Corrective Action Plans

The Government concurs with the auditor's findings and recommendations. The formal process for completing and retaining Subrecipient Agreements is now operational to ensure compliance with programmatic obligations. As the Recipient, it is the Territory's responsibility to notify the Subrecipient when the federal funds are obligated and provide them with a subrecipient agreement which outlines the terms and conditions of the program. The Disaster Program Financial Specialist is responsible for reconciling that the subrecipient agreement has been signed by the Applicant and Governor's Authorized Representative and provided to the Territorial Public Assistance Officer. As such, no funds will be disbursed until the Subrecipient signs and returns the subrecipient agreement. These agreements are saved in a centralized location for documentation and audit purposes.

The Government concurs with the auditor's findings and recommendations. VIDE acknowledges the need for strengthened controls to ensure subrecipient compliance with federal audit requirements, as specified in 2 CFR Part 200, Subpart F. VIDE is committed to implementing effective measures to ensure that all subrecipients adhere to federal regulations and that sufficient oversight is provided. VIDE will ensure all subrecipient agreements include explicit reporting requirements and compliance expectations under 2 CFR Part 200, Subpart F. In addition, training will be given to internal staff on subrecipient monitoring requirements and best practices to ensure consistent implementation.

The Government concurs with the auditor's findings and recommendations. OMB will identify and monitor the federal awarding agencies and will request single audit results for the applicable recipients beginning FY25 and include the results in the monitoring reviews. For revenue replacement projects, based on Treasury’s Final Rule FAQ (13.14), “Recipients’ use of revenue loss funds does not give rise to subrecipient relationships given that there is no federal program or purpose to carry out in the case of the revenue loss portion of the award.” As such, they are not subject to the Single Audit Act.

The Government concurs with the auditor's findings and recommendations. OMB will develop and enforce a robust framework that includes detailed monitoring procedures, regular compliance checks, and comprehensive oversight mechanisms. This framework will ensure that all subrecipients adhere to federal requirements, thereby promoting accountability and proper use of federal funds. These measures will help mitigate risks, enhance transparency, and ensure that subrecipients fulfill their obligations under federal statutes effectively.

Finding 2022-001 – Subrecipient Monitoring Corrective Action Planned: The Organization concurs with the finding. We recognize that our current subrecipient monitoring procedures did not adequately address compliance with payroll tax reporting and filing requirements for the Community Based Organizations that were the grant subrecipients. To strengthen our oversight, the Organization will take the following corrective actions: 1. Policy Update: Revise our subrecipient monitoring policy to explicitly require verification of payroll tax compliance, including review of IRS Form 941 filings and evidence of payroll tax payments. 2. Monitoring Procedures: Implement a standardized monitoring checklist that includes obtaining periodic compliance certifications from subrecipients and requiring submission of payroll-related documentation. 3. Staff Training: Provide training to staff responsible for subrecipient monitoring to ensure awareness of Federal compliance requirements, including payroll tax obligations. 4. Ongoing Oversight: Require annual subrecipient monitoring visits or desk reviews to evaluate compliance with financial and Federal reporting requirements. Anticipated Completion Date: December 31, 2025 Responsible Party for Implementation: Willa Lang, Executive Director (312-742-5105) Views of Responsible Official: The Organization agrees with the auditor’s finding and is committed to taking corrective actions to ensure full compliance with Federal requirements going forward.

THE ORGANIZATION WILL USE EXPENDITURE REPORTS BY CLASS TO SUPPORT BASE EXPENDITURES FOR THE PERIOD. WILL BE IN PLACE FOR THE 2025 SINGLE AUDIT AND BEGAN THIS PROCESS IN 2024. KAREN SHARPNACK, EXECUTIVE DIRECTOR KJS@IDAHOIMMUNE.ORG AND NEW CPA FIRM TO BE DETERMINED. THE ORGANIZATION THROUGH ITS BOARD OF DIRECTORS WILL CREATE A “FINANCIAL POLICY COMMITTEE” WHICH WILL BE RESPONSIBLE TO WORK WITH THE EXECUTIVE DIRECTOR, THE NEW CPA TO OUTLINE AND CREATE NEW POLICIES, PROCEDURES AND PROCESSES, ALONG WITH OVERSIGHT OF THE FINANCIAL WELL-BEING OF THE ORGANIZATION AND REPORT TO THE BOARD OF DIRECTORS. IMMEDIATELY, THE PROCESS WILL BEGIN TO RECRUIT THE COMMITTEE ON JUNE 25, 2025.

