Corrective Action Plans

Pursuant to federal regulations, Uniform Administrative Requirements Section 200.511, the following is the finding as noted in the Altarum Institute and Subsidiaries Single Audit report for the year ended December 31, 2023, and the corrective action to be completed. 2023-001 – Payroll and Fringe Benefit Charges Auditor Description of Condition and Effect. The Institute has self-reported one individual that was working on the research and development cluster that had impermissible time charged to the grant for salaries and fringes. As a result of this condition, the Institute did not fully comply with the Uniform Guidance applicable to the above noted grant. Auditor Recommendation. It is our understanding that the Institute has already enhanced its practice facilitator oversight and management protocols by requiring check-in calls with participating clinics to verify practice facilitator engagement. It has also provided employees with compliant timekeeping and employee reimbursement training in 2023. Corrective Action. Altarum conducted quality assurance investigations and meetings with affected participating practices. To prevent this type of issue in the future, Altarum enhanced its practice facilitator oversight and management protocols to ensure that practice facilitators are appropriately conducting their assigned activities. This includes continuing the check-in calls with participating clinics. Altarum also provided employees with Compliant Timekeeping and Employee Expense Reimbursement training in July 2023, as well as the leadership team reiterating to the project team the importance of accurate books and records, including timekeeping and expense reporting. Altarum also launched its annual Government Contracting education module shortly thereafter, which also includes training on timekeeping and expense reporting. Lastly, Altarum took appropriate personnel actions and offered the Government a credit. Responsible Person. Tracy M. Lawyer, General Counsel and Secretary Anticipated Completion Date. 2024

Finding: 2023-001 – Federal Funding Accountability and Transparency Act (FFATA) Reporting Auditor Description of Criteria, Condition, and Effect: Under the requirements of the Federal Funding Accountability and Transparency Act direct recipients of grants or cooperative agreements are required to report first-tier subawards of $30,000 or more to the Federal Funding Accountability and Transparency Act Subaward Reporting System (FSRS). Direct recipients must report key data elements by registering through the FSRS and reporting subaward data through that system. Direct recipients that are awarded a federal grant are required to file a FFATA sub-award report by the end of the month following the month in which the prime awardee awards any sub-grant equal to or greater than $30,000. The County did not submit the required key data elements through the FSRS reporting system as required by the Uniform Guidance. As a result, the County did not follow federal requirements for FFATA reporting through the FSRS and as a result has not completed the appropriate sub-award reporting that is required for direct recipients. Auditor Recommendation: We recommend that the County review its procedures for FFATA reporting through FSRS and ensure that all key data elements are reported timely moving forward. Corrective Action: The County will ensure that its procedures for FFATA reporting on all required grants are updated to ensure future compliance with this requirement. Responsible Person: Ellis Johnson II, Finance and Operations Manager (Office of Community and Economic Development) Anticipated Completion Date: December 31, 2024

Finding ref number: 2023-003 Finding caption: The District did not have adequate internal controls for ensuring compliance with allowable activities and costs and federal wage rate requirements. Name, address, and telephone of District contact person: Gabriela Chacon (509) 932-4565 EXT 3031 411 E Saddle Mountain Drive Mattawa, WA 99349 Corrective action the auditee plans to take in response to the finding: (If the auditee does not concur with the finding, the auditee must list the reasons for disagreement). Wahluke School District is currently working on implementing adequate internal controls for prevailing wages We now have new staff in place, so we are currently creating internal controls over prevailing wage requirements by doing the following: 1. Policy and Procedure Documentation: Establish clear policies and procedures outlining the school district's commitment to complying with prevailing wage requirements. 2. Training and Education: Provide training to relevant staff members responsible for payroll, human resources, and project management on prevailing wage requirements. 3. Vendor and Contractor Oversight: Require contractors to provide certified payroll reports regularly, detailing wages paid to each worker on prevailing wage projects. 4. Recordkeeping and Documentation: Maintain detailed records of all labor costs associated with prevailing wage projects. This includes employee time cards, payroll records, fringe benefit payments, and any other documentation required by state law. 5. Segregation of Duties: Implement segregation of duties to prevent one individual from having sole control over the entire process. For example, separate individuals should be responsible for approving timecards, preparing payroll, and reconciling payroll records. 6. Regular Audits and Reviews: Conduct regular internal audits or reviews of payroll records to ensure compliance with prevailing wage requirements. This can help identify any discrepancies or errors that need to be addressed promptly. 7. Monitoring and Enforcement: Establish mechanisms for monitoring compliance with prevailing wage requirements.Enforce consequences for non-compliance, such as withholding payments until issues are resolved or terminating contracts with repeat offenders. 8. Communication Channels: Maintain open lines of communication with employees, contractors, and relevant government agencies regarding prevailing wage requirements. 9. External Assistance: Consider engaging external consultants or legal counsel with expertise in prevailing wage compliance to provide guidance and assistance as needed. By implementing these internal controls, Wahluke School District can help ensure that it meets its obligations under prevailing wage laws, minimizes the risk of non-compliance, and maintains transparency and accountability in its operations. The Wahluke School District has established internal controls to track expenses diligently and ensure that the claims submitted are only for allowable activities and cost. Program Directors and Building Administrators receive weekly budget reports that they review for accuracy to ensure that only allowable activities are charged to their grants. The district has also included the Grants Manager in the review and approval of requisitions and time cards. This ensures that all proposed expenditures and time worked is allowable and aligns with the grant spending plan. Anticipated date to complete the corrective action: 8/31/2024

