Corrective Action Plans

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Finding No.: 2021-008 AL Program: 93.268 Immunization Cooperative Agreement Area: Special Tests and Provision Control, Accountability and Safeguarding of Vaccine Questioned Costs: -0- Contact Person(s): Program Manager Corrective Action Plan: CHCC concurs with the finding. To address this finding, t...
Finding No.: 2021-008 AL Program: 93.268 Immunization Cooperative Agreement Area: Special Tests and Provision Control, Accountability and Safeguarding of Vaccine Questioned Costs: -0- Contact Person(s): Program Manager Corrective Action Plan: CHCC concurs with the finding. To address this finding, the Immunization Program conducts the following reconciliation of vaccination records as follows: Vaccination records: daily entries of vaccination records are captured through the patient encounter form for all providers administering vaccinations. Data Entry Assistants and Program Assistants are responsible for entering the vaccinations based on the form. The Immunization Information Systems (IIS) team are responsible for ensuring data quality elements are complete on the form and reflected on the WebIZ system. Patient screening forms: also known as the patient encounter form is the paper-based document in which patient demographics and vaccination data elements are recorded upon visit for all providers. Data Entry Assistant and Program Assistant capture demographic and input vaccines an individual is to receive for the visit. The vaccinator then inputs vaccination data elements (lot number, manufacturer, site, route, etc.) to be inputted into the registry, WebIZ. Temperature log: utilized to document the vaccine storage unit temperature based on the thermometer reading and logged at the start and end of each workday, as well as after hours and weekends/holidays. The VFC Coordinator and Security team logs the temperatures on a daily, routine basis. Vaccine inventory: monitored weekly by the Logistics Technician via spreadsheet and tracked using the registry WebIZ for overall vaccine inventory management. Inventory is reported to CDC by the Program Manager every 14 days. Vaccine wastage from all providers is submitted to the program at the first week of each month for the previous month reporting period. Overall wastage reporting is done monthly to CDC. A summary report of FY2021 vaccine transactions on the CNMI Immunization Registry, WebIZ was submitted via spreadsheet format under, “Vaccine Inventory Reports” Additionally, the CHCC has conducted the following steps to strengthen that annual site visits for VFC providers are completed and documented appropriately to evaluate adherence to the VFC program requirements: - Provided training to the staff member assigned/responsible (VFC Coordinator) for conducting site visits - Worked with CDC Subject Matter Experts to ensure that data systems for site visit findings/reporting were accessible to the VFC Coordinator. Training on the system was also provided to the VFC Coordinator. This system is cloud based and accessible to anyone provided access. Therefore, should staff turnover occur, access to prior reports and the system for submitting new site visit reports will continue to be accessible to the organization and to team members who will take on the responsibility. - Ensure that Position Description for the VFC Coordinator clearly specify responsibilities for implementing the VFC Program in accordance with VFC Operations Guide, which outlines the requirements for annual provider compliance site visits, including the sampling of patient records to verify eligibility screening and administration of VFC vaccine only to eligible children. - Entries of vaccine reconciliation documentation such as vaccine inventory (orders, transfers, and wastages) are accessible on the registry, CNMI WebIZ, as well as routine reporting to CDC VtrckS Site visits were suspended per the CDC Project Officer during that time period due to the COVID-19 response. E-mail communication from the CDC Project Officer is attached. The Program continued to continuously monitor VFC Providers were maintaining proper storage of vaccines and reviewing medical records for eligibility screening despite not conducting a formal site visit. Responsible Official: Program Manager, Program Administrator, and Director of Public Health Services Proposed Completion Date: On-going
Finding No.: 2021-006 AL Program: 21.027 Coronavirus State and Local Fiscal Recovery Funds Area: Activities Allowed or Unallowed Allowable Cost/Cost Principles Questioned Costs: $-0- Contact Person(s): Chief Financial Officer, Division of Grants and Financial Integrity Corrective Action Plan: CHCC c...