Finding 2022-006 – Subaward Monitoring In response to the finding, GEM enhances subaward monitoring by instituting the following. GEM will establish written documentation to ensure appropriate oversight of sub-awardee compliance with NSF program responsibilities. Anticipated date of completion: We received the "No cost extension" and this was completed by September 30, 2023. Written documentation instituted that outlines specific actions and timeline of deliverables expected of sub-awardee as well as corrective actions if sub-awardee is not in compliance with responsibilities. Responsible party: Dr. Marcus Huggans Principal Investigator

As part of our current policies and procedures review and revision process, we plan to incorporate the subrecipient monitoring and management provision of 2 CFR§ 200.331 and 2 CFR §200.332 of the Uniform Guidance to emphasize accountability and compliance in managing federal funds and subrecipients. Specifically and prospectively, effective November 1, 2024, the Organization’s practices will include: 1. Using a checklist for the determination of subrecipient or contractor classification as guidance; Perform a comprehensive risk assessment before entering into any subrecipient agreement. 2. Provide identification details such as CFDA number, amount of federal funds obligated, and the award period for determined subrecipient awards. 3. Require subrecipients to submit programmatic and financial reports as specified in the subrecipient agreement. 4. As part of the subrecipient process, ensure subrecipients that expend $750,000 or more in federal funds during a fiscal year undergo a single audit in accordance with 2 CFR Part 200, Subpart F. Review their audit reports and address any findings related to their federal awards, taking appropriate corrective actions Retroactively, for the audit periods July 1, 2022 – June 30, 2023 and July 1, 2023 – June 30, 2024, the Organization will perform a risk assessment of the existing subrecipient portfolio during this period to identify high-priority risks. The objective of this risk assessment review is to identify, evaluate, and prioritize risks that could adversely impact the organization’s ability to achieve its strategic, operational, and quality assurance goals, ensuring that all products, services, and processes align with established standards and fulfill processes. The above reflects the current planned practices of the Organization and the overall financial policies and procedures are in the process of being updated to align to the subrecipient monitoring and management provision of 2 CFR §200.331 and 2 CFR §200.332 of the Uniform Guidance. The Organization has prioritized the completion and distribution of the updated financial policies and procedures by December 31, 2024.

Finding 2022-006 – Subaward Monitoring In response to the finding, GEM enhances subaward monitoring by instituting the following. GEM will establish written documentation to ensure appropriate oversight of sub-awardee compliance with NSF program responsibilities. Anticipated date of completion: We received the "No cost extension" and this was completed by September 30, 2023. Written documentation instituted that outlines specific actions and timeline of deliverables expected of sub-awardee as well as corrective actions if sub-awardee is not in compliance with responsibilities. Responsible party: Dr. Marcus Huggans Principal Investigator

