Corrective Action Plans

The New Jersey Department of Education (NJDOE) Office of Grants Management (OGM) understands the need to be compliant with FFATA reporting in accordance with the Uniform Guidance. Internal controls and processes are in place to ensure NJDOE’s FFATA reporting process is working efficiently and timely. This noncompliance finding is not due to a lack of controls within NJDOE but lies squarely on system issues at SAM.gov and the FFATA Subaward Reporting System (FSRS) sites and until the issues listed below are corrected on these federal system sites, NJDOE will continue to be noncompliant with timely FFATA reporting. Issues with the SAM.gov and FSRS sites: • SAM.gov has approved NJDOE’s local education agency (LEA) registrations without a ZIP+4, but FSRS reporting system for FFATA uploads requires ZIP+4 for each LEA. The two systems use the same database, which means information registered on SAM.gov feeds directly into the FSRS system. However, because FSRS batch uploads require a ZIP+4, those LEAs that were approved by SAM.gov without a ZIP+4 during the registration process, are rejected from the FFATA report batch upload. There is an option to manually load each LEA and their details into the system, but the process becomes incredibly time consuming, given the 700+ LEAs in the state, the number of federal awards granted, and the steps for identifying & removing rejected LEAs from the batch upload. • Issues NJDOE has with SAM.gov and FSRS have been shared with the federal helpdesk and a USED representative without avail, as the systematic issue remains unresolved and continues to delay our FFATA reporting process. • There are several rural LEAs in the state that do not have a ZIP+4. These LEAs will continue to be rejected from the batch upload, delaying our FFATA reporting process, if SAM.gov and FSRS do not come up with a viable solution. • There were a number of LEAs that were continuously rejected from the upload by FSRS for no obvious reasons. The error message received was the same exact error we receive for incorrect zip codes. After spending much time investigating the cause with the helpdesk support, it was identified that FSRS did not update their system to reflect the Congressional District code changes during New Jersey’s redistricting process. • The FSRS system rejects batch uploads if a single lower-case SAM UEIs is entered in the batch file. However, SAM.gov search box and the FSRS manual uploads are not case sensitive. Batch uploads are the only place where SAM UEIs are case sensitive. Further, this information is not included in any of the FSRS User Guides or manuals. I have shared this with the FSRS helpdesk, but no solution was provided. Again, this discrepancy in their system affects and delays our FFATA reporting processes. NJDOE dedicated personnel, including the director of OGM, continuously work with SAM.gov, FSRS system, and both system sites’ help desks, to bring to light the issues mentioned above in order to express the urgent need for corrective actions at the federal system sites to allow for timely FFATA reporting. In addition internal controls and procedures are in place at NJDOE related to FFATA reporting and corrective actions are constantly performed in real time to perform the below NJDOE Internal Controls and Procedures. Some of these procedures include reviewing internal SAM applications and troubleshooting with NJDOE’s local education agencies (LEAs) to correct data in the application and resubmit to the federal reporting system sites with more detail included below. NJDOE Internal Controls and Procedures: • Due to the large number of LEAs in the state (700+), each FFATA report must be submitted via batch upload, which saves an enormous amount of time it takes to input data manually for every single LEA, for every grant. To address this need and to expedite the process, our vendor has created a reporting tool that generates a FFATA batch report. • We have been contacting the federal helpdesk to address the issues on their sites and asking for support. Some of those tickets were closed without providing any support and most were not helpful. • We have created and implemented an in-house System for Award Management (SAM) application, mandatory for all of our federal grant recipients. This was done specifically for FFATA reporting purposes to ensure data in these applications are directly tied to the FFATA batch reports. • The SAM applications go through a thorough review process, where data entered by the districts is compared with the data registered with SAM.gov (applicants are required to upload a copy of their Entity Overview Record, issued by SAM.gov). • SAM applications are returned for changes whenever an applicant has entered data that is inconsistent with data on SAM.gov (i.e.. Incorrect SAM UEI, incorrect zip code, incorrect zip+4, incorrect City name). • We have asked many of our districts to contact SAM.gov and update their physical address information to include the full 9-digit zip code, which was SAM.gov reviewers’ oversight. Our school districts have commented that this process can take months. • We are communicating with our districts/applicants on a daily basis through the review summary checklist, outlining the changes that must be made, as well as by email and phone. • We have implemented an automatic messaging system, where applicants are reminded to update their SAM registration expiration date, multiple times a month leading up to their expiration date. Due to the system discrepancy in the FSRS system’s batch upload, we had to create a workaround pertaining to the district’s SAM UEIs. As stated above, SAM UEIs, in batch FFATA reports, are case sensitive while not case sensitive anywhere else in the two system sites. We have updated our instructions in NJDOE’s SAM application and have added another layer of application review, to ensure that all UEIs entered are in all capital letters. Because the federal helpdesk has ignored this discrepancy and did not resolve the issue, we are obligated to take additional steps and spend additional time on FFATA batch reports. COMPLETION DATE/ CONTACT PERSON Indeterminate – Completion based on federal implementation of fixes to SAM.gov and FSRS portal as noted in views. Martin Egan, Director NJDOE Office of Grants (609) 376-9089 Martin.Egan@doe.nj.gov

