Corrective Action Plans

Finding 503610 (2024-001)

None 2024

CA

Procurement, Suspension & Debarment § 200.303 § 200.319 § 200.320

Management Response: The management staff of Hubbs-SeaWorld Research Institute take very seriously the federal compliance related to the procurement of goods and services. Hubbs-SeaWorld Research Institute acknowledges the finding and has subsequently updated their procurement policy and procedures...

Management Response: The management staff of Hubbs-SeaWorld Research Institute take very seriously the federal compliance related to the procurement of goods and services. Hubbs-SeaWorld Research Institute acknowledges the finding and has subsequently updated their procurement policy and procedures to be in compliance with 2 CFR 200.303. Management has adopted a plan of action to prevent future instances of non-compliance. Action Taken: Hubbs-SeaWorld Research Institute plans to modify its procurement procedures for federal grants to comply with 2CFR section 200.319 by continuing to require at least three bids (or a sole source statement, if applicable) for any purchases over the micro-purchase threshold, currently $10,000. In addition, we will monitor cumulative vendor purchases on a monthly basis to ensure that price or rate quotations are obtained from an adequate number of qualified sources, that is, at least three bids (or a sole source statement, if applicable.)

View Audit 325801

Finding 503360 (2024-002)

Significant Deficiency 2024

Dawson County

NE

Procurement, Suspension & Debarment § 200.214 § 200.303

Program: AL 21.027 - COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Suspension and Debarment Corrective Action Planned: The County has procedures in place; when a contractor is hired, sam.gov will be utilized to verify the entity has not been suspended or debarred. Anticipated Compl...

Program: AL 21.027 - COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Suspension and Debarment Corrective Action Planned: The County has procedures in place; when a contractor is hired, sam.gov will be utilized to verify the entity has not been suspended or debarred. Anticipated Completion Date: September 30, 2024 Responsible Party: Michaela Arndt, County Clerk

View Audit 325523

Finding 503152 (2024-003)

Significant Deficiency 2024

Hill Top Home of Comfort, Inc.

ND

Questioned Costs Special Tests & Provisions Significant Deficiency § 200.303

Finding 2024-003 Federal Agency Name: Department of Agriculture Program Name: Community Facilities Loans andGrants CFDA #10.766 Finding Summary: There was no formal review separate from the preparer performed over reconciliations of the USDA program reserve fund. Responsible Individuals: Gerry Le...

Finding 2024-003 Federal Agency Name: Department of Agriculture Program Name: Community Facilities Loans andGrants CFDA #10.766 Finding Summary: There was no formal review separate from the preparer performed over reconciliations of the USDA program reserve fund. Responsible Individuals: Gerry Leadbetter, Administrator Corrective Action Plan: Management will ensure a review separate from the preparer of the reconciliation for the program's reserve fund is completed with formal documentation noting the review. The Business Office Manager will reconcile the bank statement and will sign off on the bank statement, along with the Administrator for the USDA Loan Reserve Bank Account. Anticipated Completion Date: Ongoing

View Audit 325174

Finding 503146 (2024-001)

Material Weakness 2024

Amridge University, Inc.

AL

Student Financial Aid Reporting Matching / Level of Effort / Earmarking § 200.303

Correction action University personnel corrected the records in NSLDS and Clearinghouse on July 26, 2024 that were identified in Finding 2024-001. Additionally, university personnel conducted a thorough review of all students to ensure the records in NSLDS properly reflected an accurate enrollment s...

