward. Proposed Completion Date: Ongoing

View Audit 371187 Questioned Costs: $1

Finding 1161242 (2022-035)

Material Weakness 2022

Commonwealth of the Northern Mariana Islands

MP

Questioned Costs Subrecipient Monitoring Allowable Costs / Cost Principles § 200.308 § 200.309 § 200.344 § 200.403

Finding No.: 2022-035 AL Program: 93.767 - Children’s Health Insurance Program Area: Period of Performance Questioned Costs: $38,556 Contact Person(s): Geroge J. Cruz, Medicaid Director Corrective Action Plan: The CNMI Medicaid Office respectfully disagrees with this finding. Due to internal schedul...

Finding No.: 2022-035 AL Program: 93.767 - Children’s Health Insurance Program Area: Period of Performance Questioned Costs: $38,556 Contact Person(s): Geroge J. Cruz, Medicaid Director Corrective Action Plan: The CNMI Medicaid Office respectfully disagrees with this finding. Due to internal scheduling constraints and the compressed timeline required to complete the FY22 audit, the requested documents were not submitted by the specified deadline, resulting in this finding. However, the office maintains all relevant supporting documentation and is prepared to provide it upon request from the Grantor. Proposed Completion Date: Ongoing

View Audit 371187 Questioned Costs: $1

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