Corrective Action Plans

Finding 2022-004 Subrecipient Monitoring and Special Tests and Provisions Material Weakness in Internal Control Over Compliance and Material Noncompliance Federal Agency Name: Department of Health and Human Services Program Name: Immunization Cooperative Agreements CFDA Number: 93.268 Finding Summary: The County did not formally communicate the required information to the subrecipient. No subrecipient agreement was executed. In addition, no monitoring activities were documented, including monitoring of the program?s special tests and provisions. Responsible Individuals: Allie White, County Health Department Executive Director Corrective Action Planned: Dubuque County is working with the Dubuque Visiting Nurse Association on implementing a subrecipient agreement and will put a control process in place to monitor. Anticipated Completion Date: June 30, 2023

Recommendation: We recommend that the agency review its procedures for communicating information to subrecipients and implement the procedures necessary to ensure information is included in the subrecipient award documents at time of funding. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: KDEM will revise award letters to encompass all required information. Name(s) of the contact person(s) responsible for corrective action: Jennifer Deal and/or Chris Noe Planned completion date for corrective action plan: December 2023

Recommendation: We recommend the agency obtain certifications from vendor stating their organization is not suspended, debarred, or otherwise excluded from participation in federal assistance programs or document the procedures performed to verify the vendor is not identified as suspended or debarred on SAM. We recommend that the agency have proper procedures in place to ensure that all contractual documentation is maintained and able to be located. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: KDHE is in the process of implementing a new contract system which will include steps for verifying suspension and debarment status for all contracts and sub-recipient agreements which KDHE is a party to. Name(s) of the contact person(s) responsible for corrective action: Kelly Chilson Planned completion date for corrective action plan: July 1, 2023

Recommendation: We recommend that the agency review its procedures for communicating information to subrecipients and implement the procedures necessary to ensure information is included in the subrecipient award documents at time of funding. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The sub-recipient expenditures in question were funds distributed to support COVID-19 Staffing & Infrastructure, Expanded Infrastructure, Care Resource Coordination and Expanded Testing. The critical need to get the funds paid out quickly for support at the height of the pandemic resulted in an alternative document being used as the Subaward agreement instead of the established Sub-Recipient Agreement which contains the required information. KDHE has since developed an alternative document that can be used on an exception basis that will facilitate a faster payment process in the event that a future Public Health Emergency or other situation would require that Subawards be made that due to time constraints cannot follow the established Sub-Recipient Agreement process. The alternative document contains the required information. Name(s) of the contact person(s) responsible for corrective action: Kelly Chilson Planned completion date for corrective action plan: April 1, 2023

March 6, 2023 CORRECTIVE ACTION PLAN Latino Network respectfully submits the following corrective action plan for the year ended June 30, 2022. Name and address of independent public accounting firm: Kern Thompson 1800 SW First Avenue, Suite 410 Portland, Oregon 97201 Audit Period: 07/01/2021 ? 06/30/2022 The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. Finding ? 2022-001 Criteria/Requirement: In accordance with 2.CFR?200.331, a pass-through entity must monitor the activities of subrecipients to ensure that federal awards are used for authorized purposes in compliance with laws, regulations, and the provisions of contracts and grants agreements. Condition/Context: Latino Network passed through $85,311 in funding to subrecipients. During our audit, we noted that the Latino Network did not have documented written controls or procedures 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. Cause: Procedures are not in place to ensure that Latino Network is maintaining adequate monitoring for each federal subrecipient. Effect: Failure to maintain sufficient subrecipient monitoring may result in the wrongful use of federal funds and non-compliance with the provisions of applicable requirements. Questioned Costs: $85,311 Recommendation: The Organization should establish written policies and procedures regarding the monitoring of subrecipients, as well as establish monitoring procedures to ensure that such policies and procedures are being followed. Management?s Response: We agree with the auditors' comments, and the following action will be taken to improve the situation. We will create and document the policies and procedures for effective monitoring of federally granted subrecipients by the end of the fiscal year. We will then perform monitoring of all federally granted subrecipients prior to our FY23 financial audit. Revisions to the users' manual will be made as needed to ensure the manual is current at all times. Grants & Contracts Accountants and Accounting Manager will be trained to perform federally granted subrecipient monitoring.