Finding No.: 2021-006 AL Program: 21.027 Coronavirus State and Local Fiscal Recovery Funds Area: Activities Allowed or Unallowed Allowable Cost/Cost Principles Questioned Costs: $-0- Contact Person(s): Chief Financial Officer, Division of Grants and Financial Integrity Corrective Action Plan: CHCC concurs with the findings. Payroll procedures will be revised to review the calculation of any new differential and review of creation and activation of new pay types to ensure that there is no over or underpayment of benefits. Aside from this preventative control, any supplemental payroll for premium payment shall be reviewed by the Comptroller for compliance to the specific regulations before payment processed. Responsible Official: Comptroller and Payroll Proposed Completion Date: 12/31/2026
Finding No.: 2021-005 AL Program: 15.875 Economic, Social, and Political Development of the Territories Area: Procurement and Suspension and Debarment Questioned Costs: $304,590 Contact Person(s): Director of Procurement and Supply and Chief Financial Officer, Division of Grants and Financial Integr...
Finding No.: 2021-005 AL Program: 15.875 Economic, Social, and Political Development of the Territories Area: Procurement and Suspension and Debarment Questioned Costs: $304,590 Contact Person(s): Director of Procurement and Supply and Chief Financial Officer, Division of Grants and Financial Integrity Corrective Action Plan: CHCC concurs with the compliance finding concerning the absence of documented, contemporaneous suspension and debarment verification but respectfully disagrees with the questioned costs of $304,590. Under 2 CFR 200.516(b)(5), the effect of an audit finding should establish a clear and logical link between the identified condition and its actual or potential impact. Although CHCC did not retain evidence that the vendors’ exclusion status was verified before entering into the covered transactions, the historical SAM.gov Exclusions reports confirm that neither vendor was suspended, debarred, or otherwise excluded during the relevant procurement periods. Accordingly, the procedural deficiency did not result in an award to an ineligible vendor. Additionally, 2 CFR 200.516(b)(6) requires questioned costs to be identified and their computation explained. The $304,590 represents the total expenditure under the two covered transactions rather than costs demonstrated to be unallowable, unsupported, unreasonable, or incurred with an excluded vendor. The expenditures were supported, incurred for authorized program purposes, and resulted in goods or services received by CHCC. This finding is substantially the same as the suspension and debarment findings reported in CHCC’s FY2020 Single Audit. The U.S. Department of the Interior, Office of Insular Affairs, subsequently reviewed CHCC’s corrective-action documentation and determined that CHCC had provided sufficient and appropriate evidence to resolve Finding 2020-005, which included questioned costs of $551,917 Responsible Official: Director of Procurement and Supply, Director of DGFI and Chief Financial Officer Proposed Completion Date: 09/30/2026
Finding No.: 2021-004 AL Program: 15.875 Economic, Social, and Political Development of the Territories Area: Equipment and Real Property Management Questioned Costs: Undeterminable Contact Person(s): Director of Procurement and Supply and Chief Financial Officer Corrective Action Plan: CHCC concurs...
Finding No.: 2021-004 AL Program: 15.875 Economic, Social, and Political Development of the Territories Area: Equipment and Real Property Management Questioned Costs: Undeterminable Contact Person(s): Director of Procurement and Supply and Chief Financial Officer Corrective Action Plan: CHCC concurs with the findings. CHCC updated its Capital Assets policy on June 10, 2026, to comply with the requirements of 2 CFR 200.313. Pursuant to the revised policy, CHCC will update the fixed assets listing for all the required components and proper documentation reconciliation results. Responsible Official: Director of Procurement and Supply, Director of DGFI and Chief Financial Officer Proposed Completion Date: 12/31/2026
The condition occurred due to the absence of a formalized reconciliation procedure to identify third-party reimbursements (e.g., insurance recoveries) prior to the compilation of federal expenditures reported in the SEFA. Corrective Measures, internal Control Enhancement, the Authority has revised i...
