FAC Explorer

Finding 1179809 (2020-013)

Material Weakness Repeat Finding
Requirement
L
Questioned Costs
-
Year
2020
Accepted
2026-03-16
Audit: 392188
Organization: Commonwealth Healthcare Corporation (MP)
Auditor: ERNST & YOUNG (CNMI) INC

AI Summary

  • Core Issue: CHCC failed to provide any of the required monthly fiscal reports for audit review, indicating a lack of proper document management.
  • Impacted Requirements: This noncompliance with reporting requirements does not result in questioned costs, but it highlights significant gaps in CHCC's record-keeping practices.
  • Recommended Follow-Up: CHCC should implement stricter document retention policies, including creating backups and maintaining a centralized server for easy access to all submitted reports.

Finding Text

Federal Agency: U.S. Department of Health and Human Services CFDA Program: 93.323 Epidemiology and Laboratory Capacity for Infectious Diseases Award Number: 6-NU50CK000499-01-04, 6-NU50CK000499-01-05 and 5-NU50CK000499-02-00 Area: Reporting Questioned Costs: $ -0- Criteria: In accordance with the applicable reporting requirements stated in the grant agreements, monthly fiscal reports are required to be submitted for non-expired or non-terminated grants. Condition: For eight (or 100%) of eight monthly fiscal reports selected for testing, CHCC did not provide copies of the fiscal reports for inspection by the audit team. Cause: CHCC lacks controls or procedures that allows them to properly maintain submitted reports and extract copies on a timely manner. Effect: CHCC is in noncompliance with applicable reporting requirements but no questioned cost result as the finding is non-monetary in nature. Recommendation: CHCC should establish a more stringent document retention policies and procedures, such as creating backup copies or maintaining a server that contains all the submitted reports to allow them to retrieve documents on a timely manner. Views of Responsible Officials: CHCC agrees with the findings and will establish a stringent records retention policy, even for reports that were electronically completed and submitted using Grantor portals. These fiscal reports were done on the RedCap before 2023 and were readily accessible, hence ELC Program Staff did not maintain separate offline copies of the reports. When ELC transitioned to ELC CAMP, CHCC lost access to the submitted and saved reports. Hence, CHCC cannot provide supporting documents to its assertion that all reports were submitted.

Corrective Action Plan

Finding No.: 2020-013 CFDA Program: 93.323 Epidemiology and Laboratory Capacity for Infectious Diseases Area: Reporting Questioned Costs: $-0- Contact Person(s): Program Administrator, Director of DGFI and Chief Financial Officer Corrective Action Plan: CHCC agrees with the Findings and will establish a stringent records retention policy, even for reports that were electronically completed and submitted using Grantor portals. These fiscal reports were done on the RedCap before 2023 and were readily accessible, hence ELC Program Staff did not maintain separate offline copies of the reports. When ELC transitioned to ELC CAMP, we lost access to the submitted and saved reports. Hence, we cannot provide supporting documents to our assertion that all reports were submitted. Proposed Completion Date: On-going

Categories

Reporting

Other Findings in this Audit

  • 1179797 2020-004
    Material Weakness Repeat
  • 1179798 2020-005
    Material Weakness Repeat
  • 1179799 2020-006
    Material Weakness Repeat
  • 1179800 2020-004
    Material Weakness Repeat
  • 1179801 2020-005
    Material Weakness Repeat
  • 1179802 2020-006
    Material Weakness Repeat
  • 1179803 2020-007
    Material Weakness Repeat
  • 1179804 2020-008
    Material Weakness Repeat
  • 1179805 2020-009
    Material Weakness Repeat
  • 1179806 2020-010
    Material Weakness Repeat
  • 1179807 2020-011
    Material Weakness Repeat
  • 1179808 2020-012
    Material Weakness Repeat
  • 1179810 2020-014
    Material Weakness Repeat