Finding ref number: 2023-001 Finding caption: The District did not have adequate internal controls for ensuring compliance with allowable activities and costs, equipment and restricted purpose requirements. Name, address, and telephone of District contact person: Gabriela Chacon (509) 932-4565 EXT 3031 411 E Saddle Mountain Drive Mattawa, WA 99349 Corrective action the auditee plans to take in response to the finding: (If the auditee does not concur with the finding, the auditee must list the reasons for disagreement). Thank you for your comprehensive recommendations regarding our utilization of ECF Program funds. The district concurs with the finding. We acknowledge the importance of ensuring compliance and accountability in our use of these resources. Regarding the recommendation to collaborate with the awarding agency for audit resolution, we will promptly initiate communication to address any outstanding issues and work diligently to resolve them in accordance with regulatory requirements. Additionally, we understand the significance of establishing robust internal controls to safeguard against misuse and ensure adherence to program guidelines. We will take the following actions to strengthen our internal controls: 1. Reimbursement Requests: We will institute a thorough review process to ensure that reimbursement requests are submitted only for eligible equipment and services provided to students and staff with identified unmet need. Documentation demonstrating compliance will be meticulously maintained to facilitate transparency and accountability. 2. Inventory Management: We will enhance our inventory management practices to include all necessary elements for tracking the use of equipment and services procured with ECF Program funds. This will enable us to accurately monitor the allocation and utilization of resources, thereby mitigating the risk of mismanagement or loss. 3. Device and Connection Allocation: To align with the requirements of the ECF Program, we will strictly adhere to the provision of no more than one device per student and employee, as well as no more than one broadband connection per location. This measure will ensure equitable distribution and optimize the impact of the resources allocated. By implementing these measures, we are committed to upholding the integrity of the ECF Program and maximizing its benefits for our students and staff. We appreciate your guidance and will proactively work towards achieving full compliance with program regulations. Anticipated date to complete the corrective action: 8/31/2024

2023‐002 Coronavirus State and Local Fiscal Recovery Funds U.S. Department of Treasury Assistance Listing Number: 21.027 Recommendation: We recommend that the City design processes and procedures to ensure that all reports are submitted timely as required by grant agreements. We recommend the City develop an internal compliance checklist that includes required reports and due dates to be maintained for tracking and record keeping purposes to assist in monitoring compliance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: A checklist is already in place and the City will evaluate and work with the Department of Treasury for ways to overcome the technical issues encountered, and acknowledged by the Department, that restricts the filing of reports in a timely manner. Quarterly filings with the Department will continue to be closely monitored. Name(s) of the contact person(s) responsible for corrective action: Mark C. Mason, CPA, Financial Services Director; Crystal S. Feast, MBA, Deputy Financial Services Director Planned completion date for corrective action plan: April 25, 2024

Finding 2023-001: Federal Funding Accountability and Transparency Act Finding: During the testing of the reporting compliance requirement related to the Poison Center Support and Enhancement Grant, it was determined that FFATA reporting to FSRS was not done for the Association’s subrecipient. Corrective Actions Taken or Planned: Effective July 1, 2024, he Association will implement procedures in its existing contract review process to identify subawards issued under prime federal awards that meet the threshold dollar amount that triggers reporting pursuant to FFATA and file its report within the required timeframe. The Association will complete the required FFATA reporting to FSRS for the current subaward. Responsible Party: Jean Kirkel, Vice President and Controller (JKirkel@team-iha.org)

Name of contact person – Angela Riley, CFO Corrective action – The Corporation agrees with the finding and has continued to implement strategies to address these issues throughout 2023, including: assembled and deployed a team of external consultants and temporary workers to assist site staff in completing tenant recertifications, hired a team of 6 additional roving property management/compliance teams to cover open property management positions and to support site staff in completing tenant recertifications, developed a new training program to onboard site staff, and developed a monitoring program to set expectations and hold employees accountable to those expectations. Proposed completion date – Management has begun the corrective action and is expected to have additional internal control and training done by December 31, 2024.