The Department of Labor and Workforce Development (DLWD), as the prime recipient of the federal awards, will ensure that all first-tier subawards made to entities totaling $30,000 or greater will be entered timely into the FSRS in accordance with FFATA reporting requirements. The audit sample selections in question were based on manual DLWD notice of awards that were not communicated correctly to staff who are responsible for entering the required subaward information into FSRS. Going forward, DLWD staff who are responsible for entering data into the FSRS will be copied on all emails containing the manual notice of award(s) once the notice is signed by the DLWD Commissioner. These email communications will trigger the information to be entered into the FSRS. COMPLETION DATE/ CONTACT PERSON April 4, 2024 Michael Varga (609) 351-3000 Michael.Varga@dol.nj.gov

The Department of Human Services (DHS), Central Office Payroll group will run reports biweekly to determine if any employees are on a leave without pay status greater than 10 days. This added reporting function will ensure that all DHS employees who are on a leave of absence without pay beyond 10 days have their PMIS histories updated upon each extension and return to work. COMPLETION DATE/ CONTACT PERSON March 26, 2024 Maureen Taylor (609) 292-6106 Maureen.Taylor@dhs.nj.gov

The Department of Labor and Workforce Development (DLWD) transitioned from a manual contract agreement process to a web-based grant administration system in recent years that employs the System for Administering Grants Electronically (SAGE) and IntelliGrants (IGX) applications. The DLWD FFATA Reporting Unit has access to these automated systems and monitors them on a monthly basis to identify when new subaward contracts/agreements are approved in order to report required data in the FFATA system timely. DLWD corrective actions regarding FFATA reporting are expected to be fully implemented as of June 30, 2024. COMPLETION DATE/ CONTACT PERSON June 30, 2024 Theresa Vallely (609) 984-1779 Theresa.Vallely@dol.nj.gov

The Department of Labor and Workforce Development’s (DLWD) Office of Information Management, Services & Solutions (OIMSS) will continue its efforts to ensure staff compliance with existing controls over program change controls for the New Jersey Local Office Online Payment System (NJLOOPs). DLWD’s efforts will continue to be guided by statewide change management best practices. OIMSS will add a Director-level approval step to the program promotion process that will validate that the required documentation has been uploaded to the change ticket. Except in circumstances involving emergency off-hours break fix resolution, separation of duties will be included as a check-off for approval to deploy program changes. COMPLETION DATE/ CONTACT PERSON April 3,2024 Matthew Curtis (609) 376-4021 Matthew.Curtis@dol.nj.gov Robert Schisler (609) 571-2391 Robert.Schisler@dol.nj.gov

