Corrective Action Plans

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Mount Sinai Foundation, Incorporated 703 Blue Street Fayetteville, North Carolina 28301 CORRECTIVE ACTION PLAN December 3, 2025 U.S. Department of Housing and Urban Development Five Points Plaza Building 40 Marietta Street Atlanta, Georgia 30303 Mount Sinai Foundation, Incorporated respectfully subm...
Mount Sinai Foundation, Incorporated 703 Blue Street Fayetteville, North Carolina 28301 CORRECTIVE ACTION PLAN December 3, 2025 U.S. Department of Housing and Urban Development Five Points Plaza Building 40 Marietta Street Atlanta, Georgia 30303 Mount Sinai Foundation, Incorporated respectfully submits the following Corrective Action Plan for the year ended December 31, 2023. Bernard Robinson & Company, L.L.P. 1501 Highwoods Blvd., Suite 300 Post Office Box 19608 Greensboro, North Carolina 27419-9608 The findings for the year ended December 31, 2023 Schedule of Findings and Questioned Costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS - Financial Statement Audit and Federal Award Program Audits Finding 2023-001 - U.S. Department of Housing and Urban Development, Mortgage Insurance Rental and Cooperative Housing for Moderate Income Families and Elderly, Market Interest Rate (Sections 221d(3) and (4) Multifamily - Market Rate Housing), CFDA #14.135 Recommendation: That management review/enhance its accounting and internal control procedures to ensure that all key accounts are reconciled and reviewed with supporting evidence of such review. Action Taken: We agree with Finding 2023-001 and the recommendation described in the accompanying schedule of findings and questioned costs. The Corporation has executed a new management agreement with Remnant Management Inc. effective October 1, 2024. Remnant Management Inc. will ensure that all transactions are properly recorded and that key accounts are reconciled and reviewed on a periodic basis beginning October 1, 2024 and going forward. Sincerely yours, Shannon Pow President Remnant Management, Inc. Managing Agent effective October 1, 2024
• Implement procedural reviews and standardized templates to enhance subrecipient oversight, monitoring, and documentation. • Note: Questioned costs unwarranted as no tests conducted on state-level expenditures. 9/30/2026 Mr. Marcus Samo, Secretary of FSMNG Health Email: marcus.samu@fsmhealth.gov.fm
• Implement procedural reviews and standardized templates to enhance subrecipient oversight, monitoring, and documentation. • Note: Questioned costs unwarranted as no tests conducted on state-level expenditures. 9/30/2026 Mr. Marcus Samo, Secretary of FSMNG Health Email: marcus.samu@fsmhealth.gov.fm
• Monitor submission of SF-425 reports quarterly via staff meetings to ensure timely and accurate filing. • Enhance file maintenance for deeper reviews and accessibility. • Note: Re-review located 100% of cited "missing" reports; underlying support was available. Tagging is not mandatory. 9/30/2026 ...
• Monitor submission of SF-425 reports quarterly via staff meetings to ensure timely and accurate filing. • Enhance file maintenance for deeper reviews and accessibility. • Note: Re-review located 100% of cited "missing" reports; underlying support was available. Tagging is not mandatory. 9/30/2026 Ms. Senny Phillip, Asst. Secretary of Investment & International Financing Email: senny.phillip@gov.fm
• Strengthen monitoring controls to verify period of performance, including obligation/incurrence and liquidation timelines. • Collaborate with grantors to clarify and document allowable liquidation periods for drawdowns. • Implement systematic filing of supporting documents for easy retrieval. • No...
• Strengthen monitoring controls to verify period of performance, including obligation/incurrence and liquidation timelines. • Collaborate with grantors to clarify and document allowable liquidation periods for drawdowns. • Implement systematic filing of supporting documents for easy retrieval. • Note: Drawdowns conducted in close collaboration with grantors, confirming compliance with agreed terms. 9/30/2026 Ms. Senny Phillip, Asst. Secretary of Investment & International Financing Email: senny.phillip@gov.fm
• Review all files for completeness before submission to auditors starting FY2024 audit onward. • Enhance file organization for deeper reviews and systematic access to drawdown reports, invoices, and payments. • Note: Re-review located >90% of cited "missing" documents; underlying support was availa...
• Review all files for completeness before submission to auditors starting FY2024 audit onward. • Enhance file organization for deeper reviews and systematic access to drawdown reports, invoices, and payments. • Note: Re-review located >90% of cited "missing" documents; underlying support was available. Management believed all requested files were provided. 9/30/2026 Ms. Christina Elnei, Asst. Secretary of National Treasury Email: christina.elnei@dofa.gov.fm
• Enhance documentation management and quarterly monitoring of performance/reporting requirements through staff coordination. • Note: Re-review of files located nearly 100% of cited documents; underlying support was available. Tagging is not mandatory; future audits to apply professional skepticism ...
