Corrective Action Plans

Finding No.: 2022-015 AL Program: 15.875 - Economic, Social, and Political Development of the Territories Area: Equipment and Real Property Management Questioned Costs: Unknown Contact Person(s): Epiphanio Cabrera, Jr., Grants Administrator, OGM-SC / Geraldine Cruz, Procurement Services Director Corrective Action Plan: The Procurement Services Division agrees with this finding. The CNMI has recently implemented the MUNIS Financial Management System to improve recordkeeping and compliance processes. All equipment and real property records acquired with federal funds will now be entered, tracked, and maintained within MUNIS. Supporting documentation will also be filed in accordance with standardized retention procedures to ensure that accurate and sufficient audit evidence is readily available. Current staff are undergoing formal training on the use of the MUNIS system, with particular emphasis on modules related to asset and property management. This training will ensure staff are fully capable of inputting, maintaining, and retrieving compliance-related records to support audit readiness. The CNMI is actively working on completing the FAIR (Federal Asset Inventory & Reconciliation) project, which aims to reconcile all existing federal property records. Upon completion of this project, a random physical inventory of federal property assets will be conducted to verify accuracy and completeness of records within the system. Results will be documented and used to address any discrepancies. Corrective Action Plan: To support sustained compliance, CNMI will develop internal procedures that align with federal property management regulations. These procedures will define roles and responsibilities, documentation requirements, and timelines for conducting regular physical inventories and system updates. Proposed Completion Date: June 30, 2026

Equipment and Real Property Management College of the Marshall Islands acknowledges the finding and confirms that a new system has been put in place to transition from manual to automated processes for improved recordkeeping and monitoring. The College has implemented the MIP Fixed Asset Module to maintain complete and accurate capital asset records, conduct timely reconciliations, and strengthen asset safeguarding controls. Internal procedures have been enhanced to ensure periodic physical inventory, prompt updates, and independent reviews of capital asset records. The full reconciliation and migration of all capital asset data into the new system is actively ongoing and scheduled to be completed by December 2025. These measures will ensure compliance with federal property management requirements and prevent recurrence of similar issues in the future.

The Government concurs with the auditor's findings and recommendations. The Epidemiology Division has established robust procedures to manage and monitor property and equipment effectively, adhering to Property and Procurement guidelines. All equipment is meticulously inventoried, and employees sign acknowledgment forms listing the items assigned to them, such as laptops or cell phones, with serial numbers clearly documented and safeguarded. However, DOH recognize the need for improved coordination between the Epidemiology Division and Property and Procurement. To enhance asset management, the Department of Health will update our Fixed Asset SOP to require that each division shares its asset inventory with Property and Procurement on a quarterly basis, ensuring more accurate and up-to-date records.

The Government concurs with the auditor's findings and recommendations. VIDE acknowledges the finding regarding the management and documentation of federally funded equipment. VIDE will ensure the reliability of its asset tracking system and ensure the maintenance of a centralized record of all assets acquired with federal funds, to include property description, serial number or other identification number, source of property, titleholder, acquisition date, cost of the property, percentage of Federal participation, location, use and condition of the property, and disposition information. The Procurement Division will schedule quarterly inventory audits and reconciliation processes to ensure all federal program assets are accounted for and that records align with actual inventory. Any discrepancies identified during these audits will be resolved promptly. The Fixed Asset Director will create a protocol to facilitate regular communication and updates among Programs/Divisions responsible for asset acquisition, maintenance, and recordkeeping. Monthly status reports on federal asset records will be required from each Program/Division to ensure data accuracy and timely updates.

The Government concurs with the auditor's findings and recommendations. VIDE acknowledges the finding regarding the management and documentation of federally funded equipment. VIDE will ensure the reliability of its asset tracking system and ensure the maintenance of a centralized record of all assets acquired with federal funds, to include property description, serial number or other identification number, source of property, titleholder, acquisition date, cost of the property, percentage of Federal participation, location, use and condition of the property, and disposition information. The Procurement Division will schedule quarterly inventory audits and reconciliation processes to ensure all federal program assets are accounted for and that records align with actual inventory. Any discrepancies identified during these audits will be resolved promptly. The Fixed Asset Director will create a protocol to facilitate regular communication and updates among Programs/Divisions responsible for asset acquisition, maintenance, and recordkeeping. Monthly status reports on federal asset records will be required from each Program/Division to ensure data accuracy and timely updates.