Correction action University personnel corrected the records in NSLDS and Clearinghouse on July 26, 2024 that were identified in Finding 2024-001. Additionally, university personnel conducted a thorough review of all students to ensure the records in NSLDS properly reflected an accurate enrollment status. The university immediately (August 2024) implemented training for the newly appointed Interim Registrar on the importance of timely and accurate reporting of enrollment status changes and graduation status. This training was conducted in coordination with the Vice President of Student Services, the Director of Financial Aid, the Controller, and the Director of Information Technology. In addition to hands-on training provided by university personnel, online resources were utilized from NSLDS, Clearinghouse, and the United States Department of Education. The policies and procedures for enrollment reporting has been strengthened, and includes the following reporting schedule: a student roster schedule will be submitted every 30 days. The exceptions report will be reviewed immediately and will be corrected within 10 days. Within 15 days of the end of each semester, a list of graduated students will be submitted to NSLDS. Exceptions will be corrected immediately to ensure all records in NSLDS match the student’s record. The university is confident that the finding related to enrollment reporting has been resolved. Enrollment files are being submitted every 30 days. Summer 2024 completers graduated on August 9, 2024. These students were reported through Clearinghouse, exceptions were addressed, and enrollment statuses of “Graduated” show on NSLDS as certified on September 13, 2024. The schedule of enrollment and reporting and graduation reporting will ensure that the statuses will be accurate in NSLDS. Responsible Person Rose Mulkey, Interim Registrar Anticipated completion date Completed as of July 26, 2024.

View Audit 325158

Finding 501986 (2024-002)

Significant Deficiency 2024

Dixon County

NE

Procurement, Suspension & Debarment § 200.214 § 200.303

Program: AL 21.027 - COVID-19- Coronavirus State and Local Fiscal Recovery Funds - Suspension and Debarment Corrective Action Planned: The County will implement procedures to ensure when a contractor is paid with federal funds, sam.gov will be utilized to verify the entity has not been suspended o...

Program: AL 21.027 - COVID-19- Coronavirus State and Local Fiscal Recovery Funds - Suspension and Debarment Corrective Action Planned: The County will implement procedures to ensure when a contractor is paid with federal funds, sam.gov will be utilized to verify the entity has not been suspended or debarred and such procedure will be adequately documented. Anticipated Completion Date: August 16,2024 Responsible Party: Dixon County Board of Supervisors: Don Andersen, Deric Anderson, Roger Peterson, Neil Blolun, Lisa Lunz, Terry Nicholson, and Steve Hassler.

View Audit 324145

Finding 499522 (2024-003)

Significant Deficiency 2024

Richardton Health Center

ND

Questioned Costs Special Tests & Provisions Significant Deficiency § 200.303

Finding 2024-003 Federal Agency Name: United States Department of Agriculture Program Name: Community Facilities Loans and Grants Federal Assistance Listing #10.766 Finding Summary: During our testing, there was no formal review separate from the preparer over the reserve fund reconciliation for the...

Finding 2024-003 Federal Agency Name: United States Department of Agriculture Program Name: Community Facilities Loans and Grants Federal Assistance Listing #10.766 Finding Summary: During our testing, there was no formal review separate from the preparer over the reserve fund reconciliation for the federal program and there was no formal review of the balance in comparison to the required minimum reserve balance. Responsible Individual: Mandy Robinson, Administrator Corrective Action Plan: We will implement additional control processes to ensure a formal review over the reserve fund reconciliation and a formal review of the balance in comparison to the required minimum reserve balance is completed by staff separate from the preparer. Anticipated Completion Date: 12/31/2024

View Audit 322385

Finding 497911 (2024-001)

None 2024

Kansas City Care Clinic D/b/a Kc Care Health Center

MO

Procurement, Suspension & Debarment § 200.214 § 200.303

Management's Response: KC CARE Agrees Views of Responsible Officials and Corrective Action: This appears to be an isolated incident where the vendor was not entered at the correct time in our contract management database. But, in response to this incident, management created a clearer policy and ou...

Management's Response: KC CARE Agrees Views of Responsible Officials and Corrective Action: This appears to be an isolated incident where the vendor was not entered at the correct time in our contract management database. But, in response to this incident, management created a clearer policy and outlined the timing of entering new vendors into the database and then making sure to do initial exclusion check during procurement process. Responsible Official: Dennis Dunmeyer, COO Anticipated Completion Date: Already implemented.

View Audit 320498

Finding 1229677 (2023-013)

Material Weakness 2023

Municipality of Anchorage, Alaska

AK

Allowable Costs / Cost Principles § 200.303

Allowable Costs – Noncompliance and Significant Deficiency in Internal Control Over Compliance Corrective Action Plan: The Municipality has begun implementing enhanced grant compliance review procedures to ensure expenditures are allowable, adequately supported, and incurred within the applicable pe...