Finding: 2022-033 Department of Public Instruction Response/Corrective Action Plan: The Department of Public Instruction agrees with the finding. For the FY 2021 audits we increased the emphasis on reviewing subrecipient?s single audits. We had a 100% response rate on our audit survey and reviewed submitted reports in a timely manner. We still have some subrecipients who have not completed their FY 2021 audits do to various reasons. We check in with these entities on a quarterly basis to get updates on the status of their audits. We are on track for similar results for the FY 2022 audits. Contact Person Jamie Mertz, Director of Fiscal Services Anticipated Completion Date Already implemented

Finding 2022-005 Contact Person Responsible for Corrective Action: Debbie Morton-Crum, County Auditor Contact Phone Number: 765-482-2940 View of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The County Commissioners are responsible for the American Rescue Plan project list along with that responsibility is to have a sub-recipient agreement in place with those outside entities that received American Rescue Plan grant monies from the County. An Internal Control is now in place that requires a sub-recipient agreement in place before a warrant can be paid to those outside entities. We will put procedures in place to ensure that money disbursed to sub-recipient is monitored. Anticipated Completion Date: October 1, 2023

Finance and the Office of Highway Safety will work together to create policies and procedures to ensure compliance with subrecipient monitoring. Anticipated Completion Date: September 30, 2023 Contact Person: Loren Doyle, Acting Chief Operating Officer / Chief Financial Officer Department of Transportation loren.doyle@dot.ri.gov

SUBRECIPIENT MONITORING ALN Number 93.558 Temporary Assistance for Needy Families (TANF) 93.575, 93.596 Child Care Development Fund (CCDF) 2022-017 Strengthen Controls over Subrecipient Monitoring for the Child Care Development Fund (CCDF) and Temporary Assistance for Needy Families (TANF) Programs to conform with Uniform Guidance. Response: MDHS concurs that it needs to strengthen controls over subrecipient monitoring for the Child Care Development Fund (CCDF) and Temporary Assistance for Needy Families (TANF) programs to conform with Uniform Guidance. Corrective Action Plan: 1. Please refer to MDHS response in 2022-018 for measures already taken and ongoing by MDHS and all future corrective actions. 2. Responsible Parties: Kameron Harris, Chief Compliance Officer, Director of Monitoring, Laketha Gilmore 3. Anticipated Completion Date: This corrective action has been implemented and is ongoing.

SUBRECIPIENT MONITORING ALN Number 93.568 Low Income Home Energy Assistance (LIHEAP) 2022-018 The Mississippi Department of Human Services Should Strengthen Controls Over Onsite Monitoring for the Low-Income Home Energy Assistance Program (LIHEAP). Response: MDHS Concurs that controls should be strengthened over On-Site monitoring for the LIHEAP Program. MDHS also concurs with the following specific recommendations of the OSA and incorporates those recommendations as the foundation for the MDHS Corrective Action Plan (CAP) related to this finding. Corrective Action Plan: 1. Strengthen controls over the subrecipient monitoring process: A. The Office of Compliance, Division of Monitoring has made significant strides in strengthening controls over the subrecipient monitoring process. The Division continues to review and update the processes and procedures as necessary to ensure processes are adequate and effective. Staff are constantly notified/trained on updates to policies, procedures, and regulations to ensure continued compliance with monitoring the agency's subgrant agreements. B. Responsible Party: Kameron Harris, Chief Compliance Officer, Director of Monitoring, Laketha Gilmore C. Completion Date: This corrective action has been implemented and is ongoing. 2. Ensure subgrants are monitored timely and the Report of Findings is issued in a timely manner: A. The Office of Compliance, Division of Monitoring continues to improve upon the monitoring review process. The Division has implemented timeliness requirements to ensure the Agency's compliance with the monitoring process. B. Responsible Parties: Kameron Harris, Chief Compliance Officer, Director of Monitoring, Laketha Gilmore C. Anticipated Completion Date: This corrective action has been implemented. 3. Maintain all supporting monitoring tools, reports, and correspondence in the monitoring file: A. The Division of Monitoring has implemented a quality control measures to ensure all required documentation is included in the monitoring file. B. Responsible Parties: Kameron Harris, Chief Compliance Officer, Director of Monitoring, Laketha Gilmore C. Anticipated Completion Date: This corrective action has been implemented.

