Corrective Action Plans

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Management's Response: Management concurs with the above finding and will ensure that human resources, fiscal services and Title Ill all have proper approvals, budgets and written authorization of anything that deviates from the approved budget. The corrective action will be implemented immediately ...
Management's Response: Management concurs with the above finding and will ensure that human resources, fiscal services and Title Ill all have proper approvals, budgets and written authorization of anything that deviates from the approved budget. The corrective action will be implemented immediately and completed by June 2025.
View Audit 338909 Questioned Costs: $1
Upon identification of costs allocated to more than one grant, the Organization identified allowable costs previously charged to program income and reallocated the duplicated expenditures without creating other instances of noncompliance (such as cash management or period of performance). Although t...
Upon identification of costs allocated to more than one grant, the Organization identified allowable costs previously charged to program income and reallocated the duplicated expenditures without creating other instances of noncompliance (such as cash management or period of performance). Although the initial support provided to auditors contained instances of expenditures charged to more than one grant, expenditure justification has been updated to reflect corrections and all subsequent grant expenditure detail has been reviewed to ensure no recurrence in the subsequent period. The Organization has also reviewed our internal processes to capture all salaries supported by grants accurately and timely. Additional internal controls such as limiting the number of grants an employee can be on at one time and the reduction of more catch-up drawdowns to account for staffing changes within the organization were implemented. We are also working with our accounting software vendor and payroll vendor to automate the allocation of grant salaries based on time and effort of each individual rather than after-the-fact allocations to grants. This will reduce the need to maintain manual spreadsheets to track staff and essentially eliminate the risk of charging expenditures to more than one grant. Further, relevant staff participated in a training focused on CHC grants management matters in December 2024 and will continue to look for learning opportunities to support and challenge compliance matters. Official Responsible for Ensuring the Corrective Action Plan: Danielle Hahn, Progressive Community Health Center Chief Financial Officer. Planned Completion Date for the Corrective Action Plan: The Organization has implemented the corrective action plan as of December 2024 and will continue to monitor throughout the year.
View Audit 334670 Questioned Costs: $1
The Agency updated procedures for developing the SEFA in accordance with 2 CFR 200.502 which states, “The determination of when a federal award is expended must be based on when the activity related to the Federal award occurs.”The Agency is required to comply with 2 CFR 200.403 which indicates that...
The Agency updated procedures for developing the SEFA in accordance with 2 CFR 200.502 which states, “The determination of when a federal award is expended must be based on when the activity related to the Federal award occurs.”The Agency is required to comply with 2 CFR 200.403 which indicates that allowable costs must be determined in accordance with accounting principles generally accepted in the United States of America (GAAP). The Agency updated procedures for developing the SEFA in accordance with both 2 CFR 200.502 and 2 CFR 200.403 to include the following process improvement: The agency has modified its current process to ensure the direct and indirect costs charged to the federal programs include only the costs incurred during the current fiscal year.
View Audit 334071 Questioned Costs: $1
Condition: The District submitted the Sp. Ed. IDEA Preschool 2024 grant budget late and claimed costs preceding the budget submission date, resulting in questioned costs of $4,646. Recommendation: The District should take steps to submit grant applications in a timely manner to ensure that they are ...
Condition: The District submitted the Sp. Ed. IDEA Preschool 2024 grant budget late and claimed costs preceding the budget submission date, resulting in questioned costs of $4,646. Recommendation: The District should take steps to submit grant applications in a timely manner to ensure that they are able to claim all expenses as budgeted. We recommend reviewing the general ledger to the expenditure reports before submitting for more accurate reporting. Management Response: The District will take steps to submit grant applications in a timely manner. The District will review the general ledger to the expenditure reports before submitting.
View Audit 334048 Questioned Costs: $1
Condition: The District submitted the Title I 2024 grant budget late and claimed costs preceding the budget submission date, resulting in questioned costs of $114,912. Recommendation: The District should take steps to submit grant applications in a timely manner to ensure that they are able to claim...
Condition: The District submitted the Title I 2024 grant budget late and claimed costs preceding the budget submission date, resulting in questioned costs of $114,912. Recommendation: The District should take steps to submit grant applications in a timely manner to ensure that they are able to claim all expenses as budgeted. We recommend reviewing the general ledger to the expenditure reports before submitting for more accurate reporting. Management Response: The District will take steps to submit grant applications in a timely manner. The District will review the general ledger to the expenditure reports before submitting.