The Department of Labor and Workforce Development (DLWD) continues to monitor all first payment and non-monetary time lapse figures in order to meet the established USDOL Acceptable Levels of Performance (ALP). As workloads return to normal levels after the increased activity from the COVID-19 pandemic related claims, greater emphasis will continue to be placed on meeting all ALPs. Specifically relating to first payments and the previously discussed issues with claimants verifying their identity before any payments can be made, the DLWD has made some internal changes to how returned verified IDs from our ID verification partner (ID.me) are handled. These modifications to the internal process used to clear verified IDs are expected to have a positive impact on overall time lapse numbers as verified claimants will not be delayed longer than they previously were under the old process. The month of April starts the new reporting year for these figures to USDOL and New Jersey expects to see significant increases to first payment and non-monetary time lapse figures by the third quarter of calendar year 2024. COMPLETION DATE/ CONTACT PERSON September 2023 Theresa Vallely (609) 984-1779 Theresa.Vallely@dol.nj.gov

The Department of Labor and Workforce Development (DLWD) will continue to review and enhance controls to ensure that BAM quality control case investigations are completed timely, that reviews are signed as required by appropriate staff, and that all required case review supporting documentation is maintained in case files. DLWD corrective actions will be completed by September 30, 2024. COMPLETION DATE/ CONTACT PERSON September 30, 2024 Theresa Vallely (609) 984-1779 Theresa.Vallely@dol.nj.gov

The Reemployment Services and Eligibility Assessments (RESEA) policy and controls presently in place at the Department of Labor and Workforce Development (DLWD) require eligibility interviews to be conducted and eligibility review forms to be completed and signed by the participant and UI program representative. DLWD implemented a new process that allows staff to electronically obtain signatures through Simpligov, beginning June 2023. This process requires that staff obtain all necessary signatures before a RESEA claimant record is completed. Supervisors are assigned to monitor this process in order to mitigate the risk associated with missing information on any single RESEA customer registration. DLWD will monitor this process to ensure that all interviews are properly documented, and forms are signed and electronically uploaded to its electronic case management system of record for future reference. During the initial rollout of this process, there were records that didn’t migrate to the case management system of record. This issue has now been addressed through training. DLWD has also developed dashboards that will assist with monitoring data entry. Monthly reviews of RESEA data entry will be conducted to identify possible errors. These RESEA process changes that will be implemented by DLWD will ensure compliance with regulatory standards and assist with maintaining the integrity of its data management process. COMPLETION DATE/ CONTACT PERSON June 30, 2023 Baden Almonor (609) 777-1042 Baden.Almonor@dol.nj.gov

The Department of Labor and Workforce Development (DLWD) has controls in place to only allow an FPUC payment to be made when an underlying Unemployment Insurance (UI) payment has also been processed. FPUC payments should not be issued to any claim without the underlying UI payment being made for the same week. The FPUC payments issued and noted as exceptions during eligibility testing will be reviewed independently by DLWD to determine if the payments issued were to eligible recipients or not. For the PUA exceptions noted during Eligibility testing, overall the DLWD issued PUA payments to over 680,000 claimants during the COVID-19 pandemic. DLWD had controls in place to require a COVID related reason to make the claim PUA eligible and the weekly PUA certification required claimants to choose a COVID related reason for why they were out of work before they could get paid. The PUA payments in question will be reviewed independently by the DLWD to determine if the payments issued under PUA were appropriate or if they should have been paid instead under the regular UI program. DLWD corrective actions related to FPUC and PUA payments were fully implemented as of September 2023. COMPLETION DATE/ CONTACT PERSON September 2023 Theresa Vallely (609) 984-1779 Theresa.Vallely@dol.nj.gov

Federal Agency Name: Department of Treasury Program Name: Community Development Financial Institutions Equitable Recovery Program (CDFI ERP) CFDA #21.033, Award 22ERP060843 Finding Summary: The internal control structure for procurement is not designed to properly test and document for suspension and debarment of vendors prior to entering contracts. Responsible Individuals: Mesude Cingilli - VP of Finance, Nelly Chick - Controller, Kevin Grafstrom - Accountant. Corrective Action Plan: The Organization is currently revising its procurement policy and procedures to include clear guidance on search required on vendors for Federally Funded Programs. It is anticipated that the revised policy will be implemented by December 31, 2024. Anticipated Completion Date: December 31, 2024