84.027 Special Education - Grants to States (IDEA, Part B) 84.173 Special Education - Preschool Grants (IDEA, Preschool) Subrecipient Monitoring 2022-029 Strengthen Controls to Ensure Compliance with On-Site Subrecipient Monitoring Requirements for Special Education Cluster Programs. Response The MDE Office of Special Education (OSE) acknowledges the findings identified by the Office of the State Auditor's as described above. MDE OSE has maintained the review of the Single Audits and provided follow-up on corrections needed by LEAs with funding under IDEA programs. In addition, MDE OSE provides technical assistance to LEAs regarding such. Further, MDE OSE utilizes the District Determinations (SPP/APR) data to provide proactive technical assistance to LEAs. During the 2020-2021 school year, MDE OSE conducted cyclical monitoring to the best of its ability given school closures related to the COVID-19 pandemic. During SY 20-21, the existing procedure required onsite visits for every monitoring activity. However, during that time, and under the guidance of the National Center for Systemic Improvement (NCSI) , MDE OSE monitored LEAs via Special Education Determination Reports, Mississippi Comprehensive Automated Performance-based System (MCAPS) funding application review, and Formal State Complaints using previous procedures while MDE OSE developed new procedures and risk assessments. Additionally, with the onset of COVID-19, the districts and state agencies faced challenges in meeting monitoring requirements and timelines during the first six months of the 2020-2021 school year due to health and safety restrictions. In its implementation of new procedures and risk assessments, MDE OSE has incorporated broad revisions to the agency's subrecipient monitoring procedures and made a significant investment in building the capacity of new OSE management team members to monitor subrecipient compliance and ensure that subawards are used for authorized purposes. Those newly developed procedures were piloted during the 2021-2022 school year, finalized in May 2022, and fully implemented for school year 2022-2023. It should be noted that in June 2023, the MDE OSE received a program determination letter (PDL) from the U.S. Department of Education (US DOE), Office of Special Education and Rehabilitative Services (OSERS) that resolved a similar finding 2021-037 from Audit 04-21-39984 conducted by the State of Mississippi, Office of the State Auditor. The corrective actions included in finding 2021-037 are the same as those seen below. The PDL indicated that the MDE OSE produced evidence of revised systems to ensure compliance with the agency?s requirements for subrecipient monitoring. Corrective Action Plan: A. The MDE OSE will continue the programmatic and cyclical monitoring of LEAs that began as a pilot in the spring of 2020. The newly implemented procedures will be utilized fully in the 2022-2023 school year. B. The MDE OSE will continue to complete the risk-based assessment, that includes the SPP/APR data, each year as universal monitoring of all LEAs to identify those in need of intensive intervention and support. C. The MDE OSE will continue to review, approve and monitor budgets and expenditures through the Mississippi Comprehensive Automated Performance-based System (MCAPS) to oversee the use of IDEA grant funds to subrecipients. D. The MDE OSE has established a procedure of virtual self-assessment via desk audits if the process is once again interrupted due to health and safety concerns.

Views of Responsible Officials: The National Disability Institute will adopt a formal risk assessment pre-award policy that outlines detailed and specific levels of monitoring for subrecipients based on the assessed level of risk. The National Disability Institute will document the pre-award risk assessment process and resulting linked level of monitoring on its subrecipients as part of the pre-award process.

Finding 2022-002 Planned Corrective Action: Montgomery County concurs with the finding. Based on the information included in 2 CFR ? 200.331 through 2 CFR ? 200.333, the Department of Finance will produce a written communication that outlines the requirements and responsibilities related to subrecipient disclosures and monitoring. The requirements and responsibilities will further be discussed in a targeted training session, to include the County?s Department of Health and Human Services. Name of Contact Person: Michael Lee, General Accounting Manager Anticipated Completion Date: June 30, 2023

Views of Responsible Officials: JCA Response - I agree with all the comments. Suggested Solutions and Steps by JCA - JCA will take steps to formalize a written policy regarding the monitoring of sub-recipients. JCA will also need to evaluate the FFATA (Federal Funding Accountability and Transparency Act) reporting requirements and comply with the act.

Monitoring (Significant Deficiency) Management?s Response or Department?s Response Management agrees with the finding and recommendation. Views of Responsible Officials and Corrective Action 1. County will assess existing policies, design, and implement additional internal control activities over the subrecipients to improve monitoring compliance requirements under the Uniform Guidance. 2. County will establish policies and procedures to document pre-award determinations of whether each agreement it makes for the disbursement of Federal award funds casts the party receiving the funds in the role of a subrecipient or a contractor. 3. County will implement a training program for all staff directly involved in the administration of Federal award funds to become knowledgeable of the cost principles and requirements under the Uniform Guidance. Anticipated Completion Date/Completion Date August 2023 Contact Information of Responsible Official Name: George Uc Title: Principal Administrative Analyst Phone: 559-600-1231

Documentation procedures are being reviewed and corrected.

Views of Responsible Official: We concur with the audit finding with respect to the monitoring of subrecipients for the American Rescue Plan funding. The County monitored the subrecipient agreement for the 50% matching requirement, and the subrecipient was paid properly. However, we did not obtain quarterly progress reports on the program. Description of Corrective Action Plan: Effective January 1st, 2024, the County will obtain progress reports on a quarterly basis for all active subrecipient agreements. Completion date: December 20, 2023.

Management concurs with the audit finding. The County’s Subrecipient Monitoring Policy and our compliance review project, initiated in 2022, has allowed us to continue to ensure that all subrecipient’s are monitored during the contract period noted in the contractual agreements. We have identified and updated the annual monitoring plan to ensure that all subrecipient are monitored and incompliance with the 2 CFR 200.331 federal standards.

