Corrective Action Plans

EXECUTIVE OFFICE OF LABOR AND WORKFORCE DEVELOPMENT 2023-012 WIOA Cluster, Employment Service Cluster – Assistance Listing No. 17.258, 17.259, 17.278, 17.207, 17.801 Action taken in response to the finding: The corrective action plan (CAP) for this finding was implemented and completed in Fiscal Year 2023 with the addition of the FAIN numbers to the subawards and the completion of FY23 CommCorp monitoring. MDCS continues to include FAIN as part of the revised documented process and monitoring is current and timely performed. MDCS therefore considers this item to be completed and closed. Name of the contact person responsible for corrective action: Michael Williams, Director of Field management and Oversight Planned completion date for corrective action plan: December 31, 2022

2023-003 – Subrecipient Monitoring Compliance Person responsible for corrective action – Andrea Olson, Executive Director Responsible official’s response – Management is in agreement with this finding. Corrective action planned – CAPND has subsequently requested all audit reports from all subrecipients. Additionally, CAPND has changed subaward formatting to ensure that all required information is included within the award. Planned implementation date of corrective action – July 10, 2024

Views of Responsible Officials: The Organizations concur with the auditor's assessment and are in the process of implementing a pre-award risk assessment procedure.

Research and Development – Assistance Listing No. 10.216 Research and Development – Assistance Listing No. 43.008 Research and Development – Assistance Listing No. 93.433 Recommendation: We recommend the University review its procedures for the subrecipient monitoring process to ensure the reviews are completed timely and implement procedures necessary to ensure information is included in the subrecipient award documents at the time of funding. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Langston is strengthening processes to use and distribute disclosures to subrecipients and follow-up for incomplete/unsigned documents from subrecipients. Name(s) of the contact person(s) responsible for corrective action: Mr. Robert Dixon, Director, Grants and Contracts Fiscal Administration at Oklahoma State University. Planned completion date for corrective action plan: March 2024

The County Grants Manager will ensure that all subrecipients receiving $750,000 in Federal Funds undergo a Single Audit as required by 2 CFR Part 200. The Grants Manager will review the SEFA and contact all necessary subrecipients for their audits. Name of Contact Person: Kristi D. Bosch, Grants Manager Anticipated Completion Date: 12/31/2024

The County will review the monitoring plan related to the program and will ensure these procedures are done timely and meet the federal requirements for monitoring subrecipients.

The County will require departments receiving federal funding to complete a subrecipient and contractor relationship checklist based on the Uniform Guidance prior to entering into a contract with any vendor. This checklist will ensure proper identification of subrecipients and serve as documentation of this procedure. This checklist will be part of our Grants Acknowledge form implemented by our Grants department that recipient departments are required to complete at a grant’s inception. Completed checklists will be retained and reviewed by the Finance department prior to SEFA compilation to ensure subrecipient expenditures are being properly recorded on the SEFA. For awards identified as being passthroughs to subrecipients, the County has developed additional procedures to document this relationship. This includes a subrecipient package requiring signatures from the County and subrecipient to acknowledge the subrecipient relationship. This package will include relevant award identifiers such as award date, period of performance and Federal awarding agency and Assistance Listing Number and title. Recipient departments will also be required to perform monitoring procedures on identified subrecipients including assessing the subrecipient’s risk of noncompliance with Federal statutes, regulations and the terms and conditions of the subaward. The County has developed a questionnaire for biannual monitoring meetings with the subrecipient that is intended to further document the subrecipient is utilizing funds for authorized purposes, in compliance with Federal statutes, regulations, and the terms and conditions of the subaward, and that subaward performance goals are achieved. This questionnaire also requests obtaining copies of the subrecipients financial statements and single audit to verify the subrecipient is audited as required by Subpart F - Audit Requirement under the Uniform Guidance

SUBRECIPIENT MONITORING – COMMUNITY DEVELOPMENT BLOCK GRANTS Recommendation: It is recommended that the County reviews their policies to ensure they are monitoring subrecipients and retaining documentation as required by federal guidelines. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will implement policies to ensure all documentation is kept and subrecipient monitoring is in place. Name of the contact person responsible for corrective action plan: Nancy Malecha, Finance Director Planned completion date for corrective action plan: December 31, 2024