The Government concurs with the auditor's findings and recommendations. The Asset Management Division (AMD) has consistently followed Federal equipment and maintenance guidelines. Assets are tagged, and records are created using the Tyler Munis Resource Planning system (ERP). The serial numbers, model numbers, acquisition dates, cost of equipment, and agency that received the items are included. In 2022, AMD conducted inventory for four agencies, ensuring that all assets were accounted for and managed according to Federal regulations. Additionally, AMD have completed the Standard Operation Policies and Procedures (SOPP), which is currently in the approval process. Implementing SOPP is essential to enhancing internal controls and ensuring compliance with Federal regulations. Training sessions will be conducted for fixed assets employees across all Government agencies to provide detailed insights and updates on the processes. It has been identified that additional staff will be required to support this initiative effectively.

Finding Reference Number: SA 2022-006 Equipment Management AL Number: 14.218 Assistance Listing Title: CDBG - Entitlement Grants Cluster – Community Development Block Grants/Entitlement Grants COVID-19 - Community Development Block Grants/Entitlement Grants-CV Federal Agency: Department of Housing and Urban Development Federal Award Identification Number: B-14-MC-06-0037, B-15-MC-06-0037, B-16-MC-06-0037, B-17-MC-06-0037, B-18-MC-06-0037, B-19-MC-06-0037, B-20-MC-06-0037, B-20-MW-06-0037, B-21-MC-06-0037 • Fiscal Year of Initial Finding: 2022 • Name(s) of the contact person: Jennifer Block, Management Analyst Kiranjeet Sanghera, Finance Manager • Corrective Action Plan: The City will update its capital assets records to specify funding source. Procedures will be developed to meet physical inventory requirements. • Anticipated Completion Date: October 2025

Individual(s) Responsible: Chelsea BadHawk, Chief Financial Officer Action: Management will prepare and implement an internal control system that provides effective oversight of operations, reporting, and compliance. The systems and controls will be designed based on standards set forth in the Government Accountability Office Green Book. Anticipated Completion Date: 12/31/2025.

FINDING 2022-002 Information on federal program: Subject: Water and Waste Disposal Systems for Rural Communities - Equipment and Real Property Management Federal Agency: U.S. Department of Agriculture Assistance Listing Number: 10.760 Federal Award Number: 92-02 92-03 Pass-Through Entity: NIA Compliance Requirements: Equipment and Real Property Management Audit Findings: Significant Deficiency Condition: An effective internal control system was not in place at the City to ensure compliance with requirements related to the grant agreement and the Equipment and Real Property Management compliance requirement. Context: The City did not maintain an updated asset listing that reflects the construction in process balance related to the project funded with federal funds. Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Management will ensure that the capital asset listing is maintained throughout the year and CIP is tracked. Responsible Party and Timeline for Completion: The Clerk-Treasurer is the responsible party. The completion will go into effect during 2025.

RECOMMENDATION: Create a property management system and adopted written policies and procedures. These procedures should be reviewed and updated to, at a minimum, adhere to the newest federal guidelines under OMB Uniform Guidance. Physical inventories should be performed periodically and reconciled to the property management records. Property management records should also include copies of the original asset purchase documentation. Action Taken: The School agrees with this finding and will implement this recommendation within 120 days of this audit report.

January 31, 2025 To Whom it May Concern: The City of Harrisburg, Pennsylvania respectfully submits the following summarized corrective action plan for the Fiscal year ending December 31, 2022. The Audit Report was prepared by Boyer & Ritter LLC, Certified Public Accountants and Consultants, 211 House Avenue Camp Hill, PA 17011. Related findings are described in detail as contained within the City’s Single Audit Report, schedule of findings and questioned costs, and such are numbered in the corrective action plan in accordance with that assigned in the schedule. Any questions regarding this plan can be directed to Bryan McCutcheon, Accounting Manager at bmccutcheon@harrisburgpa.gov. Bryan McCutcheon, Accounting Manager City of Harrisburg Building and Housing Development Director of Housing and Economic Development, and Accounting Manager By or before 12/31/20025 Expenditures of CDBG grant funding for capital outlays on equipment and real property are readily identifiable within the City’s fixed assets module of the accounting system, including subsequent retirements of any such capital assets. The Department acknowledges related physical inventory observations to identify these assets have not been consistently performed and will work to formalize such inventory procedures. The City will look to complete such process as soon as is feasibly possible.