Allowable Costs – Noncompliance and Significant Deficiency in Internal Control Over Compliance Corrective Action Plan: The Municipality has begun implementing enhanced grant compliance review procedures to ensure expenditures are allowable, adequately supported, and incurred within the applicable period of performance. Standardized documentation, supervisory review, and monitoring procedures will be incorporated into routine grant administration. Management will evaluate the effectiveness of these controls through completion of a full audit cycle. Anticipated Completion Date June 30, 2027

View Audit 410871

Finding 1229674 (2023-012)

Material Weakness 2023

Municipality of Anchorage, Alaska

AK

Material Weakness Reporting Matching / Level of Effort / Earmarking § 200.303 § 200.512

Reporting - Deadline for Federal Single Audit - Noncompliance and Material Weakness in Internal Control Over Compliance Corrective Action Plan: The Municipality has begun strengthening year-end financial reporting and audit planning through formal close schedules, defined responsibilities, milestone...

Reporting - Deadline for Federal Single Audit - Noncompliance and Material Weakness in Internal Control Over Compliance Corrective Action Plan: The Municipality has begun strengthening year-end financial reporting and audit planning through formal close schedules, defined responsibilities, milestone tracking, enhanced interdepartmental coordination, and increased management oversight to support the timely completion of future Federal Single Audits. Management will evaluate the effectiveness of these improvements through completion of a full audit cycle. Anticipated Completion Date June 30, 2027

View Audit 410871

Finding 1229621 (2023-011)

Material Weakness 2023

Municipality of Anchorage, Alaska

AK

Subrecipient Monitoring § 200.303 § 200.332 § 200.501

Subrecipient Monitoring – Material Noncompliance and Material Weakness in Internal Control Over Compliance Corrective Action Plan: The Municipality has begun implementing standardized subrecipient monitoring procedures, including documented risk assessments, monitoring protocols, supervisory review,...

Subrecipient Monitoring – Material Noncompliance and Material Weakness in Internal Control Over Compliance Corrective Action Plan: The Municipality has begun implementing standardized subrecipient monitoring procedures, including documented risk assessments, monitoring protocols, supervisory review, and enhanced oversight to strengthen compliance with Uniform Guidance requirements. Management will evaluate the effectiveness of these controls through completion of a full audit cycle. Anticipated Completion Date June 30, 2027

View Audit 410871

Finding 1229593 (2023-009)

Material Weakness 2023

Municipality of Anchorage, Alaska

AK

Material Weakness Reporting Matching / Level of Effort / Earmarking § 200.303

Reporting – Material Noncompliance and Material Weakness in Internal Control Over Compliance Corrective Action Plan: The Municipality has begun implementing an enterprise-wide corrective action strategy to strengthen grant administration and reporting processes. Corrective actions include developing...

Reporting – Material Noncompliance and Material Weakness in Internal Control Over Compliance Corrective Action Plan: The Municipality has begun implementing an enterprise-wide corrective action strategy to strengthen grant administration and reporting processes. Corrective actions include developing standardized policies and procedures, formalizing documentation and supervisory review requirements, improving subrecipient monitoring, strengthening cross-departmental coordination, and incorporating these processes into formal year-end close and audit planning activities. Management will evaluate the effectiveness of these controls through completion of a full audit cycle. Anticipated Completion Date March 31, 2027

View Audit 410871

Finding 1228734 (2023-004)

Material Weakness 2023

Activate Work Inc.

CO

Allowable Costs / Cost Principles Subrecipient Monitoring Matching / Level of Effort / Earmarking § 200.303 § 200.307 § 200.403

Action Taken in Response to Finding: Financial practices addressing program income were in place; however, processes were formalized to ensure full compliance with 2 CFR §200.307. ActivateWork developed and implemented a Program Income Policy as part of its Financial Policies and Procedures, adopted...