Findinq No.:2022-023 Subrecipient Monitoring Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director (DOA) As for Fiscal Year 2022, payments to beneficiaries under the GEDA program were made directly by DOA. GEDA was not in receipt of any funds and by that plain language cannot be considered a subrecipient. DOA determined in accordance with 2CFR 200.331 that GEDA was not a Subrecipient: Auditors may, but have not to date, requested access to GEDA and DOA records for verification eligibility. CFRS200.331 reads.' "(c) Use of judgment in making a determination. ln determining whether an agreement between a pass-through entity and another non-federal entity casts the latter as a subrecipient or a contractor, the substance of the relations is more important than the form of the agreement. All the characteristics listed above may not be present in all cases, and the pass-through entiflr must use judgement in classifying each agreement as a subaward or a procurement contract."

Agency: National Center for the Advancement of STEM Education, Inc. (nCASE) Person Responsible for Corrective Action: Name: Nancy Priselac Title: Executive Director Anticipated Completion Date: December 8, 2023 Response to Finding: Management concurs with audit recommendation. Correction Action to be Taken: nCASE has reviewed language in subaward agreements. Subaward agreements have been updated to include all relevant stipulations and requirements. DoD has reviewed the matters covered in the audit report thoroughly, and the grant was closed out without any repayment of funds to DoD. Upon subsequent review and reconciliation, amounts were not overcharged.

Finding 2021-006: Subrecipient Monitoring Federal Program: Research and Development Cluster (Education and Human Resources) Assistance Listing Number and Title: 47.076 STEM Education Name of Federal Agency, Pass Through Entity (when applicable), Award Number and Year: National Science Foundation: 1640791 (9/15/2016 – 8/31/2022) Condition: During our audit work over subrecipient monitoring, we were unable to verify that pre-award risk assessment procedures were performed. It is our understanding that AAPT has ongoing relationships with these subrecipients and evaluation of these subrecipients' risk is a continual process; however, these procedures were not documented. Views of Responsible Officials and Planned Corrective Actions: Management will continue to perform risk assessment procedures and will thoroughly document the processes and evaluations. Anticipated Completion Date: 12/31/2022 Responsible Official: Michael Brosnan, CFO

Finding 2021-006: Subrecipient Monitoring Federal Programs: Research and Development Cluster: Stem +C Cause: AAPT's internal policies and procedures governing risk assessment on subrecipient was not performed. Views of Responsible Officials and Planned Corrective Actions: Management will continue to perform risk assessment procedures and will thoroughly document the processes and evaluations. Anticipated Completion Date: December 17, 2021 Responsible Official: Michael Brosnan CFO

Finding 2021-009 Management agrees with the finding and is implementing the accompanying corrective action plan. Views of Responsible Officials: Jessica Martinez, Program Director Joel Rusco, Chief Financial and Administrative Officer Jacy Hyde, Executive Director Contact Person: Jessica Martinez, Program Director Corrective Action Plan: • CFSC has retained Clark Nuber to assist in updating its policies and procedures to include a risk assessment for all subrecipients. The updated procedure includes a review of the subrecipients’ past audits and the development of a thorough monitoring plan based on an assessment of risk and/or audit findings pertaining to federal awards. • CFSC will update its policies and procedures to require subrecipients to report matching funds on a quarterly basis to ensure the matching requirement is met by the end of the grant period. Anticipated Completion Date: CFSC will implement these corrective actions by the end of Quarter 2 of 2024.

Finding 2021-008 Management agrees with the finding and is implementing the accompanying corrective action plan. Views of Responsible Officials: Jessica Martinez, Program Director Jacy Hyde, Executive Director Contact Person: Jessica Martinez, Program Director Corrective Action Plan: • CFSC will update the subaward development procedure to include a review of the subaward agreement to ensure all applicable information and requirements are communicated to subrecipients at the time of the subaward in accordance with 2CFR 200.331(a). • Clark Nuber has reviewed the current subaward management policies and procedures as well as the subaward agreements. Clark Nuber has prepared an updated subaward agreement appendix that will be included with every new subaward. The subaward agreement will include all the necessary information to comply with the Uniform Guidance before the subaward agreement is provided to the subrecipient. After review and approval by CFSC management, the updated subaward shall be used by CFSC staff. Anticipated Completion Date: CFSC will update and implement its policies and subaward agreement by the end of Quarter 2 of 2024.

Finding 2020-006: Subrecipient Monitoring Federal Program: Research and Development Cluster (Education and Human Resources) Assistance Listing Number and Title: 47.076 STEM Education Name of Federal Agency, Pass Through Entity (when applicable), Award Number and Year: National Science Foundation: 1640791 (9/15/2016 – 8/31/2022)Cause: AAPT's internal policies and procedures governing risk assessment on subrecipient was not performed. Views of Responsible Officials and Planned Corrective Actions: Management will continue to perform risk assessment procedures and will thoroughly document the processes and evaluations. Anticipated Completion Date: 12/31/2022 Responsible Official: Michael Brosnan CFO