2022 – 009: Activities Allowed and Unallowed, Allowable Costs, Period of Availability (Compliance; Internal Controls Over Compliance) (Repeat Finding: 2018-006, 2019-008, 2020-008 and 2021-007) Significant Deficiency ALN 93.441 Indian Self Determination ALN 20.205 Highway Planning & Construction ALN 15.030 Indian Law Enforcement ALN 93.575 Child Care and Development Block Grant ALN 21.027 Coronavirus State and Local Fiscal Recovery Funds (ARPA) Condition: During compliance requirement testing for Activities Allowed and Unallowed, Allowable Costs and Period of Performance for the above noted major programs, we selected 120 transactions for testing from each major program. The following number of transactions were not provided for our review during the audit: ALN 93.441 – Indian Self Determination – 47 transactions ALN 20.205 – Highway Planning and Construction - 11 transactions ALN 15.030 – Indian Law Enforcement – 8 transactions ALN 93.575 – Child Care and Development Block Grant – 22 transactions ALN 21.027 – Coronavirus State and Local Fiscal Recovery Funds – 9 transactions Corrective Action Plan: The Finance Department will become familiar with the requirements of 2 CFR, Part §200.313(a) and establish appropriate internal control policies and procedures to ensure compliance with the requirements of Uniform Guidance and each major program. In addition, all staff will be trained on those policies and procedures so they are familiar with the requirements. The Finance Department will not process payment for disbursements that does not contain sufficient, appropriate supporting documentation and necessary approvals. The Finance Department will implement and execute an internal audit, by pulling random vouchers packets to test for compliance mid-year.

Views of Responsible Officials The Organization agrees with this finding. Corrective Action Plan The Organization will update its property records to include all required information. Additionally, the Organization plans to complete a physical inventory count and related reconciliation on an annual basis. Name(s) of Responsible Individuals Lacy Kimes, Board President Anticipated Completion Date October 31, 2024

Management will assign personnel responsible for the monitoring of all Federal funded equipments and establish internal control policies and procedures to perform the required physical inventory and reconciliation of all equipment and real properties acquired from Federal funds at least every year.

Procedures and policies surrounding equipment and real property management, physical inventory and data retention are being reviewed and updated to ensure requirements under Uniform Guidance are met.

We are currently working on a project to integrate the accounting system in the warehouse and Receiving module with the property module that will significantly improve the accuracy of asset management. With this action we will establish a communication protocol between these systems and ensures that equipment and property are meticulously tracked and reconciled. This seamless integration will not only streamline the recording process, but also provide a reliable method for maintaining the integrity of the general ledger. We expect to have this integration by the end of 2024.

Finding 2022-013 Equipment and Real Property Management - Noncompliance and Significant Deficiency in Internal Control Over Compliance Corrective Action Plan: Management agrees with this finding and will work to achieve compliance with the requirements outlined in 2 CRF Sections 200.313. Specifically, Management will enhance controls over the review and disposal of equipment and real property and enhance supervisory reviews over this accounting function. Anticipated Completion Date: December 31, 2024

Finding 2022-012 Equipment and Real Property Management - Noncompliance and Significant Deficiency in Internal Control Over Compliance Corrective Action Plan: Management agrees with this finding and will strive to create and to maintain a complete and accurate equipment and real property listing. Further, staff will perform regular reconciliations for the equipment and real property listing to ensure that its accuracy is maintained. Anticipated Completion Date: December 31, 2024

Finding 2022-011 Equipment and Real Property Management - Material Noncompliance and Material Weakness in Internal Controls Over Compliance Corrective Action Plan: Management agrees with this finding and will strive to create and to maintain a complete and accurate equipment and real property listing. Further, staff will perform regular reconciliations for the equipment and real property listing to ensure that its accuracy is maintained. Anticipated Completion Date: December 31, 2024

District subsequently sought and obtained CDE approval for the expenditures identified in finding 2022-003.District has initiated a procedure where any requisitions for purchases utilizing Federal funds are routed through the Director of state and federal programs prior to being approved. The director of state and federal programs, prior to approving the purchase requisition, will obtain approval from the CDE. All contracts utilizing federal funds will include language related to Federal wage rate requirements. The supervisor of Purchasing will be tasked with ensuring the contract language is present in agreements for services utilizing Federal funds.

The University has reviewed and enhanced its procedures and internal controls surrounding physical inventory of equipment and real property acquired with federal funds to ensure the physical inventory is performed at least biennially to meet the two-year requirement.

FINDING 2022-003Contact Person Responsible for Corrective Action: John Kenny and William LutherContact Phone Number: (812) 330-7700Views of Responsible Official: We concur with this finding. This finding has been remediated as of the completion dateshown below.Description of Corrective Action Plan:The asset mentioned in the finding now includes the source of funding. All future capital assets purchased with EducationStabilization Funds will include the source of the funding on the capital asset listing. The MCCSC will perform a physicalinventory during the current audit period.Completion Date: March 22, 2023