View Audit 334048 Questioned Costs: $1
Views of Responsible Officials and Planned Corrective Action: Management agrees with the finding. The Health System has finalized the standard work procedure titled, Request for Funds/Reimbursement Claims (2-201’s), to ensure costs are appropriately charged based on the contract’s performance period...
Views of Responsible Officials and Planned Corrective Action: Management agrees with the finding. The Health System has finalized the standard work procedure titled, Request for Funds/Reimbursement Claims (2-201’s), to ensure costs are appropriately charged based on the contract’s performance periods. Review of cost activity will occur in fiscal year 2025 to ensure policy is followed.
FINDING 2024-002 Subject: COVID-19 - Education Stabilization Fund - Activities Allowed or Unallowed Federal Agency: Department of Education Federal Program: COVID-19 - Education Stabilization Fund Assistance Listing Number: 84.425U Federal Award Numbers and Years (or Other Identifying Numbers): ...
FINDING 2024-002 Subject: COVID-19 - Education Stabilization Fund - Activities Allowed or Unallowed Federal Agency: Department of Education Federal Program: COVID-19 - Education Stabilization Fund Assistance Listing Number: 84.425U Federal Award Numbers and Years (or Other Identifying Numbers): S425U210013 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Activities Allowed or Unallowed, Allowable Costs/Cost Principles Audit Finding: Material Weakness Condition: An effective internal control system was not in place at the School District to ensure compliance with requirements related to the Education Stabilization Fund and Activities Allowed or Unallowed. FINDING 2024-002 (Continued) Context: During the testing of payroll disbursements charged to the Education Stabilization Fund grant awards during the audit period, the following exceptions were noted: • For 16 payroll disbursements, in a sample of 40, management was unable to provide an approved employee contract or hourly rate ordinance to support the selected employees' bi-weekly pay rate. • For one transaction selection, an employee received a $730.43 one-time payment for a Teacher Appreciation Grant (TAG) funded by the 84.425U award. The Teacher Appreciation Grant has its own fund and is a state/local grant received to reward high-performing, eligible certified staff. The selected employee is a noncertified employee and did not qualify for a TAG award. There was no documentation provided to support work performed under this award to support allowability of the cost incurred. Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Management will ensure records of approved contracts are maintained for all employees and that payroll charged to federal awards is reviewed each pay period for allowability. The HR Coordinator is currently storing each contract both by hard copy in the employee file and digitally in our software. The Deputy Treasurer/Payroll Coordinator reviewing the distribution report prior to payroll submission. The Treasurer is also reviewing and will sign off on the distribution report for each payroll. Responsible Party and Timeline for Completion: Kelli Kizzee - HR Coordinator, Jessica Elliot - Payroll Coordinator, Moriah Crane - Treasurer. The process is already in place.
View Audit 332497 Questioned Costs: $1
FINDING 2024-004 Subject: Special Education Cluster (IDEA) - Activities Allowed or Unallowed Federal Agency: Department of Education Federal Program: Special Education Grants to States, Special Education Preschool Grants Assistance Listing Number: 84.027 Federal Award Numbers and Years (or Other...
FINDING 2024-004 Subject: Special Education Cluster (IDEA) - Activities Allowed or Unallowed Federal Agency: Department of Education Federal Program: Special Education Grants to States, Special Education Preschool Grants Assistance Listing Number: 84.027 Federal Award Numbers and Years (or Other Identifying Numbers): H027A220084, H027A230084 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Activities Allowed or Unallowed, Allowable Costs/Cost Principles Audit Finding: Material Weakness Condition: An effective internal control system was not in place at the School District to ensure compliance with requirements related to the Special Education Cluster and Activities Allowed or Unallowed. Context: During the testing of a sample of 40 payroll disbursements charged to the Special Education Cluster during the audit period, the following exceptions were noted: • For eight transactions selected, management was unable to provide an approved contract to support the selected employees' bi-weekly pay rate. • For two transactions selected, management was unable to provide approved timecards for the selected hourly employee and time period. • For seven transactions selected, management was unable to provide time and effort logs to support the allocation of one employee's salary between the federal grant and the Education fund. The lack of controls was systematic throughout the audit period. Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Management will ensure records of approved contracts and approved timecards are maintained for all employees. Management will ensure payroll charged to federal awards is reviewed each pay period for allowability. The HR Coordinator is currently storing each contract both hard copy in the employee file and digitally in our software. The Deputy Treasurer/Payroll Coordinator will review the distribution report prior to payroll submission. As time cards are being approved in our software system, a print out of the approvals will be maintained for each payroll. The Treasurer will review and sign off on the distribution and approval report for each payroll. Responsible Party and Timeline for Completion: Kelli Kizzee - HR Coordinator, Jessica Elliot - Payroll Coordinator, Moriah Crane - Treasurer. The process is already except for the printed time card approval report which will be in place starting with the January 2025 payrolls.