Name of contact person – Angela Riley, CFO Corrective action – The Corporation agrees with the finding and has continued to implement strategies to address these issues throughout 2023, including: assembled and deployed a team of external consultants and temporary workers to assist site staff in completing tenant recertifications, hired a team of 6 additional roving property management/compliance teams to cover open property management positions and to support site staff in completing tenant recertifications, developed a new training program to onboard site staff, and developed a monitoring program to set expectations and hold employees accountable to those expectations. Proposed completion date – Management has begun the corrective action and is expected to have additional internal control and training done by December 31, 2024.

Name of contact person – Angela Riley, CFO Corrective action – The Corporation agrees with the finding and has continued to implement strategies to address these issues throughout 2023, including: assembled and deployed a team of external consultants and temporary workers to assist site staff in completing tenant recertifications, hired a team of 6 additional roving property management/compliance teams to cover open property management positions and to support site staff in completing tenant recertifications, developed a new training program to onboard site staff, and developed a monitoring program to set expectations and hold employees accountable to those expectations. Proposed completion date – Management has begun the corrective action and is expected to have additional internal control and training done by December 31, 2024.

Name of contact person – Angela Riley, CFO Corrective action – The Corporation agrees with the finding and has continued to implement strategies to address these issues throughout 2023, including: assembled and deployed a team of external consultants and temporary workers to assist site staff in completing tenant recertifications, hired a team of 6 additional roving property management/compliance teams to cover open property management positions and to support site staff in completing tenant recertifications, developed a new training program to onboard site staff, and developed a monitoring program to set expectations and hold employees accountable to those expectations. Proposed completion date – Management has begun the corrective action and is expected to have additional internal control and training done by December 31, 2024.

Name of contact person – Angela Riley, CFO Corrective action – The Corporation agrees with the finding and has continued to implement strategies to address these issues throughout 2023, including: assembled and deployed a team of external consultants and temporary workers to assist site staff in completing tenant recertifications, hired a team of 6 additional roving property management/compliance teams to cover open property management positions and to support site staff in completing tenant recertifications, developed a new training program to onboard site staff, and developed a monitoring program to set expectations and hold employees accountable to those expectations. Proposed completion date – Management has begun the corrective action and is expected to have additional internal control and training done by December 31, 2024.

Grant Program: Department of Housing and Urban Development HUD Counseling Program – Assistance Listing #14.169 Description of Deficiency: It is noted that NWMT failed to report subawards greater than $30,000 under the Federal Funding Accountability and Transparency Act (FFATA) and is considered noncompliance as of September 30, 2023. Corrective Action Proposal: NWMT will complete the reporting of the required pass through payments to subrecipients subject to FFATA reporting in the FY23 amount of $201,484. NWMT will also implement the necessary updated procedures to ensure all subrecipients subject to FFATA reporting are properly reported for any further federal awards through the HUD Counseling Program at time of award. Individual(s) Responsible for Corrective Action: Hanna Tester (Homeownership Director) and Kaia Peterson (Executive Director) Corrective Action to be Completed by: All required subjects from 10/1/2022 to present will be properly reported within the Federal Subaward Reporting System no later than June 30, 2024.

Finding 2023-001 - Return of Title IV Funds Management Response: Management concurs with the finding Views of Responsible Officials and Corrective Action Plan: Point Park University uses PowerFAIDS software to complete the Federal Return of Title IV calculation. The University reviewed the Return of Title IV process within PowerFAIDS and found that the days completed were not properly updated to exclude the days of the University's spring break from the numerator of the calculation. This resulted in an incorrect amount being returned. The University is in the process of returning the underpayment of $454 for the 2022-2023 academic year. The University is implementing an additional procedure to review each Return of Title IV calculation from PowerFAIDS prior to the issuance of the refund. A spreadsheet has been created to independently check each calculation based upon withdrawal dates, number of days in the semester, number of davs completed and factoring in break days as applicable. Anticipated Completion Date: April 30, 2024 Name of Responsible Person: George Santucci, Director of Financial Aid (412) 392-3498 gsantucci@pointpark.edu