REPORTING – COMMUNITY DEVELOPMENT BLOCK GRANTS Recommendation: It is recommended that the County reviews their policies to ensure reporting requirements are met including a review of the subrecipient reports prior to submission. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will implement policies to ensure reporting processes include review by someone other than the preparer. Name of the contact person responsible for corrective action plan: Nancy Malecha, Finance Director Planned completion date for corrective action plan: December 31, 2024

The Department of Behavioral Health (DBH) agrees with the findings. Eligibility of Subrecipients: Training will take place for Fiscal Services Staff to ensure that screening for eligibility for the program takes place. The requirement for screening will be added as a required data element so screening can be monitored in the grants management system. Earmarking Requirements for Subrecipients: ICR will be set up based on allowable costs from the NOA in grants management system. Training will be conducted for Fiscal and Program Monitors so that they are aware of how ICR is determined and calculated. Monitoring of Subrecipients: DBH will conduct training to ensure that Fiscal and Program Monitors understand the requirements of on-going documentation to identify risk and compliance to the program. DBH will have the monitoring form created in the new grants management system so that failure to complete the documentation will trigger a system alert with an escalation process to ensure compliance. Contact - Eligibility of Subrecipients: Anthony Baffour, Director, Fiscal Services, Earmarking Requirements for Subrecipients: Sharon Hunt, State Opioid Treatment Authority and Anthony Baffour, Director, Fiscal Services, Monitoring of Subrecipients: Sharon Hunt, State Opioid Treatment Authority and Anthony Baffour, Director, Fiscal Services See Corrective Action Plan for chart/table Estimated Completion Date - Staffing Training: August 1, 2024, Grants Management System: January 1, 2025 See Corrective Action Plan for chart/table

The Department of Energy and Environment (DOEE), Office of Neighborhood Safety and Engagement (ONSE) and various other District agencies agree with the conditions and recommendations of this finding. DOEE: The agency will add a section regarding a subrecipient’s prior year audit report to the risk analysis conducted by program staff. For any prior year audit findings, the agency will request a copy of the subrecipient’s corrective action plan. ONSE: The agency will conduct and review, on a monthly and quarterly basis, site visits/reports and will follow up with subrecipients to submit reports on a timely basis. Various Other District Agencies: The agencies will review the details of subrecipients amount generated from the system and perform a vendor or subrecipient analysis to ensure accuracy of amounts to be reported in SEFA. Contact - Lisa Mae Crawford, Associate Director, Residential Services Division, DOEE, Yasha Williams, Chief Operating Officer, ONSE, Various District Cluster Controllers Estimated Completion Date - September 30, 2024; March 1, 2025 See Corrective Action Plan for chart/table

Views of Responsible Officials: While the Organization did evaluate sub-recipients prior to each sub-award, documentation of that evaluation was not retained as required. For any new subrecipients, the Organization will perform the required pre-award risk assessment and retain adequate documentation of the work performed and results.

Circle Health acknowledges and agrees with this finding. We did have contracts in place with subrecipients, but they were outdated. Both program and finance staff work closely with subrecipients and ensure that they are aware of the grant requirements, reporting requirements, allowable costs, etc. Subrecipient monitoring is performed on a regular basis via review of submitted invoices, programmatic meetings and performance reviews. We will create new contracts and have all outstanding, unsigned agreements signed. We will maintain a checklist of due dates for all subrecipient agreements and review periodically throughout the year.

Management concurs with this finding. As noted in the response to Subrecipient Monitoring – Improper Communication to Subrecipient, Subrecipient vs. contractor differentiation has been an area of continued improvement. Management believes recent efforts to properly differentiate between subrecipients and contractors has resulted in accurate determinations. However, documentation, ongoing monitoring, and communication are areas for further improvement. To that end, Management has implemented a new subrecipient/contractor determination form that includes both documentation of the determination and a checklist for ongoing compliance and monitoring for both subrecipients and contractors. This form requires that a subrecipient monitoring plan be put in place which will address compliance with all applicable federal award conditions including Single Audits. Management believes implementation of this form/process will reduce the risk of further noncompliance.

As of January 2, 2024 CAL, hired a staff account (Melanie Richards) to ensure all expenses are recorded in compliance with performance periods. The Associate Director of Finance will review all postings monthly and consult with the Vice President of Finance on any corrections or recommendations.

Corrective Action Plan: Management will ensure controls are put in place to adequately monitor all subrecipient monitoring requirements. Anticipated Completion Date: Fiscal Year 2024.