Action Taken in Response to Finding: Financial practices addressing program income were in place; however, processes were formalized to ensure full compliance with 2 CFR §200.307. ActivateWork developed and implemented a Program Income Policy as part of its Financial Policies and Procedures, adopted May 2026. As of March 2026, a standardized program income tracking and reconciliation is performed monthly as part of the month-end (EOM) close. This process includes: • Identification and tracking of program income by funding source • Application of program income to actual allowable expenses • Mapping of Federal reimbursement requests to underlying expenses to ensure program income is applied prior to reimbursement • Validation that no duplication of funding occurs between program income and Federal reimbursements These enhancements establish a structured and auditable framework for program income tracking, application, and compliance. Control Enhancement: Program income is tracked and recorded within a standardized Excel-based tool (Program Income vs. Unreimbursed Cost Analysis) and applied in accordance with federal requirements. A standardized program income tracker: • Applies program income to actual expenses • Links expenses to reimbursement requests • Ensures program income is fully utilized prior to requesting Federal reimbursement, unless otherwise specified by award terms • Prevents duplication of income and reimbursement Monitoring & Review: • Program income tracking is reviewed monthly as part of the EOM close process • Review is performed by the Senior Accountant • A secondary review is performed by the Director of Finance & Operations to validate completeness and compliance • Any discrepancies are identified and resolved prior to reimbursement submission Testing & Validation: • Beginning in June 2026, quarterly internal reviews will be conducted to validate program income tracking and application • Testing will confirm that: o Program income is accurately recorded o Program income is applied prior to reimbursement o No duplication of funding exists • Results will be documented and tracked for remediation Documentation & Evidence: • Program income tracker maintained in Teams / SharePoint • Supporting documentation tied to underlying expenses Control Owner(s): • Director of Finance & Operations • Finance Team Responsible Party: Helen Young Hayes, Founder / Chief Executive Officer, in coordination with the Director of Finance & Operations and Finance Staff Anticipated Completion Date: All corrective actions will be implemented by June 30, 2026. Ongoing monthly monitoring, reconciliation, and quarterly validation will continue. Status: • Program Income Policy: Implemented May 2026 • Program income tracking process: Implemented April 2026 • Monthly reconciliation and application (EOM Close): Implemented May 2026 • Quarterly internal reviews will be conducted to validate program income tracking and application: June 2026.

View Audit 410398

Finding 1228548 (2023-006)

Material Weakness 2023

Mental Health Kokua

HI

Cash Management Subrecipient Monitoring Period of Performance § 200.303 § 200.334

Management agrees with the finding and will implement procedures to ensure reimbursement request documentation and supporting schedules are retained in a centralized location and readily accessible for future monitoring and audit purposes. Anticipated Completion Date: September 30, 2026.

View Audit 410168

Finding 1228044 (2023-007)

Material Weakness 2023

City of Nenana

AK

Allowable Costs / Cost Principles § 200.303

Finding 2023-007: Lack of Internal Control And Noncompliance With Activities Allowed or Unallowed; Allowable Costs/Cost Principles Name of Contact: Josh Verhagen, Patricia Jirsa Corrective Action Plan: Similar answer as it was to 2023-002. A new and rigorous system has been implemented that ensures ...

Finding 2023-007: Lack of Internal Control And Noncompliance With Activities Allowed or Unallowed; Allowable Costs/Cost Principles Name of Contact: Josh Verhagen, Patricia Jirsa Corrective Action Plan: Similar answer as it was to 2023-002. A new and rigorous system has been implemented that ensures all expenses are being reviewed, approved and entered with proper expensing and filing. Proposed Completion Date: December 2026.

View Audit 409787

Finding 1227859 (2023-006)

Material Weakness 2023

Island Health, Inc.

MA

Cash Management HUD Housing Programs Material Weakness § 200.302 § 200.303 § 200.305

Item 2023.006 – Cash Management Recommendation The Center should develop written procedures to review all drawdowns that occur in order to ensure accuracy. Repeat Finding Yes Action Taken Island Health Care will take the following actions to address this recommendation: • Prepare written procedures ...