Finding 2023-005 Lack of Internal Control / Noncompliance over Subrecipient Monitoring Name of Contact Person: Elena Begojevic, Business Manager Corrective Action Plan: HCSD established a Subrecipient Monitoring Checklist as a monitoring tool to ensure that subrecipients are successful and compliant and the subawards are used in accordance with federal statutes, regulations, and the terms and conditions of the federal and state awards. Proposed Completion Date: Fiscal Year 2024

Unlike other subgrants managed by the Department of Law and Public Safety (DLPS), the subgrants in the Public Assistance program are not issued by the Department but instead are issued by the Federal Emergency Management Agency (FEMA). These FEMA-issued subgrants take the form of Project Worksheets (PWs) and are directly related to a specific disaster. FEMA informs the DLPS of the approved PWs after they are issued. Given the unique nature of the PW issuance, the DLPS is not in a position to report on the FFATA Subaward Reporting System (FSRS) at the time PWs are issued. This contrasts with other grant programs overseen by the DLPS, which do allow for timely subaward reporting in FSRS. The Department will continue to work with our FEMA partners, incorporating any guidance they provide, to develop procedures that ensure subawards are reported in FSRS within the FFATA reporting requirements. COMPLETION DATE/ CONTACT PERSON & PHONE# Fiscal Year 2024 and Ongoing Salvatore Marcello (609) 882-2000 ext.3046 Salvatore.Marcello@njsp.gov

The Department of Human Services, Division of Mental Health and Addiction Services (DMHAS) agrees that for fiscal year 2023 there were no Federal Funding Accountability & Transparency Act (FFATA) reporting procedures in place. It is important to note however, that DMHAS provided adequate support for subrecipient payments to each of the selected samples and corresponding dollar amounts. DMHAS was unable to comply with the FFATA reporting requirements due to insufficient staffing levels, the significant volume of data and effort required, and the significant demands and operational challenges precipitated by the Covid-19 Public Health Emergency. DMHAS will develop a formal policy with procedures to comply with FFATA reporting requirements. More specifically, the policy will identify all FFATA reporting requirements consistent with the law, and dictate standard operating procedures, including ongoing monitoring and progress reporting. DMHAS’s policy and practices will rely upon, and comport with, the applicable materials and Awardee User resources available at: https://www.fsrs.gov/ and https://www.fsrs.gov/documents/FSRS_Awardee_User_Guide.pdf. DMHAS procedures will ensure the reporting of all first-tier subawards of $30,000 or more to the FSRS with all required FFATA data elements included. DMHAS will hire at least one (1) additional staff for the requisite data entry. The new staff member will be situated in the DMHAS Fiscal Unit, and will report directly to, and be under the supervision of the Fiscal Unit Budget Manager. One hundred percent of the new hire’s effort will be dedicated to FFATA reporting and data entry. DMHAS began the new hire process on or about March 22, 2024, and anticipates that the new hire will be on boarded in approximately ninety (90) days. In addition, the DMHAS Fiscal Unit Contract Manager (or the Contract Manager’s designated staff) will work with the Budget Manager and the FFATA new hire to assist with the collection and verification of the requisite Subrecipient data that must be entered into the FSRS portal. DMHAS will require all staff with FFATA reporting duties to complete the available online trainings. Furthermore, designated staff will be required to complete a FFATA Access Request Form that will be reviewed and approved by the DMHAS Chief Financial Officer. Designated staff shall also be subject to fixed Eligibility Criteria (e.g. completion of all IT Security Trainings, FFATA training(s), current DHS Confidentiality and Non-Disclosure Agreement, etc.). Access will be revoked if a Disqualifying Event such as separation of employment or failure to complete training occurs. The Department of Human Services, Division of Mental Health and Addiction Services (DMHAS) agrees that for fiscal year 2023 there were no Federal Funding Accountability & Transparency Act (FFATA) reporting procedures in place. It is important to note however, that DMHAS provided adequate support for subrecipient payments to each of the selected samples and corresponding dollar amounts. DMHAS was unable to comply with the FFATA reporting requirements due to insufficient staffing levels, the significant volume of data and effort required, and the significant demands and operational challenges precipitated by the Covid-19 Public Health Emergency. DMHAS will develop a formal policy with procedures to comply with FFATA reporting requirements. More specifically, the policy will identify all FFATA reporting requirements consistent with the law, and dictate standard operating procedures, including ongoing monitoring and progress reporting. DMHAS’s policy and practices will rely upon, and comport with, the applicable materials and Awardee User resources available at: https://www.fsrs.gov/ and https://www.fsrs.gov/documents/FSRS_Awardee_User_Guide.pdf. DMHAS procedures will ensure the reporting of all first-tier subawards of $30,000 or more to the FSRS with all required FFATA data elements included. DMHAS will hire at least one (1) additional staff for the requisite data entry. The new staff member will be situated in the DMHAS Fiscal Unit, and will report directly to, and be under the supervision of the Fiscal Unit Budget Manager. One hundred percent of the new hire’s effort will be dedicated to FFATA reporting and data entry. DMHAS began the new hire process on or about March 22, 2024, and anticipates that the new hire will be on boarded in approximately ninety (90) days. In addition, the DMHAS Fiscal Unit Contract Manager (or the Contract Manager’s designated staff) will work with the Budget Manager and the FFATA new hire to assist with the collection and verification of the requisite Subrecipient data that must be entered into the FSRS portal. DMHAS will require all staff with FFATA reporting duties to complete the available online trainings. Furthermore, designated staff will be required to complete a FFATA Access Request Form that will be reviewed and approved by the DMHAS Chief Financial Officer. Designated staff shall also be subject to fixed Eligibility Criteria (e.g. completion of all IT Security Trainings, FFATA training(s), current DHS Confidentiality and Non-Disclosure Agreement, etc.). Access will be revoked if a Disqualifying Event such as separation of employment or failure to complete training occurs. DMHAS conferred recently with DHS, the designated grant recipient, and secured from DHS the requisite FSRS login credentials. DMHAS Fiscal logged into the reporting system and began work on a process description. DMHAS is committed to FFATA compliance, is prioritizing FFATA policy, procedures and reporting, and is making a good faith effort to comply. DMHAS will ensure that the requisite sub-award data is entered timely (no later than the end of the month following the month of issuance) into the FSRS portal, beginning January 1, 2025. In the event DMHAS cannot complete timely data entry into FSRS because of system issues outside of its control (e.g. the underlying federal award does not appear in FSRS), DMHAS will keep a record of the requisite data and document its efforts. COMPLETION DATE/ CONTACT PERSON & PHONE# January 1, 2025 John Fogliano, Deputy CFO (609) 438-4278 John.Fogliano@dhs.nj.gov