Finding Number: 2023-006 Condition: Currently one person prepares the reimbursement requests and no one reviews them for accuracy prior to submitting the requests to the State through the Operating Assistance Report (OAR) for reimbursement. Planned Corrective Action: Management will identify a new process for OAR assignment and submission. Currently the OARs are prepared and submitted by the CFO due to staffing limitations. Nevertheless, the CFO will work to identify an individual within the Finance Department that has the skillset and capacity to prepare the OARs for CFO review prior to submission. Contact person responsible for corrective action: Colette Champine, CFO Anticipated Completion Date: July 10, 2024

Identifying Number: 2023-002 Finding: Participant Eligibility Corrective Action Taken or Planned: Procedures have been updated to include procedures and internal controls to maintain supporting documentation and ensure the existence and completeness of the participant population. Anticipated Implementation and Responsible Official: April 30, 2024, Suresh Sharma, Chief Financial Officer

2023‐005 – Year Ended June 30, 2023 Department of Health and Human Services Federal Assistance Listing/# 93.498 Activities Allowed or Unallowed and Allowable Costs/Cost Principles and Reporting Significant Deficiency in Internal Control over Compliance Finding Summary: 2 CFR 200.303(a) establishes that the auditee must establish and maintain effective internal control over the federal award that provides assurance that the entity is managing the federal award in compliance with federal statutes, regulations, and conditions of the federal award. The Facilities claimed equipment costs under the Provider Relief Fund program for a project that was not complete at the end of the period of availability, or December 31, 2022. Costs were improperly included within the Period 4 report and caused the reporting submitted to the Department of Health and Human Services to be inaccurate. Responsible Individual: Perry Howell, CFO Corrective Action Plan: The Facilities will enhance internal control policies to ensure all amounts are adequately documented and properly recorded in the reports required to be submitted to the federal agency. The Facilities will enhance internal control policies to ensure that the required reports are properly reviewed prior to submission to ensure all key line items are necessary, correct, meet the requirements of the federal program, and are properly recorded in the reports required to be submitted to the federal agency. Anticipated Completion Date: June 2024

2023‐004 – Year Ended June 30, 2023 Department of Health and Human Services Federal Assistance Listing/# 93.498 Reporting Material Weakness in Internal Control Over Compliance and Material Noncompliance Finding Summary: 2 CFR 200.303(a) establishes that the auditee must establish and maintain effective internal control over the federal award that provides assurance that the entity is managing the federal award in compliance with federal statutes, regulations, and conditions of the federal award. The Facilities did not consider the impact of the year-end audit adjustments on the quarters applicable to Period 4 when reporting lost revenue. Key line items for reporting related to lost revenue were materially misstated. No lost revenue was claimed during the current period. Responsible Individual: Perry Howell, CFO Corrective Action Plan: The Facilities will enhance internal control policies to ensure all amounts are adequately documented and properly recorded in the reports required to be submitted to the federal agency. The Hospital will enhance internal control policies to ensure that the required reports are properly reviewed prior to submission to ensure all key line items are necessary, correct, meet the requirements of the federal program, and are properly recorded in the reports required to be submitted to the federal agency. Anticipated Completion Date: June 2024

Finding 2023-002 Condition/Context The Corporation used the Lost Revenues Reporting Method: Alternative Reasonable Methodology (Option 3) for measuring lost revenues. In the Corporation's Period 4 submission for Robert Packer Hospital, TIN 24-0795463, total lost revenues were incorrectly reported as $13,011,879, rather than $12,930,176. Total lost revenues available to be used in this reporting period based on the adjusted amount was $7,142,168 on payments in the period of $7,142,168. This is not a statistically valid sample. Corrective Action Plan Corrective Action Planned: The Corporation agrees with the finding. Management increased the level of review over the lost revenue calculations for future reporting periods. Management did not believe that further corrections to the Period 4 report were necessary as the remaining available lost revenues after adjusting for the error were equal to the payments received in the period and there was no further submissions necessary for Robert Parker Hospital. Name(s) of Contact Person(s) Responsible for Corrective Action: Sean Monahan, Corporate Financial Controller and Fran Macafee, VP, CFO – Guthrie Lourdes Hospital. Anticipated Completion Date: September 30, 2023