The condition occurred due to the absence of a formalized reconciliation procedure to identify third-party reimbursements (e.g., insurance recoveries) prior to the compilation of federal expenditures reported in the SEFA. Corrective Measures, internal Control Enhancement, the Authority has revised its SEFA preparation procedures to incorporate a formal reconciliation process between General Ledger federal expenditures, Third-party reimbursement records (including insurance recoveries), and Federal award financial reports. This reconciliation will be documented, reviewed by supervisory personnel within the Comptroller’s Office, and retained as part of the SEFA supporting documentation in accordance with record retention requirements under Uniform Guidance. Training and Capacity Development: Personnel responsible for grants accounting and SEFA preparation will complete additional training on 2 CFR Part 200 (Uniform Guidance), FEMA cost eligibility and documentation requirements, Identification and treatment of non-federal offsets to federal expenditures
A specialized funds firm was hired that is working on internal controls to improve the method of accounting of federal funds that meet accounting and FEMA requirements.
A specialized funds firm was hired that is working on internal controls to improve the method of accounting of federal funds that meet accounting and FEMA requirements.
Planned Corrective Action: Management agrees with the finding and has implemented controls to match revenue received from Emergency Federal Funds with expenditures submitted on drawdown requests. This will properly capture all expenditures of Federal Funds in the correct fiscal year. Furthermore, ma...
Planned Corrective Action: Management agrees with the finding and has implemented controls to match revenue received from Emergency Federal Funds with expenditures submitted on drawdown requests. This will properly capture all expenditures of Federal Funds in the correct fiscal year. Furthermore, management will meet on a quarterly basis to review all Federal Funds and perform reconciliations on a monthly basis. In addition to quarterly financial reviews and monthly financial reconciliations, management will immediately adapt to changing guidelines on Emergencv Federal Funds in future fiscal vears. Planned Implementation Date of Corrective Action: Currently Implemented.
Finding ref number: 2021-002 Finding caption: The City did not have adequate internal controls for ensuring compliance with procurement requirements and charged expenditures that lacked support for the Water and Waste Disposal Systems for Rural Communities program. Name, address, and telephone of Ci...
Finding ref number: 2021-002 Finding caption: The City did not have adequate internal controls for ensuring compliance with procurement requirements and charged expenditures that lacked support for the Water and Waste Disposal Systems for Rural Communities program. Name, address, and telephone of City contact person: Peter Sharp, 239 2nd Ave SE, Soap Lake, WA 98851, 509-246-1211 Corrective action the auditee plans to take in response to the finding: The City acknowledges that due to staff turnover during this period, federal procurement policies, documentation for professional services and other service fees could not be located during the audit. The City will immediately study these issues and implement comprehensive corrective measures: Corrective Actions: Procurement Documentation and Monitoring: 1. Comprehensive Procurement Policy Review and Revision – The City will conduct an immediate review of existing procurement policies against federal requirements (2 CFR Part 200, Subpart D) to identify all gaps. The City will revise and adopt updated procurement policies that conform to the most restrictive requirements and include all required procedures for: • Solicitation and award procedures for public works contracts • Small purchase quotation requirements • Architectural and engineering services procurement procedures • Piggyback purchasing authorization and procedures • Cost and price analysis requirements • Bonding requirements for construction contracts • All other required procurement procedures under federal regulations 2. Standards of Conduct Policy Development – The City will immediately develop and adopt written standards of conduct procedures as required by federal regulations (2 CFR Part 200.112), establishing conflict of interest policies and certification requirements for all City officials and employees involved in federal award transactions. 3. Staff Training and Certification – Implement mandatory training for all procurement personnel and department heads to ensure full understanding and compliance with updated policies. All staff will be required to acknowledge and certify compliance with standards of conduct policies. 4. Establish a system to review and document compliance with procurement policies on all federally-funded transactions, including periodic audits to verify conformance. Financial Controls and Documentation: - Established comprehensive document retention policies requiring all expenditure supporting documentation to be maintained for the required retention period - Implemented approval workflows requiring supervisory review of all federal grant expenditures before payment Federal Grant Management: - Developing formal federal grant administration procedures compliant with 2 CFR Part 200 Uniform Guidance requirements - Established pre-approval processes for all federal program expenditures - Implemented monthly reconciliation procedures for all federal grant activities - Will establish quarterly internal compliance reviews to ensure ongoing adherence to federal requirements Anticipated date to complete the corrective action: Q1 2026
2021-012 Financial Statement Reconciliations/Tie-In Procedures Material Weakness Recommendation: The Housing Authority should adopt written reconciliation and tie-in procedures into its financial policies and procedures manual. These policies should require timely reconciliations to take place as de...