Item 2023.006 – Cash Management Recommendation The Center should develop written procedures to review all drawdowns that occur in order to ensure accuracy. Repeat Finding Yes Action Taken Island Health Care will take the following actions to address this recommendation: • Prepare written procedures to document the process for Drawdown requests, including the initial review, documented approval process, submission to the funding agency, and the recording of the drawdown in the accounting system immediately after submission • Maintain detailed records of all drawdown requests, supporting documentation, approvals, and correspondence • Conduct regular internal reviews of drawdown activities to ensure compliance with procedures and maintain audit trail • Review drawdown procedures annually to ensure they remain current with funding agency guidelines and best practices

View Audit 409789

Finding 1227840 (2023-020)

Material Weakness 2023

Commonwealth of the Northern Mariana Islands Public School System

MP

Special Tests & Provisions Subrecipient Monitoring Matching / Level of Effort / Earmarking § 200.303

Finding No.: 2023-020 AL Program: 93.243 Substance Abuse and Mental Health Services Projects of Regional and National Significance Area: Special Tests and Provisions - Key Level Management Questioned Costs: Undeterminable Views of Auditee and Corrective Action Plan: Management’s Position: PSS Manage...

Finding No.: 2023-020 AL Program: 93.243 Substance Abuse and Mental Health Services Projects of Regional and National Significance Area: Special Tests and Provisions - Key Level Management Questioned Costs: Undeterminable Views of Auditee and Corrective Action Plan: Management’s Position: PSS Management concurs with the findings. Financial and Grants Management processes were promulgated in a SOP on September 18, 2024. The SOPs are under review by an external consultant and recommendations made to improve documentation of time and effort allocable under federal awards. (See also 2023-004, 2023-0009) Corrective Action Plan: I. Establishment of Time and Effort SOPs: PSS will finalize and implement a dedicated Time and Effort Reporting SOP. This policy will explicitly define the key management Level of Effort (LOE) requirements by position and mandate the collection of specific supporting records, including Notice of Personnel Action (NOPA) forms, payroll registers, and certified timesheets. The SOP will feature robust internal controls and supervisory review procedures designed to prevent improper payments and ensure accurate labor distribution. II. Standardization of Key Management Records: PSS will obtain and systematically retain NOPA forms or equivalent documentation for all six positions identified in the grant agreement. This documentation will serve as the primary evidence to demonstrate compliance. III. Labor Distribution Monitoring Controls: PSS is implementing ongoing monitoring controls to ensure continued compliance. This includes a periodic internal review of payroll registers against the original grant agreements to verify that the labor costs charged to the award remain consistent with the approved personnel budget and documented effort. Proposed Completion Date: August 2026 Name of Contact Person and Title: Contact: Jacqueline Che, Federal Programs Officer Email Address: jacqueline.che@cnmipss.org

View Audit 409786

Finding 1227838 (2023-018)

Material Weakness 2023

Commonwealth of the Northern Mariana Islands Public School System

MP

Allowable Costs / Cost Principles Subrecipient Monitoring Matching / Level of Effort / Earmarking § 200.303

Finding No.: 2023-018 AL Program: 93.243 Substance Abuse and Mental Health Services Projects of Regional and National Significance Area: Allowable Costs/Cost Principles Questioned Costs: $-0- Views of Auditee and Corrective Action Plan: Management’s Position: PSS Management concurs with the finding....

Finding No.: 2023-018 AL Program: 93.243 Substance Abuse and Mental Health Services Projects of Regional and National Significance Area: Allowable Costs/Cost Principles Questioned Costs: $-0- Views of Auditee and Corrective Action Plan: Management’s Position: PSS Management concurs with the finding. While internal verification of disbursements is a standard part of our fiscal workflow, we recognize that our current process has the space to improve. Corrective Action Plan: To ensure that all disbursements are verified and documented prior to payment, PSS will implement the following: I. High Level Review and Approval: Implementation of Comptroller/ Director of Finance review on the Batch Invoice Summary signifying invoice entries on the said batch are verified and correct. After the review, the Comptroller will sign. II. Updated Payment Verification Process: Payments via check or ACH are reviewed by the Comptroller/ Director of Finance through Payment Manager and marking the Batch Invoice Summary that payments matched the invoice. Proposed Completion Date: December 2025 Name of Contact Person and Title: Contact: Jonathan Aguon, Director of Finance Email Address: jonathan.aguon@cnmipss.org

View Audit 409786

Finding 1227837 (2023-017)

Material Weakness 2023

Commonwealth of the Northern Mariana Islands Public School System

MP

Special Tests & Provisions Subrecipient Monitoring Allowable Costs / Cost Principles § 200.303

Finding No.: 2023-017 AL Program: COVID-19 84.425A/84.425X Education Stabilization Fund Area: Special Tests and Provisions - Private School Participation Questioned Costs: Undeterminable Views of Auditee and Corrective Action Plan: Management’s Position: PSS Management disagrees with the finding. PS...