• Enhance documentation management and quarterly monitoring of performance/reporting requirements through staff coordination. • Note: Re-review of files located nearly 100% of cited documents; underlying support was available. Tagging is not mandatory; future audits to apply professional skepticism through deeper file reviews. 9/30/2026 Mr. Kemsky Sigrah, Manager, Office of Compact Management Email: Kemskys22@gmail.com & Ms. Senny Phillip, Asst. Secretary Email: senny.phillip@gov.fm
• Review all files for completeness before submission to auditors starting FY2024 onward. • Enhance systematic filing and accessibility of drawdown reports and supporting documentation. • Note: Re-review located >90% of cited "missing" documents; underlying support was available. Tagging is not mand...
• Review all files for completeness before submission to auditors starting FY2024 onward. • Enhance systematic filing and accessibility of drawdown reports and supporting documentation. • Note: Re-review located >90% of cited "missing" documents; underlying support was available. Tagging is not mandatory. 12/15/25 (SPAF submitted) / Ongoing 09/30/26 Ms. Christina Elnei, Asst. Secretary of National Treasury Email: christina.elnei@dofa.gov.fm
• Train compliance officers on reporting processes and monitor submissions quarterly. • Improve file maintenance system with deeper reviews for easy retrieval. • Note: Re-review located all cited "missing" reports; underlying support was available. Tagging is not mandatory. 9/30/2026 Ms. Christina E...
• Train compliance officers on reporting processes and monitor submissions quarterly. • Improve file maintenance system with deeper reviews for easy retrieval. • Note: Re-review located all cited "missing" reports; underlying support was available. Tagging is not mandatory. 9/30/2026 Ms. Christina Elnei, Asst. Secretary of National Treasury Email: christina.elnei@dofa.gov.fm
• Review procurement processes and require implementing agencies to verify suspension and debarment status via SAM.gov, with documentation for all transactions. • Implement formal procedures (e.g., printed checks, certifications) prior to covered transactions. · Note: Questioned costs unwarranted as...
• Review procurement processes and require implementing agencies to verify suspension and debarment status via SAM.gov, with documentation for all transactions. • Implement formal procedures (e.g., printed checks, certifications) prior to covered transactions. · Note: Questioned costs unwarranted as no evidence of suspended/debarred vendors or noncompliance established. 9/30/2026 Mr. Marcus Samo, Secretary of FSMNG Health Email: marcus.samu@fsmhealth.gov.fm
• Maintain tailored Fixed Asset Register (FAR) for applicable programs. • Deploy staff to conduct physical asset counts and quarterly monitoring for compliance. • Note: Tailored FAR was provided during audit; full national FAR outside scope. 9/30/2026 Mr. Marcus Samo, Secretary of FSMNG Health Email...
• Maintain tailored Fixed Asset Register (FAR) for applicable programs. • Deploy staff to conduct physical asset counts and quarterly monitoring for compliance. • Note: Tailored FAR was provided during audit; full national FAR outside scope. 9/30/2026 Mr. Marcus Samo, Secretary of FSMNG Health Email: marcus.samu@fsmhealth.gov.fm
Disagree with adverse compliance opinion and findings, as auditors applied Uniform Guidance (2 CFR Part 200) requirements, which are inapplicable to Compact sector grants (ALN 15.875) governed exclusively by the Compact of Free Association, as amended, and the Fiscal Procedures Agreement (FPA). • Re...
Disagree with adverse compliance opinion and findings, as auditors applied Uniform Guidance (2 CFR Part 200) requirements, which are inapplicable to Compact sector grants (ALN 15.875) governed exclusively by the Compact of Free Association, as amended, and the Fiscal Procedures Agreement (FPA). • Request U.S. Department of the Interior, Office of Insular Affairs, to disregard these findings for grant administration and questioned costs resolution, as they do not reflect noncompliance with Compact/FPA standards. • Maintain commitment to accountability under Compact/FPA standards. 9/30/2026 Ms. Christina Elnei, Asst. Secretary of National Treasury (primary contact) Email: christina.elnei@dofa.gov.fm
Disagree with adverse compliance opinion and findings, as auditors applied Uniform Guidance (2 CFR Part 200) requirements, which are inapplicable to Compact sector grants (ALN 15.875) governed exclusively by the Compact of Free Association, as amended, and the Fiscal Procedures Agreement (FPA). • Re...