Finding 2023-001 Condition/Context The Corporation’s review process failed to detect errors in the calculation of amounts related to the pay for event program that were applied to the Federal award. Errors were discovered in 8 of the 44 items tested for the pay for event program which would have increased the allowable costs eligible for reimbursement under the Federal award by $671. This is not a statistically valid sample. Corrective Action Plan Corrective Action Planned: The Corporation agrees with the finding. Management implemented an enhanced review process to validate all amounts reported on the PRF Reporting Portal Submission, and to ensure compliance with existing policies and terms and conditions of the Provider Relief Funds. Further action was not considered necessary as the errors would result in increased costs eligible for reimbursement under the Federal award and no further funding is available. Name(s) of Contact Person(s) Responsible for Corrective Action: Kristen Maffei, Manager – Nursing Administration, Sean Monahan, Corporate Financial Controller and Fran Macafee, VP, CFO – Guthrie Lourdes Hospital. Kristen Maffei, Manager – Nursing Administration, Sean Monahan, Corporate Financial Controller and Fran Macafee, VP, CFO – Guthrie Lourdes Hospital. Anticipated Completion Date: This was corrected as of June 30, 2023, and the pay for event program was phased-out after the final Provider Relief Funds were released.

2023-033 Oregon Department of Emergency Management Implement controls over FFATA reporting MANAGEMENT RESPONSE: We agree with this recommendation. ODEM has undertaken the following corrective actions to address the recommendations made by the Secretary of State’s Audits Division: a. ODEM has developed procedures for capturing necessary information and ensuring FFATA reports are filed in compliance with federal criteria. b. ODEM has identified all awards since July 1st 2023 and is working to ensure 100% compliance from that date forward. c. ODEM will continue to review older awards to determine what actions should be taken. Anticipated Completion Date: December 30, 2024. Contact person: Jeff Flowers, Chief Financial Officer

2023-038 Department of Early Learning and Care Retain support and improve controls over reporting MANAGEMENT RESPONSE: We agree with this recommendation. DELC will work with the Department of Revenue to substantiate the amount of tax credits used in prior years to meet federal matching and maintenance of effort requirements for FY 20 to FY 22 and ensure this information is retained appropriately outside beyond just email records. In addition, DELC will update processes and procedures to ensure that tax credit amounts used in future reports are properly documented and substantiated by the Department of Revenue. Anticipated Completion Date: October 31, 2024 Contact person: Ali Webb, Operations and Policy Analyst; Connie Range, Fiscal Analyst

2023-021 Oregon Health Authority Implement controls to ensure earmarked expenditures are tracked and compliance achieved MANAGEMENT RESPONSE: We agree with this recommendation. As noted in the audit report, OHA has already taken corrective actions to ensure controls are in place for tracking applicable expenditures in SFMA to ensure compliance with federal Earmarking requirements. The Office of Financial Services, OHA Budget Unit, and block grant planners meet at least once a month to review budgeted earmarked requirements and expenditures to ensure compliance. Block grant planners meet at least once a month with the crisis team and children and family team to review required earmark budgets and expenditures. Anticipated Completion Date: June 30, 2023 Contact person: Annabelle Atalig, Budget and Fiscal Manager; Travis Labrum, Grant Accounting Manager

2023-019 Oregon Housing and Community Services Ensure documentation is retained to support amounts reported MANAGEMENT RESPONSE: We agree with this recommendation. Staff have received training and documentation is now retained consistently to support reported figures. Anticipated Completion Date: June 30, 2024 Contact person: Dean Criscola, Controller

2023-018 Oregon Housing and Community Services Ensure grant management report control is performed and documented MANAGEMENT RESPONSE: We agree with this recommendation. A dedicated staff resource has been trained and has brought grant reconciliations and reporting current. Additional training has been provided for awareness of the earmarking and obligation requirements as well. Anticipated Completion Date: June 30, 2024 Contact person: Dean Criscola, Controller