FINDING 2022-009Subject: COVID -19 - Education Stabilization Funding - Equipment and Real PropertyManagementFederal Agency: Department of EducationFederal Program: Education Stabilization FundAssistance Listings Numbers: 84.425DFederal Award Number and Year (or Other Identifying Number): S425D210013Pass-Through Entity: Indiana Department of EducationCompliance Requirement: Equipment and Real Property ManagementAudit Findings: Material Weakness, Modified OpinionContact Person Responsible for Corrective Action: Chad Yencer, SuperintendentContact Phone Number: 765-348-7550Views of Responsible Official: We concur with this findingDescription of Corrective Action Plan:Each building principal shall maintain an up-to-date inventory on prescribed forms orelectronic format supplied by the business office. Each teacher shall maintain an up-to-dateinventory of equipment and supplies in his/her shop, laboratory, or classroom. The teachershall submit a complete inventory on the prescribed form (paper or electronic) to the buildingprincipal prior to the teacher?s leaving at the end of the school year. The building principal shallcertify to the business office that the inventory has been checked and approved. There shall betwo copies of the inventory: one filed with the building principal and one filed with the businessoffice, or an electronic copy and a paper copy.An equipment inventory will be maintained on all computers and capital outlay items exceeding$1000.00 in value. The inventory will serve the functions of both control and conservation.The technology coordinator shall be responsible for assuring the maintenance of acomprehensive inventory of administrative and instructional computer hardware and software.The coordinator should work with the corporation technology department to developprocedures to be followed in maintaining such an inventory.The librarian for each building shall be responsible for keeping a complete inventory of allaudio-visual items in his/her building and providing the inventory information to the buildingprincipal, or by using electronic entry.INDIANA STATE BOARD OF ACCOUNTS50The running inventory shall be maintained on 1) building and grounds equipment; 2) furniture;3) administrative equipment; 4) educational equipment; 5) vehicles; and 6) textbooks andsupplementary books.The maintenance supervisor and business manager shall be responsible for inventories relativeto buildings and grounds equipment and vehicles. The building principal and business managershall be responsible for the inventories relative to furniture, administrative equipment,educational equipment, and textbooks and supplementary books.The superintendent will ensure that the capital asset inventory records will be updated uponreceipt of equipment, and that the proper identification and records will be maintained. BCS willengage Ad-Tech as well to annually perform an audit of assets and update the inventory recordsand necessary property records.Anticipated Completion Date: July 2023

Management?s View and Corrective Action PlanThe following is Novant Health?s response to the audit of Federal programs in accordance with the Uniform Guidance for year ending December 31, 2022.2022-003: Evidence of physical inspection of equipment purchased with federal funds was not maintained ? Significant deficiencyCluster: Not applicableFederal Granting Agency: Health Resources and Services Administration (?HRSA?)Award Name: COVID-19 National Bioterrorism Hospital Preparedness Program (?Bioterrorism Program?)Award #: N/AAssistance Listing #: 93.889Award Year: Fiscal year 2022Pass-through entity: North Carolina Healthcare Foundation; North Carolina Department of Health and Human Services ? Division of Health Service Regulation, Office of Emergency Medical ServicesPass-through award #: U3REP 200659; 42705; 44024Management understands the importance of inspection and maintenance of equipment purchased utilizing funding under this grant, as well as the requirement of a physical inventory and reconciliation to property records at least bi-annually. Novant Health receives a notification of award and contract from the North Carolina Office of Emergency Medical Services (NCOEMS), Healthcare Preparedness Program (HPP) that outlines a summary of the financial information, specific grant terms, scope of work, and inventory management requirements.Corrective Action Plan and Anticipated Completion DateNovant Health management?s corrective action plan includes:? Update internal inventory management system, iCams, with needed information required to meet applicable Federal requirements? Create a formal process to update the maintenance and inventory of assets that meet this requirement that can be appropriately carried out by both paid and volunteer staff.? Complete a full inventory of all equipment purchased with federal fundsNovant Health will determine and implement a best practice to properly capture the necessary information to meet the applicable Federal requirements by October 31, 2023. We will also have the inventory management system updated by March 31, 2024, with maintenance and inspection dates required for hard supplies and equipment purchased under this grant to meet applicable Federal requirements, as well as a full inventory of federally-funded equipment, completed on a rolling basis moving forward, by June 30, 2024.Additionally, the program manager will provide an email confirming completion of the above steps to the Grants Director and team.For follow-up questions and information, please contact Randy Brantley, Novant Health Grants Director at rlbrantley@novanthealth.org.Sincerely,Randy BrantleyGrants Directorrlbrantley@novanthealth.org

FINDING 2022-006Contact Person Responsible for Corrective Action: Robin PopejoyContact Phone Number: 317.758.4172Views of Responsible Official: We concur with the finding.Description of Corrective Action Plan: Those procedures and errors were discussed and adjustment will be made. TheDirector of Business will conduct and internal audit of capital assets records. New staff will also be trained on trackingcapital assets transitions and completing the necessary documentation for future capital assets transaction. There is aconstruction project that will result in capital assets being added.Anticipated Completion Date: June 2023