Disagree with adverse compliance opinion and findings, as auditors applied Uniform Guidance (2 CFR Part 200) requirements, which are inapplicable to Compact sector grants (ALN 15.875) governed exclusively by the Compact of Free Association, as amended, and the Fiscal Procedures Agreement (FPA). • Request U.S. Department of the Interior, Office of Insular Affairs, to disregard these findings for grant administration and questioned costs resolution, as they do not reflect noncompliance with Compact/FPA standards. • Maintain commitment to accountability under Compact/FPA standards. 9/30/2026 Ms. Christina Elnei, Asst. Secretary of National Treasury (primary contact) Email: christina.elnei@dofa.gov.fm
Disagree with adverse compliance opinion and findings, as auditors applied Uniform Guidance (2 CFR Part 200) requirements, which are inapplicable to Compact sector grants (ALN 15.875) governed exclusively by the Compact of Free Association, as amended, and the Fiscal Procedures Agreement (FPA). • Re...
Disagree with adverse compliance opinion and findings, as auditors applied Uniform Guidance (2 CFR Part 200) requirements, which are inapplicable to Compact sector grants (ALN 15.875) governed exclusively by the Compact of Free Association, as amended, and the Fiscal Procedures Agreement (FPA). • Request U.S. Department of the Interior, Office of Insular Affairs, to disregard these findings for grant administration and questioned costs resolution, as they do not reflect noncompliance with Compact/FPA standards. • Maintain commitment to accountability under Compact/FPA standards. 9/30/2026 Ms. Christina Elnei, Asst. Secretary of National Treasury (primary contact) Email: christina.elnei@dofa.gov.fm
Disagree with adverse compliance opinion and findings, as auditors applied Uniform Guidance (2 CFR Part 200) requirements, which are inapplicable to Compact sector grants (ALN 15.875) governed exclusively by the Compact of Free Association, as amended, and the Fiscal Procedures Agreement (FPA). • Re...
Disagree with adverse compliance opinion and findings, as auditors applied Uniform Guidance (2 CFR Part 200) requirements, which are inapplicable to Compact sector grants (ALN 15.875) governed exclusively by the Compact of Free Association, as amended, and the Fiscal Procedures Agreement (FPA). • Request U.S. Department of the Interior, Office of Insular Affairs, to disregard these findings for grant administration and questioned costs resolution, as they do not reflect noncompliance with Compact/FPA standards. • Maintain commitment to accountability under Compact/FPA standards. 9/30/2026 Ms. Christina Elnei, Asst. Secretary of National Treasury (primary contact) Email: christina.elnei@dofa.gov.fm
Disagree with adverse compliance opinion and findings, as auditors applied Uniform Guidance (2 CFR Part 200) requirements, which are inapplicable to Compact sector grants (ALN 15.875) governed exclusively by the Compact of Free Association, as amended, and the Fiscal Procedures Agreement (FPA). • Re...
Disagree with adverse compliance opinion and findings, as auditors applied Uniform Guidance (2 CFR Part 200) requirements, which are inapplicable to Compact sector grants (ALN 15.875) governed exclusively by the Compact of Free Association, as amended, and the Fiscal Procedures Agreement (FPA). • Request U.S. Department of the Interior, Office of Insular Affairs, to disregard these findings for grant administration and questioned costs resolution, as they do not reflect noncompliance with Compact/FPA standards. • Maintain commitment to accountability under Compact/FPA standards. 9/30/2026 Ms. Christina Elnei, Asst. Secretary of National Treasury (primary contact) Email: christina.elnei@dofa.gov.fm
• Disagree with adverse compliance opinion and findings, as auditors applied Uniform Guidance (2 CFR Part 200) requirements, which are inapplicable to Compact sector grants (ALN 15.875) governed exclusively by the Compact of Free Association, as amended, and the Fiscal Procedures Agreement (FPA). • ...
• Disagree with adverse compliance opinion and findings, as auditors applied Uniform Guidance (2 CFR Part 200) requirements, which are inapplicable to Compact sector grants (ALN 15.875) governed exclusively by the Compact of Free Association, as amended, and the Fiscal Procedures Agreement (FPA). • Request U.S. Department of the Interior, Office of Insular Affairs, to disregard these findings for grant administration and questioned costs resolution, as they do not reflect noncompliance with Compact/FPA standards. • Maintain commitment to accountability under Compact/FPA standards. 9/30/2026 Ms. Christina Elnei, Asst. Secretary of National Treasury (primary contact) Email: christina.elnei@dofa.gov.fm
Views of responsible officials and planned corrective action: During the transition to the new Executive Director, payroll transaction procedures have been put into effect in order to ensure that pay increases, timesheets, and performance reviews are properly reviewed and approved by management, BOD...