Finding No.: 2023-017 AL Program: COVID-19 84.425A/84.425X Education Stabilization Fund Area: Special Tests and Provisions - Private School Participation Questioned Costs: Undeterminable Views of Auditee and Corrective Action Plan: Management’s Position: PSS Management disagrees with the finding. PSS asserts that timely and meaningful consultations were conducted with private school officials prior to making decisions regarding the size, scope, and funding of equitable services for FY2023. Calculations for the equitable share under the Education Stabilization Funds were performed in accordance with federal regulations, ensuring that per-pupil allocations for eligible private school students and teachers were equitable relative to public school expenditures. PSS maintains that consultation timelines, meeting records, and allocation formulas were maintained. While PSS is continuously refining its administrative workflows, the existing documentation and controls were sufficient to satisfy the requirements of 34 CFR § 299.7. Proposed Completion Date: Resolution in progress and on track for completion by August 2026. Name of Contact Person and Title: Contact: Jacqueline Che, Federal Programs Officer Email Address: jacqueline.che@cnmipss.org

View Audit 409786

Finding 1227835 (2023-016)

Material Weakness 2023

Commonwealth of the Northern Mariana Islands Public School System

MP

Special Tests & Provisions Procurement, Suspension & Debarment Matching / Level of Effort / Earmarking § 200.303

Finding No.: 2023-016 AL Program: COVID-19 84.425A/84.425X Education Stabilization Fund Area: Special Tests and Provisions - Wage Rate Requirement Questioned Costs: Undeterminable Views of Auditee and Corrective Action Plan: Management’s Position: PSS Management concurs with the audit findings. We a...

Finding No.: 2023-016 AL Program: COVID-19 84.425A/84.425X Education Stabilization Fund Area: Special Tests and Provisions - Wage Rate Requirement Questioned Costs: Undeterminable Views of Auditee and Corrective Action Plan: Management’s Position: PSS Management concurs with the audit findings. We acknowledge that our current procurement and contract administration processes did not consistently incorporate the mandatory Davis-Bacon Act labor standard clauses or the subsequent collection of certified payrolls. PSS is committed to implementing a rigorous compliance framework for all federally funded construction and repair projects. Financial, Procurement, and Grants Management policies procedures were promulgated in a SOPs on September 18, 2024. The financial management system was subsequently changed to Tyler Munis to conform with CNMI central government requirements which will enhance capabilities. The SOPs and the Tyler Munis implementation are under review by an external consultant and recommendations made to improve documentation of cost allowability have been received. Payment procedures are being addressed in a separate SOP. Corrective Action Plan: To ensure full compliance with 29 CFR 5.5 and federal wage rate requirements, PSS will implement the following: I. Standardized Construction Contract Template: PSS Legal Counsel and the Procurement Office will develop a standardized "Federal Construction Contract Addendum." This addendum will contain all mandatory Davis-Bacon Act clauses required by 29 CFR 5.5(a)(1)-(10). Effective immediately, no contract or purchase order exceeding $2,000 for construction, alteration, or repair will be executed without the inclusion of this addendum. II. Mandatory Certified Payroll Submission Protocol: PSS will update its "Notice to Proceed" and project management guidelines to explicitly state that progress payments will be withheld until the contractor submits the required weekly certified payrolls. Contractors will be provided with the Form WH-347 (or an equivalent) to ensure they are using the correct reporting format. III. Pre-Construction Compliance Meetings: For all future Davis-Bacon covered projects, PSS will hold a mandatory pre-construction meeting with contractors to clearly communicate their obligations regarding certified payrolls and the posting of the applicable wage decision at the job site. IV. Document Retention and Review Audit: PSS will implement a "Project Close-out Checklist." Finance will not process the final retention payment for any construction project until the Labor Compliance Monitor certifies that all weekly certified payrolls have been received, reviewed, and filed. V. Updated Standard Operating Procedures and Training: PSS will finalize SOPs and policies internal controls with updated internal controls and procedures for required contract clauses and oversight. Checklists will be updated to include a specific control for Davis-Bacon reporting. Require all current contractors and those identified in this audit to submit certified payrolls for 2023 through the span of their contracts for all Davis-Bacon covered work. PSS Procurement and Supply staff will receive refresher training on cost principles annually regarding required contract clauses and documentation to support compliance with requirements. Proposed Completion Date: September 2026 Name of Contact Person and Title: Contact: Michael Jason A. Babauta, Chief Procurement & Supply Officer Email Address: michael.jason.babauta@cnmipss.org