Programs in Audit

ALN Program Name Expenditures
10.557 WIC SPECIAL SUPPLEMENTAL NUTRITION PROGRAM FOR WOMEN, INFANTS, AND CHILDREN $3.54M
93.268 IMMUNIZATION COOPERATIVE AGREEMENTS $2.73M
15.875 ECONOMIC, SOCIAL, AND POLITICAL DEVELOPMENT OF THE TERRITORIES $1.28M
93.243 SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES PROJECTS OF REGIONAL AND NATIONAL SIGNIFICANCE $1.09M
93.870 MATERNAL, INFANT AND EARLY CHILDHOOD HOME VISITING GRANT $867,903
93.323 EPIDEMIOLOGY AND LABORATORY CAPACITY FOR INFECTIOUS DISEASES (ELC) $830,826
93.982 MENTAL HEALTH DISASTER ASSISTANCE AND EMERGENCY MENTAL HEALTH $616,525
93.136 INJURY PREVENTION AND CONTROL RESEARCH AND STATE AND COMMUNITY BASED PROGRAMS $575,366
93.104 COMPREHENSIVE COMMUNITY MENTAL HEALTH SERVICES FOR CHILDREN WITH SERIOUS EMOTIONAL DISTURBANCES (SED) $527,553
93.354 PUBLIC HEALTH EMERGENCY RESPONSE: COOPERATIVE AGREEMENT FOR EMERGENCY RESPONSE: PUBLIC HEALTH CRISIS RESPONSE $523,298
93.116 PROJECT GRANTS AND COOPERATIVE AGREEMENTS FOR TUBERCULOSIS CONTROL PROGRAMS $511,398
93.898 CANCER PREVENTION AND CONTROL PROGRAMS FOR STATE, TERRITORIAL AND TRIBAL ORGANIZATIONS $440,199
93.994 MATERNAL AND CHILD HEALTH SERVICES BLOCK GRANT TO THE STATES $406,798
93.236 GRANTS TO STATES TO SUPPORT ORAL HEALTH WORKFORCE ACTIVITIES $394,060
93.069 PUBLIC HEALTH EMERGENCY PREPAREDNESS $386,129
97.088 DISASTER ASSISTANCE PROJECTS $383,157
93.959 BLOCK GRANTS FOR PREVENTION AND TREATMENT OF SUBSTANCE ABUSE $311,866
93.217 FAMILY PLANNING SERVICES $307,887
93.788 OPIOID STR $285,432
93.889 NATIONAL BIOTERRORISM HOSPITAL PREPAREDNESS PROGRAM $224,726
93.377 PREVENTION AND CONTROL OF CHRONIC DISEASE AND ASSOCIATED RISK FACTORS IN THE U.S. AFFILIATED PACIFIC ISLANDS, U.S. VIRGIN ISLANDS, AND P. R. $162,175
93.958 BLOCK GRANTS FOR COMMUNITY MENTAL HEALTH SERVICES $131,753
93.251 EARLY HEARING DETECTION AND INTERVENTION $131,198
93.165 GRANTS TO STATES FOR LOAN REPAYMENT $125,000
93.504 FAMILY TO FAMILY HEALTH INFORMATION CENTERS $81,866
93.917 HIV CARE FORMULA GRANTS $56,747
93.110 MATERNAL AND CHILD HEALTH FEDERAL CONSOLIDATED PROGRAMS $54,367
93.150 PROJECTS FOR ASSISTANCE IN TRANSITION FROM HOMELESSNESS (PATH) $48,878
93.991 PREVENTIVE HEALTH AND HEALTH SERVICES BLOCK GRANT $44,182
93.644 ADULT MEDICAID QUALITY: IMPROVING MATERNAL AND INFANT HEALTH OUTCOMES IN MEDICAID AND CHIP $33,438
93.314 EARLY HEARING DETECTION AND INTERVENTION INFORMATION SYSTEM (EHDI-IS) SURVEILLANCE PROGRAM $21,160
93.103 FOOD AND DRUG ADMINISTRATION RESEARCH $20,000
93.665 EMERGENCY GRANTS TO ADDRESS MENTAL AND SUBSTANCE USE DISORDERS DURING COVID-19 $9,691
16.575 CRIME VICTIM ASSISTANCE $5,730
93.817 HOSPITAL PREPAREDNESS PROGRAM (HPP) EBOLA PREPAREDNESS AND RESPONSE ACTIVITIES $3,573