Views of responsible officials and planned corrective action: During the transition to the new Executive Director, payroll transaction procedures have been put into effect in order to ensure that pay increases, timesheets, and performance reviews are properly reviewed and approved by management, BOD, or the executive director. Contact Persons: Carly Burwell, Board Treasurer & Bethany Alhaidri, Executive Director
Dismissal of current bookkeepers, and hired on CPA to assist with implementation of additional internal controls.
Dismissal of current bookkeepers, and hired on CPA to assist with implementation of additional internal controls.
Dismissal of current bookkeepers, and hired on CPA to assist with implementation of additional internal controls.
Dismissal of current bookkeepers, and hired on CPA to assist with implementation of additional internal controls.
McGrath Native Village agrees with the finding and is in the process of engaging with the current auditors for subsequent delinquent audits.
McGrath Native Village agrees with the finding and is in the process of engaging with the current auditors for subsequent delinquent audits.
2023-004 TIMING OF AUDIT COMPLETION - SIGNIFICANT DEFICIENCY Federal Program Community Development Block Grant/Entitlement Grant ALN 14.218; passed through the County of Berks HOME Investment Partnership Program ALN 14.239; passed through the County of Berks. Emergency Rental Assistance ALN 21.023; ...
2023-004 TIMING OF AUDIT COMPLETION - SIGNIFICANT DEFICIENCY Federal Program Community Development Block Grant/Entitlement Grant ALN 14.218; passed through the County of Berks HOME Investment Partnership Program ALN 14.239; passed through the County of Berks. Emergency Rental Assistance ALN 21.023; passed through the County of Berks. Coronavirus State and Local Fiscal Recovery ALN 21.027; passed through the Commonwealth of Pennsylvania Department of Community and Economic Development. Condition The Authority did not submit the Single Audit reporting package and Data Collection Form to the Federal Audit Clearinghouse within the required timeframe of nine months after the end of the audit period. The 2022 reporting package was submitted on May 7, 2025, which was after the one month due date of September 30, 2023. In addition, the 2023 reporting package was not submitted by the September 30, 2024 due date. Recommendation We recommend that the Authority continue to execute their plan to bring the accounting records up to date and submit outstanding audited financial statements to the Federal Audit Clearinghouse. Management Response The Authority will continue to execute their plan to bring the accounting records up to date and submit outstanding audited financial statements to the Federal Audit Clearinghouse.
2023-003 ALLOWABLE ACTIVITIES AND ALLOWABLE COSTS - SIGNIFICANT DEFICIENCY Federal Program Emergency Rental Assistance ALN 21.023; passed through the County of Berks. Condition/Cause For 23 out of 60 cases tested, the amount paid for rent or utilities did not agree to a lease agreement or bills on f...
2023-003 ALLOWABLE ACTIVITIES AND ALLOWABLE COSTS - SIGNIFICANT DEFICIENCY Federal Program Emergency Rental Assistance ALN 21.023; passed through the County of Berks. Condition/Cause For 23 out of 60 cases tested, the amount paid for rent or utilities did not agree to a lease agreement or bills on file for the following reasons: (I) clerical errors, (2) duplicate payments due to multiple staff working on the same file, or (3) failure to request or maintain support before payment was made. Known questioned costs associated with the 23 exceptions noted in our testing were $9,867. Based on the projection of the sampling results to the remaining population, we project additional likely questioned costs of approximately $173,400. The Authority did not have controls in place to detect the noncompliance prior to issuing payments. We recommend the Authority revisit and strengthen internal controls over tracking individual payments for transactions entered as batches, particularly when related to federal awards. We encourage the Authority to continue working to identify the individual transactions making up the remainder of the federal expenditures under this program. We also recommend the Authority revisit and strengthen internal controls over allowable activities and allowable costs related to grant programs. Management Response The Authority launched the Emergency Rental Assistance Program (ERAP) with little administrative guidance from the U.S. Treasury. The Authority contracted with the Berks Coalition to End Homelessness (BCEH) to undertake various aspects of the Emergency Rental Assistance Program and in the late fall of 2021, the Authority began reviewing all case documentation provided by BCEH. This review eliminated the vast majority of the errors noted. The Authority also updated case documentation checklists as well as provided training for staff involved with ERAP. Current Status of Corrective Action Plan The Authority has resolved this finding. An additional review was added at the close of each case.