2023-017 Oregon Housing and Community Services Ensure review of federal cash draws are adequately documented to support the draws are for the immediate cash needs of the program MANAGEMENT RESPONSE: We agree with this recommendation. Additional training has been provided to new team members, to ensure adequate documentation exists to support immediate cash needs. Two-step verification of all draws is also required. Refresher training has been provided to staff to ensure oversight is in place at all times. The funds inadvertently drawn were corrected the first week of March 2024. Anticipated Completion Date: June 20, 2024 Contact person: Dean Criscola, Controller

2023-040 Oregon Department of Education State did not meet maintenance of effort requirement MANAGEMENT RESPONSE: We agree with this recommendation. The Department of Education agrees with this finding; however, context is critical to understand this requirement. The Maintenance of Effort (MOE) requirements in The ARP ESSER III legislation are unique. The purpose of the requirement is to ensure that states are not using the federal pandemic funds to replace state funding and then leaving districts with a more substantial “fiscal cliff” when the pandemic funds recede. ODE administers state funding to Oregon districts, but the levels and formulas governing the distribution of the total state funds are determined by the Oregon Legislature and not ODE. While the non-compliance finding implies that Oregon reduced education funding, that is not true. Education funding in Oregon did increase annually, yet not as much as other non-education funding priorities. The United States Department of Education (USDE) formula required to evaluate MOE does not adequately reflect the investment in public education in Oregon, nor does it acknowledge the complexities of Oregon’s state budget or school funding formulas. ODE worked closely with USDE staff monitoring MOE compliance and submitted a request to USED for an MOE waiver on March 14, 2024. We are awaiting a decision from USDE. A response is anticipated by June 2024. Anticipated Completion Date: June 30, 2024 Contact person: Cynthia Stinson, Senior Manager of Federal Investments and Pandemic Renewal Effort

2023-042 Oregon Department of Education Retain support for pre-approval of equipment purchases MANAGEMENT RESPONSE: We agree with this recommendation. ODE has already developed and implemented updates to the capital expenditure request review and approval process to ensure equipment approvals are retained. Early ESSER capital project tag requests were split between a committee for large projects and the individual grant finance manager. Approvals were primarily sent via email from the grant finance manager. Some of those messages are archived in the ESSER.ODE inbox, however some went out directly from staff email. Records are available for the committee decisions. When the smaller approvals moved from the finance manager to an ESSER team, many of those decisions were made in conjunction with other meetings. Some records are available; however, the Capital Expenditure Tracker was the primary location of decisions. In October 2022, staffing changes allowed the committee and team structure to become more formalized. Committee meeting decisions shifted from a “minute”- style agenda to being more systematized in an online log. Team meeting decisions followed a similar process update in April 2023. The online agenda/log allows for consistent tracking of projects that are up for discussion and which approval are put on hold for elevation approval, correction, or clarification from the district. Committee and team meetings have been established weekly. When all information is received from a district, the project is placed on the appropriate agenda for that week. Approvals are sent out within 2 business days. A column was added to the Capital Expenditure Tracker, which remains the primary location of records, to track when the approval emails were sent. Corrections have already been developed and implemented as of April 2024. Anticipated Completion Date: April 30, 2024 Contact person: Cynthia Stinson, Senior Manager of Federal Investments and Pandemic Renewal Effort

2023-041 Oregon Department of Education Improve FFATA reporting controls MANAGEMENT RESPONSE: We agree with this recommendation. ODE will implement the following corrective action to ensure monthly FFATA reports are independently reviewed to ensure accurate and complete reporting. 1. Review and update list of all FFATA eligible federal awards monthly. 2. Implement a new query tool that will reduce manual processes. 3. Collaborate with ODE partners to access agency-collected unique entity identifier (UEI) information for sub awardees. 4. Monthly review of FFATA reporting by a second accountant. Anticipated Completion Date: June 30, 2024 Contact person: Kristie Miller, Accounting Director