Corrective Action Plan: The District has developed and implemented a Federal Funds Manual. Anticipated Corrective Action Plan Completion Date: November 18, 2024 Contact Information: For additional information regarding this finding please contact Blaise Paul, Chief Business & Finance Officer, ...
Corrective Action Plan: The District has developed and implemented a Federal Funds Manual. Anticipated Corrective Action Plan Completion Date: November 18, 2024 Contact Information: For additional information regarding this finding please contact Blaise Paul, Chief Business & Finance Officer, at 414-768-6140.
Condition: The School District's controls did not prevent or detect and correct, in a timely manner, costs charged to the grant that were more than the related invoices. Planned Corrective Action: The Grant Accounting team will develop a standard operating procedure on review and approval of journal...
Condition: The School District's controls did not prevent or detect and correct, in a timely manner, costs charged to the grant that were more than the related invoices. Planned Corrective Action: The Grant Accounting team will develop a standard operating procedure on review and approval of journal entries. The Grant Account Team will provide training to Grant Compliance staff members on the defined process. Grant Compliance Senior Director and Assistant Director will be responsible for ensuring journal requests are submitted following the outlined operating procedure. Grant Accounting staff members will review submitted materials to ensure no invoice is overcharged and then process journal request. Contact person responsible for corrective action: Jeremy Vidito, CFO Anticipated Completion Date: 3/1/2025
2024-002 Finding: Allowable Costs and Allowable Activities Federal Assistance Listing Number 84.425U - COVID-19 - Elementary and Secondary School Emergency Relief Fund (ESSER III) Passed-through Colorado Department of Education Award Number - 4414/4431/9414; Award Year 2021 Summary of Finding: The D...
2024-002 Finding: Allowable Costs and Allowable Activities Federal Assistance Listing Number 84.425U - COVID-19 - Elementary and Secondary School Emergency Relief Fund (ESSER III) Passed-through Colorado Department of Education Award Number - 4414/4431/9414; Award Year 2021 Summary of Finding: The District did not have adequate internal controls in place over the ESSER grant which resulted in unallowable costs being applied to the grant and inconsistently applying indirect costs to the grant. Status: Corrective action in progress Client Planned Action: The District concurs with the recommendations and is currently developing and implementing internal controls to ensure compliance. The inadequate internal controls that caused the inconsistency in supporting payroll information involved the End-of-Year Closeout process. The District will ensure End-of-Year Closeout procedures are up to date and adhered to. These procedures will include a second review of calculations used to determine the expenditure amount in accruals, to ensure it recalculates. The District will also conduct a second review of the supporting detail used to determine Indirect Costs to ensure they are consistent with CDE recommendations and District policies and procedures. Client Responsible Party: Annette Bass, Director of Grants Completion Date: Review of department End-of Year Closeout process began in September 2024. Adjustments and revisions will be made to these processes as needed, prior to End-of-Year Closeout, June 30, 2025.
View Audit 328203 Questioned Costs: $1
Federal Program Title: Postconviction Testing of DNA Evidence; Capital Case Litigation Initiative ALN: 16.820; 16.746 Recommendation: We recommend the University review its current procedures to ensure disallowable costs are not being charged allocated to federal programs. Explanation of disagreemen...
Federal Program Title: Postconviction Testing of DNA Evidence; Capital Case Litigation Initiative ALN: 16.820; 16.746 Recommendation: We recommend the University review its current procedures to ensure disallowable costs are not being charged allocated to federal programs. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: Boise State University is reminding faculty and staff about lobbying and the basics of charging costs to a sponsored project with an emphasis on cost allocability. Name(s) of the contact person(s) responsible for corrective action: Jen Lutke Planned completion date for corrective action plan: December 31, 2024
View Audit 327688 Questioned Costs: $1
Finding 504381 (2024-001)
Significant Deficiency 2024
Corrective Steps Taken – The District will implement the reinforcement of its internal controls. Expenditures will be verified against the MDE approved budget.