2021-012 Financial Statement Reconciliations/Tie-In Procedures Material Weakness Recommendation: The Housing Authority should adopt written reconciliation and tie-in procedures into its financial policies and procedures manual. These policies should require timely reconciliations to take place as defined under policy. Action Taken: The Housing Authority agrees with this finding and will implement this recommendation within 120 days of this audit report.
2021-011 Timely Grant Draws Material Weakness Recommendation: The Housing Authority should adopt written grant draw policies into its financial policies and procedures manual. Financials should be reviewed monthly, and drawdowns made as needed. Action Taken: The Housing Authority agrees with this fi...
2021-011 Timely Grant Draws Material Weakness Recommendation: The Housing Authority should adopt written grant draw policies into its financial policies and procedures manual. Financials should be reviewed monthly, and drawdowns made as needed. Action Taken: The Housing Authority agrees with this finding and will implement this recommendation within 120 days of this audit report.
2021-006 Minutes/Resolutions Material Weakness Recommendation: Written minutes should be prepared for each council meeting along with any approved resolutions/recommendations. The minutes and resolutions should be centrally filed, maintained by the Council’s Secretary, and easily accessible to the a...
2021-006 Minutes/Resolutions Material Weakness Recommendation: Written minutes should be prepared for each council meeting along with any approved resolutions/recommendations. The minutes and resolutions should be centrally filed, maintained by the Council’s Secretary, and easily accessible to the auditor. Action Taken: The Housing Authority agrees with this finding and will implement this recommendation within 120 days of this audit report.
2021-001 Segregation of Duties – Loan Program Significant Deficiency Recommendation: The Housing Authority’s fiscal policies should be revised to ensure that preventive controls are in place over check disbursements for loan disbursements, such that checks must be signed with live signatures at leas...
2021-001 Segregation of Duties – Loan Program Significant Deficiency Recommendation: The Housing Authority’s fiscal policies should be revised to ensure that preventive controls are in place over check disbursements for loan disbursements, such that checks must be signed with live signatures at least the signature of one Tribal Council member. Further, individuals who benefit from the loan program should not have complete discretion over recording and processing of advances and repayment. We recommend a complete list of outstanding balances be presented to the Tribal Council, or its designee, for continued monitoring. Action Taken: The SCCHA discontinued the Loan Program as of November 2019. A complete list of balances owed has been submitted to the Tribal Council with the outstanding balances of those whom had signatory authority forwarded to the St. Croix Tribal Court for further repayment actions.
Section 8 Project Based Cluster – ALN #14.195 & 14.856 Recommendation: We recommend that management review their procedures for reviewing and monitoring the required deposit amounts to ensure that each Project deposits the correct amount each month. Explanation of disagreement with audit finding: Th...
Section 8 Project Based Cluster – ALN #14.195 & 14.856 Recommendation: We recommend that management review their procedures for reviewing and monitoring the required deposit amounts to ensure that each Project deposits the correct amount each month. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Authority completed a reconciliation of required monthly replacement reserve deposit amounts for all affected properties and updated automated accounting system entries to reflect correct deposit levels. A monitoring checklist and monthly financial review process have been established to verify ongoing compliance. Finance staff received targeted training regarding reserve funding requirements and contract documentation. Name(s) of the contact person(s) responsible for corrective action: Julie Ward, Chief Financial Officer Planned completion date for corrective action plan: December 31, 2025
The BOCC will be more diligent in their overview of grant applications to ensure that all federal grant application requests are not reimbursable through any other federal grant program. All transactions regarding federal grants will be required to be flagged with the grant information and will requ...
The BOCC will be more diligent in their overview of grant applications to ensure that all federal grant application requests are not reimbursable through any other federal grant program. All transactions regarding federal grants will be required to be flagged with the grant information and will require approval by the BOCC before any action can be taken. BOCC will determine the validity of each transaction to ensure compliance with grant requirements.