The Department of Human Services, Division of Mental Health and Addiction Services (DMHAS) agrees that for fiscal year 2023 it did not provide at the time of subaward one (1) of the fourteen (14) elements required by the federal Uniform Guidance (UG) pass-through entity requirements. More specifically, DMHAS did not communicate to subrecipients at the time of subaward the date on which DMHAS received its Notice of Award from the U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment (SMAHSA). This single piece of information was omitted in each of the ten (10) samples tested. It is important to note, however, that DMHAS could certify that it did not communicate to any pool of applicants or subrecipients that funding was available until such time as DMHAS received its federal award. The failure to include the federal date of award was the result of clerical/ministerial error, and DMHAS’s inability to evidence the federal award date in its software system, known as the Contract Information Management System (CIMS). CIMS is accessible to subrecipients and DMHAS relies on it to document and track subawards. DMHAS satisfied every remaining subaward information element of the UG pass-through entity requirements with the exception of subsection (ii) – the subrecipient’s Unique Entity Identifier (UEI), for two (2) of the ten (10) samples tested. More specifically, DMHAS did not reference two (2) subrecipients UEI numbers at the time of each subrecipient’s subaward. It is important to note that DMHAS has the UEIs available to it, but it could not establish that it referenced two (2) of the UEIs at the time of award. The failure to include the UEI for each of the two (2) subrecipients was the result of clerical/ministerial error, and DMHAS’s inability to enter the data for the particular subrecipients into CIMS. Each of the two (2) samples related to a “specialty contract” that cannot be captured in CIMS. DMHAS has already undertaken efforts to update its software system and replace CIMS with SAGE AGATE. Although federal regulation does not require that every data element referenced in 2 CFR 200.332(a)(1) be available in a single document, as part of its ongoing systems improvement plans, the DMHAS is completing the procurement of a new contract information management system, SAGE AGATE, so that all federal award and contract information is available in a single report through a single software application. DMHAS has prepared a purchase order for SAGE AGATE, the State funds have been appropriated and the DMHAS is in the process of scheduling a kick off meeting, along with 3-day training sessions. The DMHAS SAGE AGATE Scope of Work includes IntelliGrants software, as well as limited customization of the IntelliGrants software to satisfy any needs particular to DMHAS. DMHAS will ensure that the final software package provides DMHAS with the means to document and communicate to subrecipients at the time of subaward each of the requisite elements of 2 CFR 200.332(a)(1), including the Federal Date of Award and the UEI. In the interim, DMHAS has drafted an updated Notice of Subrecipient Award Template, which Template includes every component required by 2 CFR 200.332(a)(1). Upon DMHAS executive review and approval of the Template, Contract staff in the DMHAS Fiscal Unit will utilize the Template for each Notice of Subrecipient Award. DMHAS anticipates that the Template will be superseded by a Notice maintained within, and/or generated by, SAGE AGATE. Prior to the date of this CAP, DMHAS Program/Initiative Managers throughout the various DMHAS treatment service and support units were responsible for preparing and executing Notices of Subrecipient Award. As a result of the Significant Deficiency identified in this The Department of Human Services, Division of Mental Health and Addiction Services (DMHAS) agrees that for fiscal year 2023 it did not provide at the time of subaward one (1) of the fourteen (14) elements required by the federal Uniform Guidance (UG) pass-through entity requirements. More specifically, DMHAS did not communicate to subrecipients at the time of subaward the date on which DMHAS received its Notice of Award from the U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment (SMAHSA). This single piece of information was omitted in each of the ten (10) samples tested. It is important to note, however, that DMHAS could certify that it did not communicate to any pool of applicants or subrecipients that funding was available until such time as DMHAS received its federal award. The failure to include the federal date of award was the result of clerical/ministerial error, and DMHAS’s inability to evidence the federal award date in its software system, known as the Contract Information Management System (CIMS). CIMS is accessible to subrecipients and DMHAS relies on it to document and track subawards. DMHAS satisfied every remaining subaward information element of the UG pass-through entity requirements with the exception of subsection (ii) – the subrecipient’s Unique Entity Identifier (UEI), for two (2) of the ten (10) samples tested. More specifically, DMHAS did not reference two (2) subrecipients UEI numbers at the time of each subrecipient’s subaward. It is important to note that DMHAS has the UEIs available to it, but it could not establish that it referenced two (2) of the UEIs at the time of award. The failure to include the UEI for each of the two (2) subrecipients was the result of clerical/ministerial error, and DMHAS’s inability to enter the data for the particular subrecipients into CIMS. Each of the two (2) samples related to a “specialty contract” that cannot be captured in CIMS. DMHAS has already undertaken efforts to update its software system and replace CIMS with SAGE AGATE. Although federal regulation does not require that every data element referenced in 2 CFR 200.332(a)(1) be available in a single document, as part of its ongoing systems improvement plans, the DMHAS is completing the procurement of a new contract information management system, SAGE AGATE, so that all federal award and contract information is available in a single report through a single software application. DMHAS has prepared a purchase order for SAGE AGATE, the State funds have been appropriated and the DMHAS is in the process of scheduling a kick off meeting, along with 3-day training sessions. The DMHAS SAGE AGATE Scope of Work includes IntelliGrants software, as well as limited customization of the IntelliGrants software to satisfy any needs particular to DMHAS. DMHAS will ensure that the final software package provides DMHAS with the means to document and communicate to subrecipients at the time of subaward each of the requisite elements of 2 CFR 200.332(a)(1), including the Federal Date of Award and the UEI. In the interim, DMHAS has drafted an updated Notice of Subrecipient Award Template, which Template includes every component required by 2 CFR 200.332(a)(1). Upon DMHAS executive review and approval of the Template, Contract staff in the DMHAS Fiscal Unit will utilize the Template for each Notice of Subrecipient Award. DMHAS anticipates that the Template will be superseded by a Notice maintained within, and/or generated by, SAGE AGATE. Prior to the date of this CAP, DMHAS Program/Initiative Managers throughout the various DMHAS treatment service and support units were responsible for preparing and executing Notices of Subrecipient Award. As a result of the Significant Deficiency identified in this 2023 Audit, and in order to correct and mitigate against clerical/ministerial errors, DMHAS is transferring responsibility for the preparation and execution of Notices of Subrecipient Award from Program/Initiative Managers, to the DMHAS Fiscal Unit, Contract Manager (and the Contract Manager’s Contract Administration staff). Such staff will have total SAGE AGATE system access, and be best suited to ensure that Notices of Subrecipient Award comply with 2 CFR 200.332. Finally, as a preventive action, the DMHAS Compliance Unit will audit the issuance of post-contract negotiation Notices of Award in three (3) months, and again in six (6) months. The internal audit will sample no less than ten (10) newly awarded/renewed deficit-funded contracts for substance use disorder services, and will measure compliance with every element identified in 2 CFR 200.332. COMPLETION DATE/ CONTACT PERSON & PHONE# July 1, 2024 John Fogliano, Deputy CFO (609) 438-4278 John.Fogliano@dhs.nj.gov