2023-002 PROGRAM INCOME - MATERIAL WEAKNESS Federal Program Community Development Block Grant/Entitlement Grant ALN 14.218; passed through the County of Berks and HOME Investment Partnership Program ALN 14.239; passed through the County of Berks. Condition/Cause During our testing of program income ...
2023-002 PROGRAM INCOME - MATERIAL WEAKNESS Federal Program Community Development Block Grant/Entitlement Grant ALN 14.218; passed through the County of Berks and HOME Investment Partnership Program ALN 14.239; passed through the County of Berks. Condition/Cause During our testing of program income received during 2023, it was noted that the Authority did not report all program income received into IDIS. As a result of not entering all program income into IDIS, our testing indicated that new entitlement funds were drawn down prior to utilizing all available program income on hand. The Authority utilizes a separate general ledger account in the financial reporting software to record all program income received for each federal grant program. The Fiscal Officer enters the program income into IDIS. No internal control existed to ensure the completeness or accuracy of the program income information entered into IDIS. Recommendation We recommend the Authority develop and implement an internal control procedure to ensure that all program income is entered timely within the IDIS system. Prior to drawing down new entitlement funding, the program income general ledger account associated with the grant program should be reviewed and compared to the program income reported within IDIS to ensure all program income is recorded and fully utilized before drawing down additional entitlement funding. Management Response The Authority implemented a new policy to track and document program income: a. Upon receipt of program income, it shall be entered individually into IDIS and assigned to an activity or activities within fifteen (15) calendar days of receipt. b. At the next request for funds for an activity which includes funding from program income, program income shall be used prior to requesting federal funds for the activity. c. The request for federal funds shall be prepared by the Fiscal Officer and reviewed by one of the Assistant Fiscal Officers to determine if program income is being used prior to the request of federal funds. d. If it has been determined and documented that program income is being used prior to the request for federal funds, the request shall be forwarded to the Executive Director for approval. Current Status of Corrective Action Plan This finding has been resolved by management. The new policy was implemented on April 1, 2025.
2023-001 REPORTING - SIGNIFICANT DEFICIENCY Federal Program Community Development Block Grant/Entitlement Grant ALN 14.218; passed through the County of Berks Emergency Rental Assistance ALN 21.023; passed through the County of Berks Condition/Cause The auditee did not have any documented or impleme...
2023-001 REPORTING - SIGNIFICANT DEFICIENCY Federal Program Community Development Block Grant/Entitlement Grant ALN 14.218; passed through the County of Berks Emergency Rental Assistance ALN 21.023; passed through the County of Berks Condition/Cause The auditee did not have any documented or implemented internal controls over the review of federal program reporting requirements. Reports were prepared and submitted without documentation of supervisory review or verification of accuracy and completeness. Management did not design or implement procedures to review reports prior to submission, relying solely on the preparer's knowledge without formal oversight. Recommendation We recommend that all grant reports are reviewed by a person independent of the preparer who has knowledge of the grant requirements. This review should include comparing the amounts reported to detailed support for accuracy. We also recommend the Authority review its recordkeeping procedures for documentation related to grant reporting. There should be a process in place to ensure all required documentation is maintained and filed in an orderly system that allows the Authority to locate and provide documentation when required. Management Response In general, management agrees with the finding. It should be noted that internal controls for supervisory review of reporting requirements were in place but were not written controls or processes. Reporting for the CDBG Program is accomplished through the preparation of the annual Comprehensive Annual Performance and Evaluation Repo11 CAPER). Written policies and procedures for the CAPER have been developed. Reporting for the Emergency Rental Assistance Program is accomplished through an online reporting system of the U.S. Treasury and by email to the Pennsylvania Human Services Department. Written policies and procedures have been developed.
Schools and Roads - Grants to States (Compliance) We recommend that the County establish and implement formal procedures to ensure public notices related to Title III funds are issued and documented at least 45 days prior to any obligation or expenditure. This process should include clear assignment...
Schools and Roads - Grants to States (Compliance) We recommend that the County establish and implement formal procedures to ensure public notices related to Title III funds are issued and documented at least 45 days prior to any obligation or expenditure. This process should include clear assignment of responsibilities and retention of documentation as part of grant compliance records. Management's Response: The County concurs with the findings. Responsible Individual: Allen Hisky, Clerk of the Board of Supervisors; Corrective Action Plan: The Clerk of the Board will ensure that sufficient internal controls are in place for proper notification of Public Hearings at least 45 days proper to obligation or expenditures. This process should include clear assignment of responsibilities and retention of documentation as part of grant compliance records; Anticipated Completion Date: June 30, 2026.
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