Corrective Action Plans

The District will require a PAR form from any employee covering a shift in Child Nutrition whose main job is not in the Child Nutrition Department. • The Director of Child Nutrition, Syed Zaidi, will identify and provide a PAR form for those employees providing services to the Child Nutrition Department in a substitute situation. To be established as of 6/30/2024.

Management will improve monitoring of any funds received from outside agencies to verify if Jackson County Utility Authority is considered a sub-award for funds received. Completion Date: Ongoing Name of Contact Person Responsbile for Corrective Action Plan: Linda Green

Finding: 2023-028 - Of the two FY 23 FMAG quarterly progress reports (QPR) selected for testing, one was not filed. Testing of the QPR for quarter ending June 30, 2023, identified incorrect amounts and data. Questioned Costs: None Assistance Listing Number: 97.046 Assistance Listing Title: FMAG Views of Responsible Officials (state whether your agency agrees or disagrees with the finding; if you disagree, briefly explain why): DNR agrees with this finding Corrective Action (corrective action planned): DNR Forestry staff responsible for preparation, review and submission of the FMAG QPR reporting will review procedures and provide corrective updates to the process. This plan will establish written policies and procedures, including independent review and validation before submission. Completion Date (list anticipated completion date): March 2024 Agency Contact (name of person responsible for corrective action): Norman McDonald, Forestry Acting Director

Finding: 2023-027 - DNR Support Services Division staff did not file the FY 23 Federal Cash Transaction Reports for quarters ending September 2022, December 2022, and June 2023. The audit reviewed the March 2023 quarterly report filed and determined inaccurate cumulative cash receipts and cash disbursements were reported. Questioned Costs: None Assistance Listing Number: 97.046 Assistance Listing Title: FMAG Views of Responsible Officials (state whether your agency agrees or disagrees with the finding; if you disagree, briefly explain why): DNR agrees with this finding. Corrective Action (corrective action planned): DNR fiscal staff responsible for preparation and review and submission of the FCTR reporting will review procedures and provide corrective updates to the process. This plan will establish written policies and procedures, including independent review and validation before submission. Completion Date (list anticipated completion date): June 30, 2024 Agency Contact (name of person responsible for corrective action): Theresa Cross, Administrative Services Director

Finding: 2023-026 - Three FY 23 Fire Management Assistance Grant (FMAG) SF-425 reports were randomly selected for testing. Two reports had incorrect matching amounts and one report for quarter ending September 2022 was not filed. Questioned Costs: None Assistance Listing Number: 97.046 Assistance Listing Title: FMAG Program Views of Responsible Officials (state whether your agency agrees or disagrees with the finding; if you disagree, briefly explain why): DNR agrees with this finding Corrective Action (corrective action planned): DNR Forestry staff responsible for preparation, review and submission of the FMAG reporting will review procedures and provide corrective updates to the process. This plan will establish written policies and procedures, including independent review and validation before submission. Completion Date (list anticipated completion date): March 2024 Agency Contact (name of person responsible for corrective action): Norman McDonald, Forestry Acting Director

Finding: 2023-019 – The Department of Education and Early Development (DEED) did not file Federal Funding Accountability and Transparency Act reports for FY 23 Education Stabilization Fund programs, Title I-A, and Title I-C subawards. Questioned Costs: None Assistance Listing Number: 84.425D; 84.425R; 84.425U; 84.425W; 84.010; 84.011 Assistance Listing Title: Elementary and Secondary School Emergency Relief Fund – COVID-19; Emergency Assistance for Non-Public Schools – COVID-19; American Rescue Plan – Elementary and Secondary School Emergency Relief Fund – COVID-19; American Rescue Plan – Homeless Children and Youth – COVID-19; Title I Grants to Local Educational Agencies (Title I-A); Migrant Education State Grant Program (Title I-C) Views of Responsible Officials (state whether your agency agrees or disagrees with the finding; if you disagree, briefly explain why):The department agrees with Finding 2023-001. Corrective Action (corrective action planned):The department will continue to work with our federal contacts to attempt to resolve FFATA reporting issues. Completion Date (list anticipated completion date): Completion date is unknown as the department has been working with the FSRS helpdesk, and federal program staff, for a significant period of time with little success. The main issue has been known since go live of FFATA reporting and the General Services Administration (GSA) claims to have implemented a solution effective March 10, 2021, however States continue to have the same issues. Agency Contact (name of person responsible for corrective action): Monique Siverly, Acting Division Operations Manager, Division of Administrative Services