Corrective Steps Taken – The District will implement the reinforcement of its internal controls. Expenditures will be verified against the MDE approved budget.
Finding 503946 (2024-001)
Significant Deficiency 2024
The Payroll Department has taken immediate action to develop additional safeguards to avoid duplicate pay. When Central Payroll adds to a payline, we will notify the requestor to inform them of this action and ask that they review their payline for accuracy. This should trigger a response from the r...
The Payroll Department has taken immediate action to develop additional safeguards to avoid duplicate pay. When Central Payroll adds to a payline, we will notify the requestor to inform them of this action and ask that they review their payline for accuracy. This should trigger a response from the requestor if they had also added the missing hours via a CU Special Pay. Additionally, as of 06/21/2024, the Late Timesheet option was turned off on CU Special Pay to strengthen controls. Individuals now contact payroll@clemson.edu for assistance. Once contacted the payroll/timekeeping team will update the timecard and ensure the missed pay is added to the next payroll cycle, assuming an emergency/off-cycle check is not needed. The College of Engineering and Applied Sciences (CECAS) will take action to strengthen internal controls to ensure accuracy and compliance. We will establish clear procedures to verify employee payroll data via paylines, as well as cross checking with CU Payroll to ensure changes are properly documented and authorized. We will provide ongoing training for departmental payroll staff on best practices and compliance requirements. Anticipated Completion Date: September 17, 2024 Person Responsible: Central Payroll – Ami Hood, Payroll Director; CECAS – Keri Cortese, Director of Procurement and Payroll Operations Contact/Responsible Party: Ami Hood, Payroll Director Contact Information: hooda@clemson.edu
View Audit 326225 Questioned Costs: $1
2024-005 Period of Performance Corrective action planned: The Fiscal Supervisor and/or the Director of Fiscal Operations will review expenditures before payment to ensure that GAAP and the accrual basis of accounting are being followed. Month-end closing procedures will include a review of all pre...
2024-005 Period of Performance Corrective action planned: The Fiscal Supervisor and/or the Director of Fiscal Operations will review expenditures before payment to ensure that GAAP and the accrual basis of accounting are being followed. Month-end closing procedures will include a review of all prepaid expenses to assure that a separate schedule is maintained and reconciled to the general ledger. Anticipated completion date: 11-30-2024 Contact person responsible for corrective action: Cathy Liles, Director of Fiscal Operations
View Audit 322303 Questioned Costs: $1
Finding #2023-002 – Statement of Condition: During our testing of period of performance, we noted that one transaction occurred prior to the period of performance beginning Response: Management concurs with the finding and is updating their internal controls around period of performance. The matter ...
Finding #2023-002 – Statement of Condition: During our testing of period of performance, we noted that one transaction occurred prior to the period of performance beginning Response: Management concurs with the finding and is updating their internal controls around period of performance. The matter was corrected by December 31, 2024
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.
Action Taken in Response to Finding: In 2023, invoices were submitted using a format aligned with initial guidance from the Colorado Department of Human Services (CDHS), reflecting a per-learner, activity-based approach. Beginning in October 2024, updated guidance required invoices to be based on ac...