The Department of Human Services, Division of Mental Health and Addiction Services (DMHAS) agrees that for fiscal year 2023 there were no Federal Funding Accountability & Transparency Act (FFATA) reporting procedures in place. It is important to note however, that DMHAS provided adequate support for subrecipient payments to each of the selected samples and corresponding dollar amounts. DMHAS was unable to comply with the FFATA reporting requirements due to insufficient staffing levels, the significant volume of data and effort required, and the significant demands and operational challenges precipitated by the Covid-19 Public Health Emergency. DMHAS will develop a formal policy with procedures to comply with FFATA reporting requirements. More specifically, the policy will identify all FFATA reporting requirements consistent with the law, and dictate standard operating procedures, including ongoing monitoring and progress reporting. DMHAS’s policy and practices will rely upon, and comport with, the applicable materials and Awardee User resources available at: https://www.fsrs.gov/ and https://www.fsrs.gov/documents/FSRS_Awardee_User_Guide.pdf. DMHAS procedures will ensure the reporting of all first-tier subawards of $30,000 or more to the FSRS with all required FFATA data elements included. DMHAS will hire at least one (1) additional staff for the requisite data entry. The new staff member will be situated in the DMHAS Fiscal Unit, and will report directly to, and be under the supervision of the Fiscal Unit Budget Manager. One hundred percent of the new hire’s effort will be dedicated to FFATA reporting and data entry. DMHAS began the new hire process on or about March 22, 2024, and anticipates that the new hire will be on boarded in approximately ninety (90) days. In addition, the DMHAS Fiscal Unit Contract Manager (or the Contract Manager’s designated staff) will work with the Budget Manager and the FFATA new hire to assist with the collection and verification of the requisite Subrecipient data that must be entered into the FSRS portal. DMHAS will require all staff with FFATA reporting duties to complete the available online trainings. Furthermore, designated staff will be required to complete a FFATA Access Request Form that will be reviewed and approved by the DMHAS Chief Financial Officer. Designated staff shall also be subject to fixed Eligibility Criteria (e.g. completion of all IT Security Trainings, FFATA training(s), current DHS Confidentiality and Non-Disclosure Agreement, etc.). Access will be revoked if a Disqualifying Event such as separation of employment or failure to complete training occurs. DMHAS conferred recently with DHS, the designated grant recipient, and secured from DHS the requisite FSRS login credentials. DMHAS Fiscal logged into the reporting system and began work on a process description. DMHAS is committed to FFATA compliance, is prioritizing FFATA policy, procedures and reporting, and is making a good faith effort to comply. DMHAS will ensure that the requisite sub-award data is entered timely (no later than the end of the month following the month of issuance) into the FSRS portal, beginning January 1, 2025. In the event DMHAS cannot complete timely data entry into FSRS because of system issues outside of its control (e.g. the underlying federal award does not appear in FSRS), DMHAS will keep a record of the requisite data and document its efforts. COMPLETION DATE/ CONTACT PERSON & PHONE# January 1, 2025 John Fogliano, Deputy CFO (609) 438-4278 John.Fogliano@dhs.nj.gov