Name of the Contact Person Responsible for the Corrective Action Plan: John Wiggins, Finance Director. Corrective Action Plan: The City of Forest Park will take necessary steps in the future to ensure that our subrecipient agreements include all of the required federal compliance language and we will ensure that risk assessments are performed for future subrecipients. Anticipated Completion Date: April 30, 2024

Federal Agency: U.S. Department of Transportation Program/Cluster: Highway Planning and Construction Federal Assistance Listing Number: 20.205 Pass‐through: California Department of Transportation Award No. and Year: 5923, 2022/2023 Compliance Requirement: Subrecipient Monitoring Type of Finding: Material Weakness in Internal Control over Compliance, Material Noncompliance Views of Responsible Officials and Corrective Action Plan: Management agrees with the finding. All Public Works contracts receiving federal funding will be evaluated to determine if the vendor is a contractor or subrecipient going forward. This practice is already followed for the other divisions within the Department, and Public Works will now be included. Responsible Individual(s): James Bezek, Director of Resources Management Anticipated Completion Date: June 30, 2024

Federal Agency: U.S. Department of Housing and Urban Development Program/Cluster: Housing Voucher Cluster Federal Assistance Listing Number: 14.871, 14.879 Pass‐through: n/a – direct award Award No. and Year: CA131, 2022/2023 Compliance Requirement: Subrecipient Monitoring Type of Finding: Material Weakness in Internal Control over Compliance, Material Noncompliance Views of Responsible Officials and Corrective Action Plan: The subrecipient agreement was updated to include required federal award identification elements and was approved by the Board of Supervisors and executed on July 25, 2023. Discussion between the County and the City of Vacaville, including several meetings about the new contract took place throughout the audit period of July 1, 2022 and June 30, 2023. The risk assessment was completed in November 2022. The risk assessment will be updated on an annual basis going forward. A site visit was conducted in December 2022. Monitoring activities were occurring for this contract but were not formally documented. Documentation will be retained as support monitoring activities are occurring for this contract going forward. Responsible Individual(s): James Bezek, Director of Resources Management Anticipated Completion Date: June 30, 2024

Finding Number 2023-213: The Department erroneously determined that two recipients of Temporary Assistance for Needy Families (TANF) funding were contractors instead of subrecipients resulting in noncompliance with the subrecipient monitoring requirements. Federal Programs: 93.558 – Temporary Assistance for Needy Families Related to Prior Finding: N/A Agency’s view: The Department agrees with this finding. Corrective Action: The Department has revised our training of personnel involved in subrecipient and contractor determinations. These contract managers and monitors completed grant training on March 12th-13th, 2024 which included sections about subrecipient and contractor determinations, risk assessment and documentation. All newly hired employees will be trained beginning April 2024 with an on-line module. For the impacted vendor, an updated Risk Assessment was completed and submitted to LSO. Additionally, the Department has started the work to effectively change the designation of the vendor and ensure all required information is provided to this subrecipient. This process will be completed by April 30th, 2024. The Department will develop internal control procedures to ensure all required information is provided to the subrecipients at the time of the subawards. These updated internal control procedures will be completed by June 30th, 2024. Anticipated Corrective Action Date: June 30, 2024 Responsible for Corrective Action: Cameron Gilliland, Division Administrator Cameron.Gilliland@dhw.idaho.gov 208-334-0641 Kelly Combs, Bureau Chief, Compliance Kelly.Combs@dhw.idaho.gov 208-334-5814