Action Taken in Response to Finding: In 2023, invoices were submitted using a format aligned with initial guidance from the Colorado Department of Human Services (CDHS), reflecting a per-learner, activity-based approach. Beginning in October 2024, updated guidance required invoices to be based on actual costs incurred, including the use of supporting documentation such as timesheets and receipts to substantiate costs. As of October 2025, CDHS updated reimbursement requirements to no longer require supporting documentation at the time of invoice submission. However, complete supporting documentation is maintained and provided upon request for monitoring or audit purposes. Standardized Excel-based tools provided by CDHS are utilized for reimbursement submission (Invoice and Ledger). Transaction-level cost tracking was implemented to ensure allowable and eligible costs are recorded and supported. Financial and grant-related policies were previously maintained and were subsequently standardized and incorporated into Financial Policies and Procedures in 2023, with a comprehensive Grant Management framework implemented in May 2026. Control Enhancement: Beginning in 2025, all costs applied toward matching requirements are recorded and tracked at the transaction level within the accounting system and are fully supported by source documentation. Matching contributions must: • Be based on actual, allowable, and allocable costs • Be verifiable from accounting records • Not include estimated or budgeted amounts A standardized approach has been implemented to ensure that matching costs are derived from the same underlying financial data used for reimbursable costs. Monitoring & Review: • Matching costs are reviewed by the Senior Accountant prior to inclusion in reimbursement requests • A secondary monthly review is performed by the Director of Finance & Operations to validate accuracy, allowability, and compliance with matching requirements • Any discrepancies between recorded costs and matching allocations are identified and resolved prior to submission Testing & Validation: • Beginning June 2026, quarterly internal reviews will be conducted to test a sample of matching costs for compliance with documentation and allowability requirements • Testing will confirm that matching costs are fully supported and traceable to accounting records • Results will be documented and tracked, and any identified deficiencies will require corrective action Documentation & Evidence: • Supporting documentation for matching costs is maintained in Microsoft Teams • Matching calculations and supporting detail are retained and available for audit or monitoring • Review and approval are evidenced via email approval and retained as part of the audit record 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 monitoring, quarterly testing, and policy updates will continue. Status: • Transaction-level tracking of matching costs: Implemented 2025 • Updated invoicing methodology: Implemented October 2024; revised October 2025 • Cost Sharing policy: Implemented May 2026 • Grant Management framework; Incorporated in Financial Policy and Procedures on May 2026. • Quarterly internal reviews will be conducted to test a sample of matching costs for compliance with documentation and allowability requirements: June 2026
Action Taken in Response to Finding: In 2023, invoices were submitted using a format aligned with initial guidance from the Colorado Department of Human Services (CDHS), reflecting a per-learner, activity-based approach. Beginning in October 2024, updated guidance required invoices to be based on ac...
Action Taken in Response to Finding: In 2023, invoices were submitted using a format aligned with initial guidance from the Colorado Department of Human Services (CDHS), reflecting a per-learner, activity-based approach. Beginning in October 2024, updated guidance required invoices to be based on actual costs incurred, supported by documentation such as timesheets and receipts. As of October 2025, CDHS no longer required supporting documentation at the time of submission; however, supporting documentation continues to be maintained and is provided upon request for monitoring or audit purposes. Standardized Excel-based tools provided by CDHS are utilized for reimbursement submission (Invoice and Ledger). Transaction-level cost tracking was implemented to ensure allowable and eligible costs are recorded and supported. Financial and grant-related policies were standardized and incorporated into Financial Policies and Procedures in May 2024, with a comprehensive grant management framework implemented in May 2026. Control Enhancement: Beginning in 2025, all grant-related expenditures are recorded and tracked at the transaction level within the accounting system. Each transaction must include appropriate supporting documentation and be coded to the correct funding source. A standardized payroll-to-invoice reconciliation process has been implemented to ensure that all costs charged to federal awards are allowable, allocable, and properly supported. Monitoring & Review: • Costs are reviewed by the Senior Accountant prior to inclusion in reimbursement requests • A secondary monthly review is performed by the Director of Finance & Operations to validate allowability, completeness, and alignment with funding requirements • Exceptions are documented and resolved prior to submission Testing & Validation: • Beginning in June 2026, quarterly internal reviews will be conducted to test a sample of transactions for compliance with documentation and allowability requirements • Results will be documented and tracked, and any identified deficiencies will require corrective action Documentation & Evidence: • Supporting documentation is maintained in Microsoft Teams / SharePoint • Review and approval are evidenced via email approval and retained as part of the audit record Control Owner(s): • Director of Finance & Operations • Finance Team Responsible Party: Helen Young Hayes, Founder / Chief Executive Officer, in coordination with the Finance Staff Anticipated Completion Date: All corrective actions will be implemented as of June 30, 2026. Ongoing monitoring, quarterly testing, and policy updates will continue.
Item 2023.007 – Period of Performance Recommendation The Center should develop written procedures to review all expenditures to ensure they are within the proper period of performance of the grant. Repeat Finding Yes Action Taken Island Health Care will take the following actions to address this rec...