ACL Centers for Independent Living – Assistance Listing No. 93.435 Type of Finding: Subrecipient Monitoring/Procurement • Material Weakness in Internal Control over Compliance • Material Noncompliance (Modified Opinion) Criteria or specific requirement: Per 2 CFR Part 200.331, a pass-through entity must make case-by-case determinations whether each agreement it makes for the disbursement of Federal program funds casts the party receiving the funds in the role of a subrecipient or a subcontractor. If a subrecipient has been identified, per 2 CFR Part 200, Subpart F, pass through entities must notify subrecipients that they are receiving Federal funds as a subrecipient and must therefore comply with federal statutes, regulations, and the terms and conditions of the award. Additionally, pass through entities must keep documentation of monitoring the subaward. The pass-through entity must have a control process in place to ensure it is in compliance with federal requirements related to subrecipient monitoring. If a subcontractor has been identified (and payment is above the micro-purchase threshold), per 2 CFR Part 200, Subpart D, the entity must have and use documented procurement procedures such as drafting a procurement policy, obtaining qualified bids, performing cost analyses and justifying reason for final selection. Condition: While there existed sophisticated procedures for reviewing, approving and monitoring applicants, they did not meet all of the Federal requirements for either those of subrecipients or subcontractors. Questioned costs: $62,857 In known questioned costs. Context: Upon receipt of the Federal ACL CARES ACT grants, the instructions were to use and disseminate the funds within the community for the purposes of supporting individuals with disabilities who were impacted by COVID and creating professional relationships in further support of individuals with disabilities. DEC was not aware of the Federal Uniform Guidance guidelines requiring DEC to make the determination of whether the vendors meet the characteristics of a subrecipient or a subcontractor and therefore did not follow the required procedures. This is an isolated instance due to the specific nature of the CARES ACT funds as DEC is not able to engage in these activities with other Federal grants. Cause: DEC did not designate these vendors as either subrecipients or subcontractors and therefore did not follow the Federal Uniform Guidance guidelines. Effect: Pass-through entities, subcontractors and/or subrecipients could be out of compliance and misusing Federal funds. Repeat Finding: No Recommendation: CLA recommends DEC review the Uniform Guidance in relation to subrecipients and subcontractors, and for each vendor under contract, make a clear determination of which type of contract they fall under. Contracts should be drafted in conformity with either subrecipients or subcontracts (as directed by the Uniform Guidance). Views of responsible officials: There is no disagreement with the audit finding. Action taken in response to finding: DEC partnered with other organizations on shortterm projects to reach populations of individuals with disabilities who have intersecting identities. Due to vague instructions on using the funds, we were unaware of the need to define funding recipients as either subrecipients or subcontractors. DEC verified the recipient’s WA state business licenses and performed monitoring for each project. These projects were part of DEC’s plan to spend one-time CARES ACT grants. DEC is not authorized to perform activities of this type with any of our other Federal grants. Name(s) of the contact person(s) responsible for corrective action: Kimberly Meck, Executive Director Planned completion date for corrective action plan: If such an opportunity becomes available in the future, DEC will ensure it will follow appropriate Federal regulations for subrecipients and/or subcontractors as required.

2022-006 Program: WIOA Cluster Federal Financial Assistance Listing Number: 17.258, 17.259, 17.277, 17.278 Federal Grantor: U.S. Department of Labor Pass-Through: California Department of Employment Development Award No. and Year: AA011008 and 2019 Compliance Requirements: Subrecipient Monitoring Type of Finding: Material Weakness Management’s or Department’s Response: Imperial County Workforce Development Office (ICWDO) agrees with the finding. Views of Responsible Officials and Corrective Action Plan: The questions from finding 2021-008 relate to a formalization of the fiscal processes and protocols. ICWDO operates under WIOA guidelines and follows Imperial County’s fiscal policies. Internal policy will be formally updated to reflect compliance with WIOA regulations, as well as Imperial County policies. These policies will include formal controls and procedures to evaluate each subrecipient’s risk of noncompliance. Once the formal procedure is drafted, it will go through the ICWDO Policy Committee for comment and direction, and then finally reviewed and approved for implementation by the full Workforce Development Board. Additionally, for any future Memorandums of Understanding (MOUs) between this Imperial County department and any outside agency, there will be an additional step to include review by Imperial County Counsel to reflect that recital around the funding source will specify the following required information: • Federal Award Identification Number • Federal award date of award to recipient by the Federal agency • Name of Federal awarding agency • CFDA Number • Specific identification of whether the award is research and development ICWDO will develop internal policies for formalizing all subrecipient monitoring process. ICWDO operates under WIOA guidelines for monitoring; therefore a formal internal policy for future contracts will be developed and implemented using the usual review and approval procedures followed by the department. ICWDO will develop a formal internal documentation system, with appropriate checks and signatures, for the evaluation and assessment of each subrecipient’s risk of noncompliance. ICWDO will utilize this formal process to properly document the risk assessment of all subrecipients. ICWDO anticipates to implement the corrective action by December 31, 2023. Name of Responsible Person: Priscilla A Lopez, ICWDB Director Implementation Date: December 31, 2023