Finding: 2023-062 – DOT&PF management did not issue a management decision for the one single audit finding requiring follow-up in FY 23 within six months as required by federal law. Questioned Costs: None Assistance Listing Number: 20.509 Assistance Listing Title: FGRA Views of Responsible Officials (state whether your agency agrees or disagrees with the finding; if you disagree, briefly explain why): Agree Corrective Action (corrective action planned): The Finance Officer will develop and implement a procedure to ensure management decisions for all subrecipient single audit findings are issued within six months of the audit report's acceptance by the federal audit clearinghouse. Completion Date (list anticipated completion date): June 30, 2024 Agency Contact (name of person responsible for corrective action): Elizabeth Dunayski, Financial Services Manager

Finding: 2023-061 – All five FY 23 FGRA subaward grant agreements tested did not include all federally required information. Questioned Costs: None Assistance Listing Number: 20.509 Assistance Listing Title: FGRA Views of Responsible Officials (state whether your agency agrees or disagrees with the finding; if you disagree, briefly explain why): Agree Corrective Action (corrective action planned): The Division of Project Delivery will amend all active FGRA subaward grant agreements to include all missing federally required information. DPD will update subaward templates and instructions to include federal award date, assistance listing title, and DOT&PF indirect cost rate to ensure federally required information is included. Completion Date (list anticipated completion date): June 30, 2024 Agency Contact (name of person responsible for corrective action): Eric Taylor, Transportation Planner 3

Finding: 2023-059 – DOT&PF's Division of Program Development does not have a formal process for managing user access to its transit data management system. Questioned Costs: None Assistance Listing Number: 20.509 Assistance Listing Title: Formula Grants for Rural Areas (FGRA) Views of Responsible Officials (state whether your agency agrees or disagrees with the finding; if you disagree, briefly explain why): Agree Corrective Action (corrective action planned): The Division of Project Delivery will develop a procedure to manage user access to the system as well as working with system programmers to automatically deactivate user accounts after a period of inactivity. Completion Date (list anticipated completion date): June 30, 2024 Agency Contact (name of person responsible for corrective action): Eric Taylor, Transportation Planner 3

Finding: 2023-058 – Contractor-certified payrolls tested for six construction projects were not submitted timely. Late payroll submission dates ranged from eight days to 189 days after the payroll payment date for the 158 certified payrolls tested. Questioned Costs: None Assistance Listing Number: 20.106 Assistance Listing Title: Airport Improvement Program Views of Responsible Officials (state whether your agency agrees or disagrees with the finding; if you disagree, briefly explain why): Agree Corrective Action (corrective action planned): DOT&PF, in coordination with the Department of Labor, has implemented the AASHTOWare Project Civil Rights and Labor Module (AWP-CRL). This module provides a web-based platform where contractors submit certified payrolls for all contracts awarded after January 1, 2021. AASHTOWare provides tracking and monitoring of certified payroll through reporting. DOT&PF staff project managers are responsible for requesting certified payroll status reports from AASHTOWare to monitor if certified payrolls are received timely and follow up with the contractors if data is not received timely. DOT&PF management will provide training to DOT&PF staff to ensure that monitoring of timely submission of certified payroll is done. Completion Date (list anticipated completion date): June 30, 2024 Agency Contact (name of person responsible for corrective action): Christine Langley, Data Modernization and Innovation Office Director

Finding: 2023-057 – DOT&PF management lacked internal controls to ensure the annual SF-271 equivalent report was supported, accurate, and complete. Questioned Costs: None Assistance Listing Number: 20.106 Assistance Listing Title: Airport Improvement Program Views of Responsible Officials (state whether your agency agrees or disagrees with the finding; if you disagree, briefly explain why): Agree Corrective Action (corrective action planned): The support documentation for the SF 425 and SF 271 equivalent are documented in the FFR Working File. The FFR Working File goes through reviews by the Grants & Projects team to ensure no errors are found before reporting. DOT&PF has updated the procedures for the current FAA FFR that was submitted in December 2023. The update adds two signatures to document the preparation and approval of the SF 271 equivalent on the FFR Working File that will be converted to PDF and filed. Completion Date (list anticipated completion date): January 31, 2024 Agency Contact (name of person responsible for corrective action): Elizabeth Dunayski, Financial Services Manager