Item 2023.007 – Period of Performance Recommendation The Center should develop written procedures to review all expenditures to ensure they are within the proper period of performance of the grant. Repeat Finding Yes Action Taken Island Health Care will take the following actions to address this recommendation: • Conduct a pre-approval of expenditures, verifying that the expense is allowable under the grant terms and falls within the period of performance • Utilize a pre-approval form that includes details of the proposed expenditure, its necessity, and confirmation in the form of authorized signatures that it is within the grant period. • Require all relevant supporting documentation with the date the expense was incurred, ensuring it falls within the grant's period of performance. This is further reviewed by the CFO who will verify that the expenditure meets all requirements and is then able to record it in the accounting system. • Conduct regular reviews of expenditures to ensure compliance with the grant period and maintain audit trail • Review these procedures annually to ensure they ongoing compliance with the grant's period of performance
Recommendation We recommend that the Center consistently enforce its internal controls over payroll to ensure that the times sheet and pay rates are reviewed and approved by the appropriate supervisor. Additionally, we recommend that the Center consistently reinforces its internal controls over nonp...
Recommendation We recommend that the Center consistently enforce its internal controls over payroll to ensure that the times sheet and pay rates are reviewed and approved by the appropriate supervisor. Additionally, we recommend that the Center consistently reinforces its internal controls over nonpayroll expenditures to ensure all expenditures were approved by the appropriate supervisor. Repeat Finding Yes Action Taken Action Taken Island Health Care will take the following actions to address this recommendation: Timesheet and Payrate Review and Approval: • Standardize timesheet submission and approval process • Utilize an electronic timesheet system to document the verification of employee payrates and ensure there is a detailed audit trail that records all submissions, reviews, and approvals by supervisors • Conduct regular audits to verify timesheets and payrates are reviewed and approved by supervisors Non Payroll Expenditures: • Evaluate and improve upon existing processes to ensure internal controls over non payroll expenditures are working. This includes enforcement of approval policies with mandatory documentation and regular monitoring throughout the process for a clear audit trail • Conduct regular audits to verify nonpayroll expenditures have been reviewed and approved by supervisors
Finding No.: 2023-006 AL Program: 84.027 Special Education Cluster - Grants to States (IDEA, Part B) Area: Activities Allowed/Unallowed, Allowable Costs/Cost Principles Questioned Costs: $5,130 Views of Auditee and Corrective Action Plan: Management’s Position: PSS Management concurs with the audit ...
Finding No.: 2023-006 AL Program: 84.027 Special Education Cluster - Grants to States (IDEA, Part B) Area: Activities Allowed/Unallowed, Allowable Costs/Cost Principles Questioned Costs: $5,130 Views of Auditee and Corrective Action Plan: Management’s Position: PSS Management concurs with the audit findings and the associated questioned costs. Financial 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. Corrective Action Plan: To prevent future occurrences and ensure full compliance with federal cost principles, PSS will implement the following: I. Review of Travel Authorization Requirements: PSS will conduct a review of its travel policy to require a written statement of alignment with program goals or objectives for every travel request. This statement must explicitly document how the travel is necessary and reasonable for the performance of the specific federal award. II. Centralized Digital Documentation Protocol: To resolve the inadequate systematic filing issue, PSS implemented a protocol to improve its digital filing procedures. All supporting documents, including invoices, boarding passes, approved timesheets, and pay rate authorizations, must be uploaded and verified before the final liquidation of any federal drawdowns. III. Strengthening Review Process: Finalize expanded SOPs and policies to include more detail on time and effort reporting (including differential pay) and travel justifications specific to allowability determinations that are currently in draft including an analysis rubric and checklist for review. Where necessary, program specific supplemental guidance for allowability determinations will be provided. PSS central office staff participated in live training in October 2025. Refresher training on cost principles will be required annually for staff making allowability determinations. Proposed Completion Date: PSS is currently in the process of implementing these corrective actions with full implementation by August 2026. Name of Contact Person and Title: Contact: Jacqueline Che, Federal Programs Officer Email Address: jacqueline.che@cnmipss.org
Condition: Management lacked adequate controls at the transaction level to ensure compliance with activities allowed or unallowed, allowable cost principles, and period of performance, which resulted in the improper inclusion of duplicate costs and costs from a prior fiscal period. Further, a lack o...