The BOCC will ensure that internal controls are developed and that procedures are adopted and implemented to help ensure compliance with federal grants. Future grant recipients will be required to have BOCC approval before expenditures can be turned in for payment. Grant recipients will also be requ...
The BOCC will ensure that internal controls are developed and that procedures are adopted and implemented to help ensure compliance with federal grants. Future grant recipients will be required to have BOCC approval before expenditures can be turned in for payment. Grant recipients will also be required to have BOCC approval before depositing grant funds. This should ensure that all transactions are in compliance with grant requirements.
Corrective Action for Condition 1: The MCD has been sending notices to borrowers as a reminder to update or renew their homeowner insurance policy. We have created a monitoring spreadsheet to ensure that the insurance policies are being updated and that notices to homeowners are being sent to remind...
Corrective Action for Condition 1: The MCD has been sending notices to borrowers as a reminder to update or renew their homeowner insurance policy. We have created a monitoring spreadsheet to ensure that the insurance policies are being updated and that notices to homeowners are being sent to remind them of their insurance status. Moving forward, we will be sending out demand notices to those listed accounts that were affected. Corrective Action for Condition 2: This loan account is noted and being monitored to ensure that future policy coverage accurately reflects the loan amount as cited. Corrective Action for Condition 3: Property insurance coverage for HP-367, HNC-403 and HNC-534 were subsequently renewed on 4/28/2022, 8/30/2022 and 11/16/2021, respectively. MCD will ensure that these account policies are being monitored for subsequent updates and renewals. Corrective Action for Condition 4: MCD will ensure moving forward that these accounts are carefully monitored and in compliance with required annual recertifications. Corrective Action for Condition 5: The two loan accounts, HL-178 and HL-196 were underwritten twenty years ago; therefore, corrective action regarding these two accounts would not be applicable. MCD verified and confirmed that the required document was not in the respective files. It is also possible the document was received but might have been misplaced or got lost in the process. Corrective Action for Condition 6: MCD will be unable to perform any corrective action to obtain such document as account is nearly twenty years old. It should be noted that the account has been referred for collection. Corrective Action for Condition 7: MCD will be unable to perform any corrective action to obtain such document as nearly twenty years has lapsed (possible misfiling or misplaced).
Management concurs that there were staffing and turnover challenges for the Organization. Adequate policies and procedures are in place to ensure timeliness of data requested. Additionally, we will establish milestones to ensure future audits progress within the Uniform Guidance timeline.
Management concurs that there were staffing and turnover challenges for the Organization. Adequate policies and procedures are in place to ensure timeliness of data requested. Additionally, we will establish milestones to ensure future audits progress within the Uniform Guidance timeline.
Corrective Action Plan: PREMA will establish and enforce procedures to ensure that quarterly SF-425 or equivalent COR3 financial reports are prepared, reviewed, reconciled to PRIFAS and SEFA records, and submitted within required deadlines; PREMA will create reconciliation checklists, ensure reports...
Corrective Action Plan: PREMA will establish and enforce procedures to ensure that quarterly SF-425 or equivalent COR3 financial reports are prepared, reviewed, reconciled to PRIFAS and SEFA records, and submitted within required deadlines; PREMA will create reconciliation checklists, ensure reports include federal and recipient share, drawdown activity, and unliquidated obligations, designate responsible personnel for review and approval prior to filing with evidence of submission retained, and provide staff training on federal reporting requirements under 2 CFR 200.327–200.329 to strengthen compliance and accuracy in financial reporting. Lead Person: Maritza Torres, Fiscal Area Director, and Contractors (Robles & Assoc.). Anticipated Completion Date: December 2025.
Corrective Action Plan: PREMA will improve its audit reporting process to ensure timely submission of the Single Audit reporting package by strengthening internal controls over report preparation, establishing a reporting calendar that includes milestones for completing reconciliations and required ...