Finding 2022-004 – Uniform Guidance Subrecipient Monitoring – Significant Deficiency/Non-Compliance Corrective Action: The County has met with Children & Youth to discuss in detail the process of monitoring Title IV-E activities. As a result of such, a formalized plan was implemented including a Sub-Recipient Monitoring Agreement for FY 2022-2023. Responsible for Implementing Corrective Action: Budget & Finance, Purchasing Joinder Board

Management is consiering its options for further appeals to the department of Labor for review. Management will work to ensure proper policies and procedures are established and followed by December 31, 2024

2022-004 Subrecipient Monitoring U.S. Department of Treasury Recommendation: We recommend the County implement internal control(s) to ensure that required subrecipient monitoring through formal agreements is completed. Explanation of disagreement with audit finding: There are no disagreement with the audit finding. Action planned/taken in response to finding: The County will implement adequate controls designed to ensure that subrecipient monitoring requirements are being met. Name(s) of the contact person(s) responsible for corrective action: Debi Reynolds Planned completion date for corrective action plan: June 30, 2024

2022-001 Subrecipient MonitoringRecommendation: We recommend the Organization review policies and procedures for subrecipient monitoring. Further, the Organization should ensure that all documentation and support for the monitoring of activities for subawards in regards to authorized purpose, terms and conditions, and performance goals are properly maintained.Corrective Action Taken: As of July 1, 2022, North Central Missouri College was selected as the Grant Recipient/Fiscal Agent for the Northeast Workforce Development Board?s grant funds. Procedures to manage, track, and account for all subrecipient grant awards are in place and will be followed.Anticipated Completion Date: July 1, 2022.

Views of Responsible Officials and Planned Corrective Actions: Over the past two (2) years, the organization has increased the skill set and capacity among teams for risk assessment and awards management. Subaward policies have also been reviewed, and all subaward recipients are required to complete pre-award surveys (which include the risk assessment unless the subrecipients are pre-approved by USAID and exempted from such policies). The Associate Director of Grants and Compliance continues to work with members of the Program team to ensure that all subrecipients have followed all necessary protocols to comply with 2 CFR 200.516(a). Astraea will also seek documentation from Federal agencies where risk assessment exemptions apply. Anticipated Completion Date: May 16, 2024 Responsible Official: Associate Director, Grants Management and Compliance; Director, Program Operations; Associate Director, Partnerships

Findings – Federal Award Material Weakness 2022-002 Finding - Subrecipient Monitoring –Material Non-Compliance and Weakness in Internal Control Over Compliance. Condition / Context: Forth passed through $75,170 in funding to subrecipients under Assistance Listing 81.086. During our audit, we noted that Forth did not have documented written procedures or controls in place to ensure compliance with the U.S. Office of Management and Budget’s Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) subrecipient monitoring requirements. Per review of subaward contracts, required federal contract information was not clearly identified. Further, subrecipients were not evaluated for risk of non-compliance, were not monitored, and there were no procedures in place to ensure the accountability of for-profit subrecipients. Recommendation: The Organization should establish written policies and procedures regarding the contracting and monitoring of subrecipients that are in line with Uniform Guidance requirements, as well as establish organizational controls to ensure that such policies and procedures are being followed. Action Taken: We agree with the auditor’s comments, and as soon as we were made aware of the deficiency in early 2024, we began to implement the following action steps to improve the situation. We will create and document the policies and procedures for effective monitoring of subrecipients of federal funds by February 2024. To ensure such policies are being followed, we will monitor all subrecipients of federal funds by May 2024. Policies and procedures will be revised as needed to ensure the guide is current. We will designate a responsible staff person in 2024 to manage the subrecipient monitoring process and provide routine training on this process so staff understand their responsibilities. Responsible Official: Gina Avalos-Limardo, Director of Finance & Operations Planned Completion Date: May 1, 2024

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.