Finding: 2023-056 – One of four randomly selected (25 percent) and two of three judgmentally selected (67 percent) 5100-126 reports tested did not tie to support, resulting in an overstatement of expenditures. One of three judgmentally selected 5100-127 reports tested (33 percent) had multiple lines in error, resulting in overstatements of revenue and net assets. Questioned Costs: None Assistance Listing Number: 20.106 Assistance Listing Title: Airport Improvement Program Views of Responsible Officials (state whether your agency agrees or disagrees with the finding; if you disagree, briefly explain why): Agree Corrective Action (corrective action planned): The Finance Officer will ensure the procedures for the preparation, review, and approval of the 5100-126 and 5100-127 reports are updated to ask for support documentation for Ketchikan and Sitka airports and a complete review and approval is done before submission of the reports. The AIA Controller will develop and implement procedures to ensure proper preparation of the 5100-126 and 5100-127 reports with supervisory review and approval prior to report submission. Completion Date (list anticipated completion date): June 30, 2024 Agency Contact (name of person responsible for corrective action): Elizabeth Dunayski, Financial Services Manager

Finding: 2023-022 - WIOA cluster FY 23 subaward agreement forms did not identify the subrecipients’ unique entity identifier number. Furthermore, one of three subaward agreements tested did not identify the Assistance Listing number associated with the subaward. Questioned Costs: None Assistance Listing Number: 17.258, 17.259, 17.278 Assistance Listing Title: WIOA Cluster Views of Responsible Officials (state whether your agency agrees or disagrees with the finding; if you disagree, briefly explain why): DOLWD agrees with the finding. Corrective Action (corrective action planned): We updated our department procedures by adding checklists that include required levels of approval, strengthening our review process. Completion Date (list anticipated completion date): March 2024 Agency Contact (name of person responsible for corrective action): Jeff Steeprow, Assistant Director

Finding: 2023-021 – Department of Labor and Workforce Development staff did not file Federal Funding Accountability and Transparency Act (FFATA) reports for FY 23 Workforce Innovation and Opportunity Act (WIOA) Cluster subawards. Questioned Costs: None Assistance Listing Number: 17.258, 17.259, 17.278 Assistance Listing Title: WIOA Cluster Views of Responsible Officials (state whether your agency agrees or disagrees with the finding; if you disagree, briefly explain why): DOLWD agrees with the finding. Corrective Action (corrective action planned): We developed department procedures for FFATA submission, and have submitted the FFATA reports on 3/4/2024. Completion Date (list anticipated completion date): March 2024 Agency Contact (name of person responsible for corrective action): Jeff Steeprow, Assistant Director

Finding: 2023-032 - Pandemic Electronic Benefit Transfer Food Benefits (P-EBT) benefit payments were not issued in accordance with the process and timeframes outlined in the federally approved state plan. Testing a sample of 136 payments found 37 issuances (27 percent) were sent to unauthorized or unsupported addresses and one issuance included unauthorized benefits. Additionally, no benefits were issued during FY 23 to Supplemental Nutrition Assistance Program (SNAP)-enrolled children in child care. Questioned Costs: AL 10.542: $27,387 Assistance Listing Number: 10.542 Assistance Listing Title: P-EBT – COVID-19 Views of Responsible Officials (state whether your agency agrees or disagrees with the finding; if you disagree, briefly explain why): DOH partially agrees with the finding. The Division communicated with FNS regarding manual benefit issuance for Alaska expressing timelines would be affected and FNS did not request an updated timeline. Communication with FNS regarding issuance remained consistent, with no indication to alter our issuance plan. Address verifications were conducted at the time of benefit payment, because addresses are subject to change from the date of eligibility. Updates to addresses were made when more recent information became available. The division has no control over DEED eligibility records including the addresses they have on file. Corrective Action (corrective action planned): Shall the Division agree to administer this federal program in the future, the commissioner will allocate resources necessary to prevent the necessity to manually administer the federal program. Completion Date (list anticipated completion date): Not applicable. This federal program is complete. Agency Contact (name of person responsible for corrective action): Josie Stern, Assistant Commissioner

Finding: 2023-035 - Daily SNAP EBT reconciliations were not performed in FY 23. Questioned Costs: None Assistance Listing Number: 10.551, 10.561 Assistance Listing Title: SNAP Cluster Views of Responsible Officials (state whether your agency agrees or disagrees with the finding; if you disagree, briefly explain why): DOH agrees with the finding. Corrective Action (corrective action planned): The Division of Public Assistance (DPA) plans to establish internal controls for daily reconciliation and monitoring procedures. Updating existing processes to meet requirements and documenting will be part of this initiative. Collaborating with Food Nutrition Services (FNS) is intended to confirm alignment with current SNAP requirements. Staff will undergo training on these internal control protocols once established. Completion Date (list anticipated completion date): DOH anticipates the finding will be resolved in FY2025. Agency Contact (name of person responsible for corrective action): Josie Stern, Assistant Commissioner