In accordance with the audit finding recommendation, the Department of Human Services’ Division of Family Development (DFD) will ensure that the applicable federal award date will be included with the contract award information as required by Uniform Guidance pass-through entity requirements. Subrecipient monitoring was performed in a timely manner in compliance with DHS Contract Policy with the exception of one subrecipient, NJSACC. NJSACC’s fiscal review documents are due back to DFD on April 15, 2024. Once received, DFD will schedule a fiscal review meeting with the agency and the entire process should be completed within one (1) month of receipt. In addition, DFD will review the current policy for clarity, reasonableness, and to ensure compliance. COMPLETION DATE/ CONTACT PERSON June 30 2024 Ann Allen (609) 588-2074 Ann.Allen@dhs,nj,gov

The Department of Human Services’ Division of Family Development (DFD) agrees with the audit finding regarding the required submission of subawards to the FFATA Subaward Reporting System (FSRS). Due to the complexity and time required to compile and report FFATA subaward data, the DFD is in the process of creating a new full-time equivalent position (FTE) for this required federal reporting task. In accordance with the finding recommendation, the DFD will develop internal controls and procedures to ensure the timely reporting of all required subawards to FSRS. An initial review of the FSRS by DFD fiscal staff appeared to indicate that some federal grant award data that should be prepopulated by the awarding federal agency and available on the website was missing (e.g. Child Care M&M available; Discretionary not found). Staff will reach out to the necessary federal agencies to communicate instances of missing federal award information in an effort to ensure that the DFD has the ability to input the required subaward information. DFD anticipates that the assessment and development of policy and procedures related to this task will take approximately three (3) months. Staff assignment, training, and submission of federal grant subaward information to the federal website will occur over the next state fiscal year. COMPLETION DATE/ CONTACT PERSON Policy Completion Date: June 30, 2024 Implementation Date: Fiscal Year 2025 Thomas Mattaliano, CFO-DFD (609) 588-3370 Thomas.Mattaliano@dhs.nj.gov