Corrective Action Plan: PREMA will improve its audit reporting process to ensure timely submission of the Single Audit reporting package by strengthening internal controls over report preparation, establishing a reporting calendar that includes milestones for completing reconciliations and required documentation, and coordinating with fiscal, program, and grants staff to ensure financial data, the SEFA, and supporting information are complete and ready within the Uniform Guidance deadline; PREMA will also assess staffing needs, implement procedures to track reporting progress, and provide training to personnel involved in the audit submission process. Lead Person: Maritza Torres, Fiscal Area Director, and Contractors (Robles & Assoc.). Anticipated Completion Date: December 2025.
Corrective Action Plan: PREMA will strengthen internal controls over financial management and reporting by improving the maintenance of subsidiary records, enhancing PRIFAS reconciliations, increasing coordination among fiscal, program, and grants personnel, and establishing written procedures to en...
Corrective Action Plan: PREMA will strengthen internal controls over financial management and reporting by improving the maintenance of subsidiary records, enhancing PRIFAS reconciliations, increasing coordination among fiscal, program, and grants personnel, and establishing written procedures to ensure timely, accurate, and complete financial information for the Statement, SEFA, and required federal reports; PREMA will also evaluate staffing needs, provide training on PRIFAS and federal reporting requirements, and conduct periodic reviews to ensure compliance with reporting deadlines and data accuracy. Lead Person: Maritza Torres, Fiscal Area Director, and Contractors (Robles & Assoc.). Anticipated Completion Date: December 2025.
View of Responsible Officials and Corrective Action Plan –The Organization agrees with this finding and notes that the Organization is revising its internal processes to ensure that each expenditure charged to grants will have as supporting documentation the Check Payment form approved by the Grant ...
View of Responsible Officials and Corrective Action Plan –The Organization agrees with this finding and notes that the Organization is revising its internal processes to ensure that each expenditure charged to grants will have as supporting documentation the Check Payment form approved by the Grant Program Director and CEO/Executive Director, or by the CFO, along with the invoice for the expenditure, and explanation of reason for the charge to the specific grant.
View of Responsible Officials and Corrective Action Plan –The Organization agrees with this finding and notes that the Organization is revising its internal processes to ensure that each expenditure charged to grants will have as supporting documentation the Check Payment form approved by the Grant ...
View of Responsible Officials and Corrective Action Plan –The Organization agrees with this finding and notes that the Organization is revising its internal processes to ensure that each expenditure charged to grants will have as supporting documentation the Check Payment form approved by the Grant Program Director and CEO/Executive Director, or by the CFO, along with the invoice for the expenditure, and explanation of reason for the charge to the specific grant.
View of Responsible Officials and Corrective Action Plan –The Organization agrees with this finding and notes that the Organization is revising its internal processes to ensure that each expenditure charged to grants will have as supporting documentation the Check Payment form approved by the Grant ...
View of Responsible Officials and Corrective Action Plan –The Organization agrees with this finding and notes that the Organization is revising its internal processes to ensure that each expenditure charged to grants will have as supporting documentation the Check Payment form approved by the Grant Program Director and CEO/Executive Director, or by the CFO, along with the invoice for the expenditure, and explanation of reason for the charge to the specific grant.
View of Responsible Officials and Corrective Action Plan – The Organization agrees with this finding and notes that the Organization is revising its internal processes to ensure that each expenditure charged to grants will have as supporting documentation the Check payment from approved by the Grant...
View of Responsible Officials and Corrective Action Plan – The Organization agrees with this finding and notes that the Organization is revising its internal processes to ensure that each expenditure charged to grants will have as supporting documentation the Check payment from approved by the Grant Program Director and CEO/Executive Director, or by the CFO, along with the invoice for the expenditure, and explanation of reason for the change to the specific grant.
View Audit 372604 Questioned Costs: $1
View of Responsible Officials and Corrective Action Plan –The Organization agrees with this finding and notes that the Organization is revising its internal processes to ensure that each expenditure charged to grants will have as supporting documentation the Check Payment form approved by the Grant ...
View of Responsible Officials and Corrective Action Plan –The Organization agrees with this finding and notes that the Organization is revising its internal processes to ensure that each expenditure charged to grants will have as supporting documentation the Check Payment form approved by the Grant Program Director and CEO/Executive Director, or by the CFO, along with the invoice for the expenditure, and explanation of reason for the charge to the specific grant.
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