Finding: 2023-034 - The amount of FY 23 SNAP benefits reported as issued by the State’s Electronic Benefit Transfer (EBT) contractor was $19,689,126 more than the amount of authorized benefits reported in data from DPA’s Eligibility Information System. Questioned Costs: AL 10.551: $19,689,126 Assistance Listing Number: 10.551, 10.561 Assistance Listing Title: SNAP Cluster Views of Responsible Officials (state whether your agency agrees or disagrees with the finding; if you disagree, briefly explain why): DOH does not agree with the finding. The Division performs monthly reconciliations and balancing efforts to ensure accuracy with FIS, EIS, and reporting. No discrepancies have been identified by the Division. None of the parties involved in the audit have been able to pinpoint the origin of the discrepancy described in this finding. The Divisions’ monthly reconciliation processes are rigorous, consistent, and thorough, ensuring accuracy and alignment with USDA data from AMA Bank. The reconciliation efforts encompass federal SNAP reports; FNS 388, FNS 46, and the EIS Balance Issuance report, all of which consistently reconcile. The reconciliation extends to ASAP and AMA batch values, with annual certification further validating accuracy. Monthly, the AMA raw data is meticulously balanced in the 388/46 reports, with only the PEBT and EA issuances requiring manual entry from the 292B report. With this steadfast commitment to monthly reconciliation and alignment with AMA data, we are confident in the absence of errors or discrepancies. Corrective Action (corrective action planned): N/A Completion Date (list anticipated completion date): N/A Agency Contact (name of person responsible for corrective action): Josie Stern, Assistant Commissioner

Finding: 2023-033 – Division of Public Assistance (DPA) management instructed staff to extend SNAP six-month certification periods after an approved waiver expired bypassing required eligibility recertifications. Furthermore, DPA continued to extend six-month certifications for consecutive periods without recertifying eligibility after being notified by the federal award agency that the practice was unallowable. Questioned Costs: AL 10.551: Indeterminate Assistance Listing Number: 10.551, 10.561 Assistance Listing Title: SNAP Cluster Views of Responsible Officials (state whether your agency agrees or disagrees with the finding; if you disagree, briefly explain why): DOH agrees with the finding. Corrective Action (corrective action planned): The Division of Public Assistance (DPA) reintroduced recertification standard for SNAP beneficiaries. Ensuring programmed auto-closure protocols are active ensures SNAP cessation if households fail to submit recertification packets. Ceasing system-generated SNAP certification extension, the division collaborates on a corrective action plan with Food Nutrition Services (FNS) for compliant benefit recertifications. Completion Date (list anticipated completion date): DOH anticipates the finding will be resolved in FY2024. Agency Contact (name of person responsible for corrective action): Josie Stern, Assistant Commissioner

Management Response: We agree with the finding. The procedure of maintaining the complete schedule of expenditures of federal awards will be implemented in fiscal year 2024.

CORRECTIVE ACTION PLAN December 7, 2023 Kansas State Department of Education and Kansas State Department of Administration Unified School District Number 214 respectfully submits the following corrective action plan for the year ended June 30, 2023. Dirks, Anthony & Duncan, LLC Po Box 885 Ulysses, KS 67880 Audit Period: June 30, 2023 FINDINGS – FEDERAL AWARD PROGRAMS AUDIT U.S. Department of Education Passed Through Kansas State Department of Education Program Name: Education Stabilization Fund Cluster Federal Assistance Listing Numbers: 84.425W, 84.425U, 84.425D Finding 2023-001 Recommendations: The Board of Directors, the Director and key positions of management should adequately document internal control procedures for equipment inventory, log maintenance, and dispositions requirements consistent with 2 CFR sections 200.313(c) through (e). Board should then periodically check that all procedures agreed upon are operational and effective, and adjust procedures as needed. Action Taken: We agree with the recommendation. Our targeted implementation date is March 2024. If the Kansas State Department of Education and/or Kansas State Department of Administration has questions regarding this plan, please call Corey Burton at 620-356-3655. Sincerely yours, Corey Burton Superintendent

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 audit finding noted one Consultative Examination (CE) provider where the qualified provider review was not completed timely and this was an oversight on the part of the Department of Labor and Workforce Development’s Division of Disability Services (DDS) due to attrition of staff. Going forward, each DDS Professional Relations Officer will be responsible for reviewing eight to 10 CE provider’s qualifications each month until the yearly review is completed for each vendor. The Chief of Professional Relations will submit a monthly report to the DDS Assistant Director detailing how many sites were visited that month and any findings that may have occurred. Each month, the report will detail how many reports remain outstanding in order to complete the yearly reviews. COMPLETION DATE/ CONTACT PERSON & PHONE# April 9, 2024 Theresa Vallely (609) 984-1779 Theresa.Vallely@dol.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. 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