CORRECTIVE ACTION PLAN March 26, 2024 City of Roanoke, Virginia respectfully submits the following corrective action plan for the year ended June 30, 2023. Name and address of independent public accounting firm: Brown, Edwards & Company, L.L.P. 3906 Electric Road Roanoke, VA 24018 Audit period: June 30, 2023 The findings from the June 30, 2023 Schedule of Findings and Questioned Costs (the "Schedule") are discussed below. The findings are numbered consistently with the number assigned in the Schedule. FINDINGS AND QUESTIONED COSTS - MAJOR FEDERAL AWARD PROGRAM AUDIT 2023-001: Workforce Investment Opportunity Cluster - Assistance Listing #17.258117.259 / 17.277 / 17.278, Subrecipient Monitoring Condition: During our review of subrecipient monitoring, we noted that the City's monitoring was not being performed according to the formal written policy. While monitoring was performed and documented during the second half of fiscal year 2023, there was a lack of evidence of testing and suggestions to the subrecipient during the first half of fiscal year 2023. Criteria: According to 2CFR 200.33l(a) of the 0MB Compliance Supplement, the City should make subrecipients aware of award information. According to the City's Program Participant Monitoring Plan, the City is supposed to conduct subrecipient monitoring on a semi-annual basis which should include desk reviews of payroll, disbursements, and other financial items. Cause: Staff turnover, particularly for the role of grant accountant, caused these procedures to be overlooked. Management prioritized core operating activities with staffing vacancies in lieu of monitoring activities. Management asserts staff went onsite to review key documents, as documented by email activities, but did not document specific items subject to review. Effect: Noncompliance with federal grant requirements with regard to subrecipient monitoring as well as an increased risk of subrecip1ent misusing funds. Questioned Cost Amount: Not applicable. Perspective Information: One out of two awards Recommendation: We recommend performing subrecipient monitoring in accordance with the City's guidelines and following the procedures laid out in the Program Participant Monitoring Plan. Corrective Action: Management concurs with the recommendation and will ensure that follow-up occurs regarding information provided by business owners. Loss of staff in this accountability area resulted in inquiry and reviews conducted by varying personnel the past few fiscal years. The Accounting Supervisor and the Accounts Payable coordinator, in the absence of a Grant Accountant, conducted the first semi-annual visit for fiscal year 2023. A grant accountant was hired in Spring 2023 along with an Accounting Manager, who were able to conduct the second visit in June 2023. Revisions to the policies and procedures were made following the June visit along with developing formalized documentation templates that show what was subject to monito ring. Fiscal year 2024 monitoring in January 2024 has been completed with follow-up to occur in June 2024. 2023-002: Coronavirus State and Local Fiscal Recovery Funds -Assistance Listing #21.027, Disbursements Condition: During our review of the locality's disbursements related to the program, it was noted that procurement policies were not being followed. In 3 of 25 instances, credit card purchases were not properly approved. Criteria: CSLFRF funds may be used for eligible expenses subject to restrictions set forth in Treasury's Interim Final Rule and Final Rule at 31 CFR Part 35. Also, 2 CFR Part 200 section 303 requires effective control over, and accountability for, all funds. According to the City's procurement policy, department managers and directors are supposed to review and approve credit card purchases on a monthly basis. Review includes ensuring appropriate supporting documentation is included. Documentation should support that transactions are for allowable expenses. Cause: Though the City has controls that push compliance, monitoring and enforcement by Finance is lacking. Additionally, the volume of transactions make monitoring challenging. Some transaction support and approval are routed electronically through US Bank for automation, but there are thousands of monthly transactions. Effect: Noncompliance with federal grant requirements with regard to disbursements. Questioned Costs: Not applicable. Perspective Information: Three out twenty-five transactions Recommendation: We recommend disbursing funds in accordance with the City's procurement policy including a process that requires approval of all credit card purchases. Corrective Action: Management concurs with the recommendation and will ensure that procurement policies including those over credit card purchases will be adhered to. Starting in fiscal year 2023 communication to department directors occurred reinforcing that reviewing and approving financial transactions is necessary under City policy. The City's Department of Finance on a monthly basis is monitoring P-Card compliance and has enhanced communication of internal deadline dates for coding and approving transactions. Follow-up is performed by the Accounts Payable coordinator to address issues with individual users and departments who have unapproved transactions. This practice will continue moving forward with issues of continued non-compliance by users and directors potentially resulting in revoking privileges of using city purchasing cards. 2023-003: Coronavirus State and Local Fiscal Recovery Funds -Assistance Listing #21.027, Disbursements Condition: During our review of the locality's revenue loss calculation, it was noted that one revenue figure was not supported by the City's transmittal form causing the lost revenue available for the City to claim to be understated by approximately $4.8 million. Criteria: Under the Final Rule, recipients can elect a one-time "standard allowance" of $10 million (not to exceed the recipient's award amount) to spend on the "provision of government services" during the period of performance. Alternatively, recipients can calculate lost revenue for the years 2020, 2021, 2022, and 2023 based on the formula provided in the Final Rule to determine the amount of SLFRF funds that can be used for the "provision of government services." According to the 0MB Compliance Supplement section 4-21.027 section III B, recipients can choose whether to use calendar or fiscal year dates but must be consistent through the period of the performance and must provide auditors with evidence supporting their revenue loss calculation. Cause: The calculation of revenue loss was performed by staff who was new to their role with the City. All figures agreed with the Auditor of Public Accounts (APA) transmittal except for one section. Supervisory review was performed but did not detect the inconsistency in the calculation with reported figures on the APA transmittal form. Effect: Noncompliance with federal grant requirements with regard to lost revenue, understating the available revenue loss the City can utilize. Questioned Cost Amount: Not applicable. Perspective Information: Three out of twenty-five transactions Recommendation: We recommend that a process be put in place that ties out all amounts used on the lost revenue calculation to amounts on the transmittal form. Corrective Action: Management concurs with the recommendation and will ensure that the APA transmittal is used for future calculations as necessary. The calculation will be subject to multiple reviews. A final ARPA revenue loss calculation is planned for the spring that will incorporate the updated revenue loss figures from fiscal year 2023 ACFR and update the reporting figures in the fiscal year 2022 ACFR. The City's plan for ARPA spending currently does not plan to utilize the entire revenue loss funds but instead seeks to spend on specific projects that are ARPA eligible. If the Federal Audit Clearinghouse has questions regarding this plan, please call Andrea Trent, Financial Management Consultant at 540-853-5224. Sincerely yours, Andrea F. Trent Financial Management Consultant