View Audit 409786

Finding 1227833 (2023-015)

Material Weakness 2023

Commonwealth of the Northern Mariana Islands Public School System

MP

Matching / Level of Effort / Earmarking § 200.303

Finding No.: 2023-015 AL Program: COVID-19 84.425A/84.425X Education Stabilization Fund Area: Matching, Level of Effort, Earmarking Questioned Costs: Undeterminable Views of Auditee and Corrective Action Plan: Management’s Position: PSS Management does not agree with the finding. PSS has allocated a...

Finding No.: 2023-015 AL Program: COVID-19 84.425A/84.425X Education Stabilization Fund Area: Matching, Level of Effort, Earmarking Questioned Costs: Undeterminable Views of Auditee and Corrective Action Plan: Management’s Position: PSS Management does not agree with the finding. PSS has allocated and expended more than 20% on evidence-based interventions to address learning loss. Specifically, projects listed under the ARP expense report are mapped directly to learning loss categories (e.g. expenses for summer school, extended learning opportunities, high dosage tutors, etc.). Based on this documentation, we request that the audit finding be revised to reflect compliance. Proposed Completion Date: Resolution in progress and on track for completion by August 2026. Name of Contact Person and Title: Contact: Jacqueline Che, Federal Programs Officer Email Address: jacqueline.che@cnmipss.org

View Audit 409786

Finding 1227829 (2023-013)

Material Weakness 2023

Commonwealth of the Northern Mariana Islands Public School System

MP

Allowable Costs / Cost Principles Subrecipient Monitoring Matching / Level of Effort / Earmarking § 200.303

Finding No.: 2023-013 AL Program: COVID-19 84.425A/84.425X Education Stabilization Fund Area: Activities Allowed/Unallowed, Allowable Costs/Cost Principles Questioned Costs: $-0- Views of Auditee and Corrective Action Plan: Management’s Position: PSS Management concurs with the findings. Financial a...

Finding No.: 2023-013 AL Program: COVID-19 84.425A/84.425X Education Stabilization Fund Area: Activities Allowed/Unallowed, Allowable Costs/Cost Principles Questioned Costs: $-0- Views of Auditee and Corrective Action Plan: Management’s Position: PSS Management concurs with the findings. Financial and Grants Management policies procedures were promulgated in SOPs on September 18, 2024. The financial management system was subsequently changed to Tyler Munis to conform with CNMI central government requirements which will enhance capabilities. The SOPs and the Tyler Munis implementation are under review by an external consultant and recommendations made to improve documentation of cost allowability have been received. Corrective Action Plan: I. Finalization of Allowability and Disbursement SOPs: PSS will finalize comprehensive Standard Operating Procedures (SOPs) and policies specifically governing allowability determinations and vendor payments. II. Enhanced Disbursement Controls: PSS is implementing a documented review and approval controls over the payment process. Before any check or ACH disbursement is finalized, a reviewer must verify that the payment amount agrees exactly with the approved invoice. This verification will be physically or digitally documented on the payment voucher to provide a clear audit trail of the pre-payment review. Proposed Completion Date: In progress for FY 2024 with full implementation and documentation processes expected to be completed in 2026. As part of this improvement, we are designing a standardized, documented review process to ensure all disbursements are verified against approved invoices prior to payment. Name of Contact Person and Title: Contact: Jonathan Aguon, Director of Finance Email Address: jonathan.aguon@cnmipss.org

View Audit 409786

Finding 1227825 (2023-010)

Material Weakness 2023

Commonwealth of the Northern Mariana Islands Public School System

MP

Allowable Costs / Cost Principles Subrecipient Monitoring Matching / Level of Effort / Earmarking § 200.303

Finding No.: 2023-010 AL Program: 84.403 Consolidated Grants to the Outlying Areas Area: Allowable Costs/Cost Principles Questioned Costs: $-0- Views of Auditee and Corrective Action Plan: Management’s Position: PSS Management concurs with the findings. Financial and Grants Management policies proce...