The Department of Community Affairs (DCA) has reviewed and enhanced internal controls and procedures to ensure that all required information, as per the federal Uniform Guidance pass-through entity requirements, is included in all new LIHEAP subaward contracts. These subaward agreement control enhancements have been implemented effective with the fiscal year 2024 contracts. COMPLETION DATE/ CONTACT PERSON April 30, 2024 Fidel Ekhelar (609) 815-3905 Fidel.Ekhelar@dca.nj.gov

The Department of Community Affairs (DCA) has recently implemented timely reporting of required FFATA subaward data in the Federal Subaward Reporting System (FSRS). The FFATA reporting process is fully documented, and additional staff have been hired and trained on the process to further support the federal reporting functions. The FFATA reports identified by the auditors with inaccurate subaward amounts reported have also been corrected in FSRS. COMPLETION DATE/ CONTACT PERSON April 30, 2024 Fidel Ekhelar (609) 815-3905 Fidel.Ekhelar@dca.nj.gov

The Department of Human Services’ Division of Family Development (DFD) agrees with the audit finding regarding the required submission of subawards to the FFATA Subaward Reporting System (FSRS). Due to the complexity and time required to compile and report FFATA subaward data, the DFD is in the process of creating a new full-time equivalent position (FTE) for this required federal reporting task. In accordance with the finding recommendation, the DFD will develop internal controls and procedures to ensure the timely reporting of all required subawards to FSRS. An initial review of the FSRS by DFD fiscal staff appeared to indicate that some federal grant award data that should be prepopulated by the awarding federal agency and available on the website was missing (e.g. Child Care M&M available; Discretionary not found). Staff will reach out to the necessary federal agencies to communicate instances of missing federal award information in an effort to ensure that the DFD has the ability to input the required subaward information. DFD anticipates that the assessment and development of policy and procedures related to this task will take approximately three (3) months. Staff assignment, training, and submission of federal grant subaward information to the federal website will occur over the next state fiscal year. COMPLETION DATE/ CONTACT PERSON Policy Completion Date: June 30, 2024 Implementation Date: Fiscal Year 2025 Thomas Mattaliano, CFO-DFD (609) 588-3370 Thomas.Mattaliano@dhs.nj.gov

The Department of Health (DOH) will enhance its internal controls and procedures, regarding federal subawards issued by other New Jersey State departments and agencies on behalf of DOH. The Department’s Memorandum of Agreement (MOA) and Memorandum of Understanding (MOU) documents will be updated and enhanced to list and define the specific responsibilities and requirements of other departments and pass-through entities more clearly when issuing subawards with federal funding derived from DOH. If necessary, the updated MOA/MOU documents may also include an Exhibit specific to Subrecipient Monitoring, containing the federal Uniform Guidance compliance requirements including mandatory reporting of subgrantee performance indicators and listing records retention requirements for all documentation of monitored subrecipient activities. COMPLETION DATE/ CONTACT PERSON April 5, 2024 Eric Carlsson (609) 376-8480 Eric.Carlsson@doh.nj.gov

Based on the Corrective Action Plan (CAP) developed for the prior year FY 2022 audit finding cited for FFATA reporting, the Department of Health (DOH) Grants Unit, with coordination from the Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) fiscal staff, added a new function to the System for Administering Grants Electronically (SAGE) that pulls all subaward data for the ELC program using the program’s 93.323 federal Assistance Listing Number (ALN). Thus, the CAP implemented in September 2022 for the prior year FY 2022 audit finding includes SAGE now pulling the subaward data for the entire ELC program by the ALN number and enables the ELC fiscal staff to access all ELC subawards within the DOH. ELC fiscal staff also has a task reminder set to report at the end of each month, enter subaward information into the FFATA Subaward Reporting System (FSRS), and upload each report submitted to the SharePoint ELC Document Library at the end of each month. As per the original CAP created under the FY 2022 audit, FFATA information for ELC subawards were entered into FSRS beginning on September 1, 2022 and DOH actions and efforts have continued to ensure compliance going forward. COMPLETION DATE/ CONTACT PERSON April 10, 2024 Rina Warehall (609) 913-5300 Rina.Warehall@doh.nj.gov