The guidance was unclear when reporting began in 2021. The delineation is now understood and will be corrected in the next quarterly report to the Treasury Department. Anticipated Completion Date: January 31, 2024.

Management agrees with the recommendation. Due to hiring of new staff and an internal audit with similar findings, these actions were in process and implemented as of November 2022. These actions are part of the Sub Team?s standard operating processes and will continue. The proposed corrective action plan is as follows: - The hiring of new team members in 2022; all team members trained on subcontracting processes and documentation requirements with an emphasis on following standard baseline procedures. - New Subcontract Administrator (SCA) position tasked with compiling final packets for each sub, which includes a quality check to ensure all documents and signatures required are included. - Use of subcontract checklist and risk assessments required and consistently done by the team.

Assistance Listings Number: Program Name: 97.024 Emergency Food and Shelter National Board Program Name of contact person: Regina Kelly, Director, Grants Management & Innovation Anticipated completion date: June 2024 Response: Pima County agrees with the finding. Pima County's federal award expenditures have more than quadrupled since 2018, dramatically increasing the volume of subrecipients and the need for monitoring. The County recognized this challenge and procured services from a third-party entity to conduct subrecipient monitoring in the short term and assist in the development of a robust and effective subrecipient monitoring program to effectively address the rapid growth of subrecipient monitoring needs.

FINDING 2022-010 Contact Person Responsible for Corrective Action: Casey Brewster Contact Phone Number: 812-752-8935 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Instead of utilizing journal entries for corrections or adjustments in generic form, corrections to large or for multiple disbursements or receipts should be completed by reversing the action within the financial software and then correctly processing the disbursements or receipts. The on-going training and the related corrective actions which ensure more frequent and more in-depth reviews of reports on a monthly basis will also reduce the need for corrections in general. However, in the event there must be journal entries for corrections, documentation supporting and related to any journal entry will be input into the financial management software, as will any related notes, and any journal entry will have documented approval contained in that software, all completed by separate people ? the Treasurer and CFO. Additional, related training will also be sought to ensure related processes and controls are understood and followed. Anticipated Completion Date: June 2023

Finding Number: 2022-008 Federal Program, Assistance Listing Number and Name: , Department of Health and Human Services, HIV Emergency Relief Project Grants Condition: Original Finding Description: Based on review of subrecipient agreements, we noted that the City?s contractor entered into a subaward agreement with the City?s subrecipients. Based on the definition of a subaward as defined by Uniform Guidance (UG), a subaward is provided by a pass-through entity to a subrecipient for the subrecipient to carry out part of a Federal award received by the pass-through entity. Further, a pass-through entity is defined as a non-Federal entity that provides a subaward to a subrecipient to carry out part of a Federal program. A contractor is not a pass-through entity. Contact Person Responsible for Corrective Action: Denise Fair Anticipated completion date: July 2023 Planned Corrective Action: The City will implement controls to ensure that the City Health Department provides oversight of the WIC participant eligibility process. The Health Department has hired a WIC Program Director who will monitor participant eligibility compliance and ensure that eligibility policies and procedures are maintained and followed. In addition, the city will perform a review of the contract and scope of service to confirm exclusion of subrecipient responsibilities.