2023-001: 172.258, 17.259, 17.278 – WIOA Cluster • Recommendation 1: We recommend that the County prepare and maintain a written plan to ensure subrecipients are aware of the Uniform Guidance requirements. • Recommendation 2: We recommend the County performs the monitoring of the subrecipients and ensure the documentation is saved within the County. • Explanation of disagreement with audit finding: There is no disagreement and management agrees with the finding. • Corrective action taken in response to finding: The County Office of Finance will (1) develop a written plan to ensure that subrecipients are aware of all the Uniform Guidance requirements; (2) due to the pandemic and the recent retirement and resignation of the top two Grant department staff members, the monitoring was not conducted during the audit period. Management will make sure that the required monitoring will be conducted and ensure compliance and proper documentation is maintained onsite. • Name of the contact person responsible for corrective action: Kevin McMahon, Office of Finance and Charles Knapp, Anne Arundel Workforce Development Corporation. • Planned completion date for the corrective action plan: June 30, 2024.

Finding 2023-009 Lack of Subrecipient Monitoring Plan: The University of Illinois Springfield will review procedures to ensure subrecipient monitoring is conducted and documented for all subawards. Expected Implementation Date: April 2024 Contact: Charles Alsbury, Director Office of Research & Sponsored Programs, Post-Award University of Illinois Springfield Ralsb01s@uis.edu 217-206-7849

Department: Transportation Title: Internal control over DOT subrecipient and contractor determinations needs improvement Questioned Costs: None Status: Corrective action complete Corrective Action: The Department has reviewed the standards for categorizing vendors and subrecipients. The Department has amended the process to include a substantive review of the initial categorization by a Financial Analyst before the report is finalized and transmitted. Completion Date: February 21, 2024 Agency Contact: Kathleen Malcolm, Financial Processing Director, DOT, 207-624-3292

Statement of Concurrence or Non-concurrence: We agree with the auditor’s finding as far as not giving subrecipients the Assistance Listing Number (CFDA#) and the below actions will be taken to improve the situation. However, ICHC management questions the degree of the audit finding due to ICHC receiving the HEC funding from the State of Alaska as a pass-through and not directly from the Centers for Disease Control and Prevention. Corrective Action Plan Interior Community Health Center (ICHC) will read and ensure the requirements of 2 CFR 200.331 (a)(1) and the OMB Compliance Supplement May 2023 are understood and implemented for future subrecipient activity. ICHC will send out a letter to all agencies who received the HEC funds with the explanation that funds were federal funds and this required factors of 2 CFR 200.331(a)(1) of the OMB Compliance Supplement May 2023. ICHC will give the awardees the Assistance Listing Numbers of the HEC funds to ensure they properly reported funding on their FY23 SEFAs. ICHC will also send a notification to the State of Alaska notifying them that ICHC will be terminating the administration of HEC grant funding on May 31st, 2024. ICHC will tell the State that an error was made in providing the subrecipients the Assistance Listing Numbers of the HEC funding. ICHC will thank the State of Alaska for the opportunity to distribute the funding to the agencies in the Fairbanks North Star Borough that deal with the vulnerable people who are at a higher risk of COVID-19. Name of Contact Person: Traci Yeckley, Chief Financial Officer Contact Number: 907-455-4567. Email: traci.yeckley@inhc.org Projected Completion Date: The anticipated completed date is April 1st, 2024