Condition: Management lacked adequate controls at the transaction level to ensure compliance with activities allowed or unallowed, allowable cost principles, and period of performance, which resulted in the improper inclusion of duplicate costs and costs from a prior fiscal period. Further, a lack of effective controls over financial reporting and over preparation of the SEFA resulted in management reporting activity on a cash basis, inconsistent with the basis of reporting established in Note 1 and with requirements established by the passthrough funding agency. Planned Corrective Action: Management will implement a new review, reconciliation and oversight process to ensure that compliance with activities allowed or unallowed, allowable cost principles, and period of performance standards are followed for future grant submissions. Contact person responsible for corrective action: Louise Arzu, Vice President, Finance Anticipated Completion Date: 9/30/2024
Allowable Costs/General Disbursements Recommendation: We recommend that management reinforce the consistent execution and documentation of existing disbursement approval and documentation procedures. This should include ensuring that all expenditure charged to federal awards are appropriately approv...
Allowable Costs/General Disbursements Recommendation: We recommend that management reinforce the consistent execution and documentation of existing disbursement approval and documentation procedures. This should include ensuring that all expenditure charged to federal awards are appropriately approved and supported by sufficient documentation prior to payment, and that management periodically monitors compliance with these procedures to confirm they are operating as designed. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Reoccurring bills such as utilities, loan payments, contract services and credit card payments do not require an expense request to be included for on going bills. We will review our procedures and update our financial policy. Our financial process includes at least two reviews prior to creating a bill in our accounting system, payments are reviewed by the director or the Deputy Director when signed. We do not use a auto signature all checks are reviewed. The Grantor billing is a P&L detailed report for that grant. This is sorted into grant line items designated billable and non-billable for compliance. Total program cost and billable to grant are tracked every month, by the grant finance manager for compliance prior to billing any grants. Timecards are reviewed, expense requests are reviewed and payments are reviewed. Prior to submission of the invoice to grantor. Name(s) of the contact person(s) responsible for corrective action: Cora Alyea Planned completion date for corrective action plan: Completed in 2023
Finding No.: 2023-041 AL Program: 93.489/93.575/93.596 – CCDF Cluster COVID-19 93.489/93.575/93.596 CCDF Cluster Area: Period of Performance Questioned Costs: $95,367 Contact Person(s): Roselle Teregeyo, CCDF Co-Administrator/Accountant Corrective Action Plan: Condition 1 & 3a: The CNMI CCDF Program...
Finding No.: 2023-041 AL Program: 93.489/93.575/93.596 – CCDF Cluster COVID-19 93.489/93.575/93.596 CCDF Cluster Area: Period of Performance Questioned Costs: $95,367 Contact Person(s): Roselle Teregeyo, CCDF Co-Administrator/Accountant Corrective Action Plan: Condition 1 & 3a: The CNMI CCDF Program agrees with this finding. To strengthen oversight and ensure adequate accountability over Federal awards, the CNMI CCDF Program has implemented a filing system Finding No.: 2023-041, continued AL Program: 93.489/93.575/93.596 – CCDF Cluster COVID-19 93.489/93.575/93.596 CCDF Cluster Area: Period of Performance Questioned Costs: $95,367 Contact Person(s): Roselle Teregeyo, CCDF Co-Administrator/Accountant Corrective Action Plan: where all documents relating to a federal award are properly maintained and labeled for accessibility. This system became effective on October 1, 2025. Proposed Completion Date: Completed Condition 2 & 3b: The CNMI CCDF Program agrees with this finding and acknowledges the need to strengthen internal controls to ensure that all expenditures are cleared by the bank before the end of the liquidation period. The CCDF Program will coordinate with the Department of Finance (DOF) Financial Services Division regarding the establishment of a monitoring log that tracks all checks issued and cleared by vendor and office. Once this log is implemented, the CCDF Program will request regular copies to allow responsible staff to verify whether payments have cleared and to follow up with vendors as needed to ensure timely bank reconciliation. To streamline payment processing and enhance compliance with federal cash management requirements, the CCDF Program is exploring a transition to a fully ACH based payment system. Moving to electronic payments will reduce delays associated with paper checks, improve tracking and reconciliation, and strengthen internal controls over disbursements. This corrective action is currently in progress. The CCDF Program anticipates full implementation of the monitoring process and/or ACH transition by October 1, 2026. Proposed Completion Date: October 1, 2026
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