Finding No.: 2023-010 AL Program: 84.403 Consolidated Grants to the Outlying Areas Area: Allowable Costs/Cost Principles Questioned Costs: $-0- Views of Auditee and Corrective Action Plan: Management’s Position: PSS Management concurs with the findings. Financial and Grants Management policies procedures were promulgated in SOPs on September 18, 2024. The financial management system was subsequently changed to Tyler Munis to conform with CNMI central government requirements which will enhance capabilities. The SOPs and the Tyler Munis implementation are under review by an external consultant and recommendations made to improve documentation of cost allowability have been received. Corrective Action Plan: I. Finalization of Allowability and Disbursement SOPs: PSS will finalize comprehensive Standard Operating Procedures (SOPs) and policies specifically governing allowability determinations and vendor payments. II. Enhanced Disbursement Controls: PSS is implementing a documented review and approval controls over the payment process. Before any check or ACH disbursement is finalized, a reviewer must verify that the payment amount agrees exactly with the approved invoice. This verification will be physically or digitally documented on the payment voucher to provide a clear audit trail of the pre-payment review. Proposed Completion Date: In progress for FY 2024 with full implementation and documentation processes expected to be completed in 2026. As part of this improvement, we are designing a standardized, documented review process to ensure all disbursements are verified against approved invoices prior to payment. Name of Contact Person and Title: Contact: Jonathan Aguon, Director of Finance Email Address: jonathan.aguon@cnmipss.org

View Audit 409786

Finding 1227814 (2023-003)

Material Weakness 2023

Commonwealth of the Northern Mariana Islands Public School System

MP

Allowable Costs / Cost Principles Subrecipient Monitoring School Nutrition Programs § 200.303

Finding No.: 2023-003 AL Program: 10.555 National School Lunch Program (NSLP) Area: Allowable Costs/Cost Principles Questioned Costs: $-0- Views of Auditee and Corrective Action Plan: Management’s Position: PSS Management concurs with the findings. Financial and Grants Management policies procedures...

Finding No.: 2023-003 AL Program: 10.555 National School Lunch Program (NSLP) Area: Allowable Costs/Cost Principles Questioned Costs: $-0- Views of Auditee and Corrective Action Plan: Management’s Position: PSS Management concurs with the findings. Financial and Grants Management policies procedures were promulgated in SOPs on September 18, 2024. The financial management system was subsequently changed to Tyler Munis to conform with CNMI central government requirements which will enhance capabilities. The SOPs and the Tyler Munis implementation are under review by an external consultant and recommendations made to improve documentation of cost allowability have been received. Corrective Action Plan: I. Finalization of Allowability and Disbursement SOPs: PSS will finalize comprehensive Standard Operating Procedures (SOPs) and policies specifically governing allowability determinations and vendor payments. II. Enhanced Disbursement Controls: PSS is implementing a documented review and approval controls over the payment process. Before any check or ACH disbursement is finalized, a reviewer must verify that the payment amount agrees exactly with the approved invoice. This verification will be physically or digitally documented on the payment voucher to provide a clear audit trail of the pre-payment review. Proposed Completion Date: In progress for FY 2024 with full implementation and documentation processes expected to be completed in 2026. As part of this improvement, we are designing a standardized, documented review process to ensure all disbursements are verified against approved invoices prior to payment. Name of Contact Person and Title: Contact: Jonathan Aguon, Director of Finance Email Address: jonathan.aguon@cnmipss.org

View Audit 409786

Finding 1227614 (2023-006)

Material Weakness 2023

Village of Maywood

IL

Reporting Subrecipient Monitoring Internal Control / Segregation of Duties § 200.303

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

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

View Audit 409628

Finding 1227161 (2023-002)

Material Weakness 2023

County of Rockingham

NH

Reporting § 200.303

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

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

View Audit 409334

Corrective Action Plans

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