Program: Homeland Security Grant Program Federal Financial Assistance Listing Number: 97.067 Federal Grantor: U.S. Department of Homeland Security Passed-Through: California Office of Emergency Services Award No. and Year: 2019-0035 and 2020; 2020-0095 and 2021 Program: Foster Care Federal Financial Assistance Listing Number: 93.658 Federal Grantor: U.S. Department of Health and Human Services Pass-Through: California Department of Social Services Award No. and Year: 2201CAFOST and 2022, 2101CAFOST and 2021 Compliance Requirements: Subrecipient Monitoring Type of Finding: Significant Deficiency in Internal Control and Instance of Noncompliance Criteria: 2 CFR Part 200.331(a), Requirements for Pass-Through Entities, states that all pass-through entities must ensure that every subaward is clearly identified to the subrecipient as a subaward and includes certain information as well as all the requirements imposed by the pass-through entity on the subrecipient so that the Federal award is used in accordance with Federal statutes, regulations, and the terms and conditions of the award. Condition: The following information was not provided at the time of the subaward for two (2) of two (2) subawards selected for testing from the Homeland Security Grant Program within the Sheriff-Coroner department: ? Federal award identification number ? Identification of whether the award is research and development ? Indirect cost rate for the federal award The following information was not provided at the time of the subaward for seven (7) of eight (8) subawards selected for testing from the SSA department for the Foster Care program: ? Subrecipient?s unique entity identifier ? Federal award identification number ? Federal award date of award to recipient by the Federal agency ? Subaward period of performance ? Amount of federal funds obligated to the subrecipient ? Amount of federal funds committed to the subrecipient ? Federal award project description ? Name of federal awarding agency ? CFDA number ? Identification of whether the award is research and development ? Indirect cost rate Cause: The Sheriff-Coroner and SSA departments procedures did not consistently ensure that the required award information and applicable requirements were communicated to subrecipients. Effect: The Sheriff-Coroner and SSA departments did not identify the required elements of the subaward to the subrecipients at the time of the subaward, increasing the risk of noncompliance. Questioned Costs: No questioned costs were identified as a result of our procedures. Context/Sampling: The entire population of two (2) subrecipients were selected for subrecipient monitoring testing for HSGP ? Sheriff-Coroner department. A non-statistical sample of eight (8) of fifty-three (53) subrecipients were selected for subrecipient monitoring testing for the Foster Care program ? SSA. Repeat Finding from Prior Years: No. Recommendation: We recommend that the Sheriff-Coroner and SSA departments modify and strengthen its current policies and procedures to ensure that all required award information and applicable requirements are communicated to subrecipients at the time of subaward in accordance with 2 CFR section 200.331(a). Management Response and Corrective Action: Sheriff-Coroner?s Department: 1. Person Responsible: Yumi Leung, Supervising Grants Manager 2. Corrective action plan: The Sheriff-Coroner Department will identify on future subaward letters whether the award is research and development, and whether there is an indirect cost rate for the federal award. 3. Anticipated Implementation date: June 2023 Social Services Agency: 1. Person Responsible: Karen Vu, Administrative Manager II, Contracts Services 2. Corrective action plan: SSA will revise the current Subrecipient Monitoring Policy and Procedures to ensure that all required award information and applicable requirements are communicated to subrecipients at the time of subaward in accordance with 2 CFR section 200.331(a). A check list will be developed to track activities and ensure that the required award information and applicable requirements were communicated to subrecipients. 3. Anticipated Implementation date: July 1, 2023

Finding Number: 2022-012 Federal Program, Assistance Listing Number and Name: ALN 21.027, Department of Treasury, COVID-19 Coronavirus State and Local Fiscal Recovery Fund (CSLFRF) Condition: Original Finding Description: The CSLFRF subrecipient agreements did not include the CSLFRF assistance Listing Number (ALN) as required per 2 CFR 200.332 (a)(1)(xii). Contact Person Responsible for Corrective Action: Sandra Yu Stahl and Terri Daniels Anticipated completion date: July 2023 Planned Corrective Action: The City has implemented a process to ensure that all subrecipient agreements contain the Federal ALN as required by 2 CFR 200.332. All subrecipient agreements will include a new exhibit as an attachment in the agreement that will include the ALN and any other required grant elements.