Corrective Action Plans

The Family Health Council of Central PA Inc. sent each provider a confirmation of all state and federal funds paid to them, which included the CFDA number, source of funds, description, contract number, and amount paid. Before finalized the FY 2023 sub-awards, fiscal staff reviewed the sub-awards and met with management and contract compliance staff to ensure that FHCCP?s FY 2023 sub-awards are in compliance with the Uniform Guidance.

Cluster: Research and Development Federal Agency: All awards with subrecipients on the SEFA Award Names: All awards with subrecipients on the SEFA Award Numbers: All awards with subrecipients on the SEFA Assistance Listing Title: All awards with subrecipients on the SEFA Assistance Listing Number: All awards with subrecipients on the SEFA Award Year: 2021 - 2022 Pass-through entity: All pass-through entities noted on the SEFA Management agrees with the finding related to the Subrecipient Risk Assessments. To address these deficiencies Research Operations will update its subrecipient monitoring policy to explicitly state the ongoing monitoring activities that must be conducted and the frequency of required monitoring. Additionally, training will be provided to the staff who perform the risk assessment to ensure they are documenting the details of the review including the date and results of the subrecipient audit report review. Furthermore, updates will be made to the risk assessment procedure to ensure subrecipient annual audits are reviewed and the results of the review and follow-up are sufficiently documented. To ensure compliance, internal monitoring will be performed. Leadership Responsible: Barbara A. Vance, PhD, CRA, Vice President, Research Operations Anticipated Completion Date: 12/31/2023; Monitoring of compliance will continue throughout FY24

2022-043 Oregon Health Authority Implement controls to ensure subrecipients are appropriately identified and monitored Federal Awarding Agency: U.S. Department of Health and Human Services Assistance Listing Number and Name: 93.958 Block Grants for Community Mental Health Services; 93.959 Block Grants for Prevention and Treatment of Substance Abuse Federal Award Numbers and Years: 93.958: 1B09SM082625, 2020; 1B09SM083823, 2021; 1B09SM086032, 2022; 93.959: 1B08TI083068, 2020; 6B08TI083472, 2021; 6B08TI084667, 2022 Compliance Requirement: Subrecipient Monitoring Type of Finding: Material Weakness; Material Noncompliance Prior Year Finding: N/A Questioned Costs: N/A Criteria: 2 CFR 200.331; 45 CFR 75.352(b); 45 CFR 75.352(d) Federal regulations require pass-through entities to determine if the recipients of disbursements of federal funds are subrecipients or contractors. The subrecipient and contractor determination will impact which federal compliance requirements recipients are subject to and how program expenditures are reported on the Schedule of Expenditures of Federal Awards (SEFA). For recipients meeting the definition of a subrecipient, federal regulations require pass-through entities to evaluate each subrecipient?s risk of noncompliance with federal statutes, regulations, and the terms and conditions of the subaward for the purpose of determining appropriate subrecipient monitoring activities. Monitoring activities should be completed based on the results of the subrecipient?s determined risk to ensure subawards are used appropriately. We reviewed the department?s classification of a sample of eight of 40 Mental Health Block Grant (MHBG) and 11 of 76 Substance Abuse Block Grant (SABG) recipients of federal funds. We judgmentally selected an additional 11 MHBG and 30 SABG recipients for review after our review of the initial sample of recipients identified inconsistencies in the classification of recipients. Based on the following inconsistencies identified in our review, it is unclear if the department correctly classified recipients as subrecipients or contractors and the related expenditures are reported accordingly. As a result, the SEFA may incorrectly report pass-through or direct expenditures. One recipient of MHBG funds and 13 recipients of SABG funds were classified as contractors by the department; however, other recipients providing the same services were classified as subrecipients. As they were identified as contractors, a SEFA correction of $1.4 million was made to report as direct expenditures rather than pass-through expenditures. Three recipients of MHBG funds and one recipient of SABG funds were classified as subrecipients by the department, but it was unclear if each met the definition of a subrecipient. One recipient of MHBG funds was classified as a contractor and appeared to meet the definition of a contractor; however, payments made to this recipient were recorded as pass-through expenditures. A SEFA correction of $329 thousand was made to report as direct expenditures rather than pass-through expenditures. One recipient of SABG funds was classified as neither contractor nor subrecipient. A SEFA correction of $215 thousand was made to report as direct expenditures rather than pass-through expenditures. We also inquired of the department?s risk assessment and monitoring activities for subrecipients. Based on our inquiries, the department does not have a formal implemented process for performing risk assessments to determine appropriate monitoring activities. Moreover, the department has not implemented a formal process to ensure subrecipients comply with federal regulations, terms and conditions of the subaward, and that subaward performance goals are achieved. If subrecipient monitoring is not performed and documented, subawards could be used for unauthorized purposes and performance goals not met. We recommend department management ensure recipients of federal funds are appropriately identified as subrecipients or contractors and the corresponding disbursement of federal funds are appropriately reported as direct or pass-through expenditures. We further recommend department management comply with subrecipient monitoring requirements, develop and implement internal controls to ensure risk assessments are performed and documented for each subrecipient, and monitoring activities are completed and documented according to risk assessment results. MANAGEMENT RESPONSE: We agree with this recommendation. HSD Contracts team has already implemented additional checklists to ensure subrecipients and vendors are identified and coded properly. We will be making the checklist automated through our grant management process and fully implemented by this fall. Anticipated Completion Date: November 30, 2023 Contact: Sarah Adelhart, Interim Manager

Name of the Contact Person Responsible for the Corrective Action Plan: Jeremi Patterson, Deputy 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: December 31, 2023

Finding 2022-004 Subrecipient Monitoring Finding Summary: Eide Bailly LLP noted the agreements between Lake Agassiz Education Cooperative did not contain language set forth in CFR 200.331 and no formal subrecipient monitoring procedures were being performed. Responsible Individuals: Scott Masten, Special Education Director Corrective Action Plan: Lake Agassiz Education Cooperative will update the language in their agreements with subrecipient districts to include language set forth in CFR 200.331. In addition, the Cooperative will implement subrecipient monitoring procedures. Anticipated Completion Date: Ongoing

Subrecipient Monitoring ? 93.243 Substance Abuse and Mental Health Services Corrective Action Plan: All grant coordinator will be trained on current monitoring procedures and to keep good monitoring records. Grant and monitoring requirements will also be reviewed with contracted agencies as part of contract orientation. Implementation Date: Contract orientations should be completed within first month of executed contract. Year 1 monitoring of contracted agencies to be completed within first year of contract period, and annually thereafter. Responding Officials: John Valera, Administrator and Melanie Muraoka, Administrative Officer/Alcohol and Drug Abuse Division

Monitoring Procedures and Risk Assessment Process ? 93.958 Block Grants for Community Mental health Services Corrective Action Plan: CAMHD will have a dedicated accountant to any grant program above $750,000 in contract reimbursements to over see the monitoring procedures and process. Implementation Date: April 1, 2023 Responding Official: Scott Shimabukuro, Acting Administrative Chief and Janet Ledoux, Administrative Officer/Child and Adolescent Mental Health Division

2022-002 (Previously 2021-001) Subrecipient Monitoring U.S. Department of Health and Human Services Child Care Development Fund Block Grant and Maternal, Infant, Early Childhood Home visiting Assistance Listing Numbers: 93.575/596 and 93.870 Recommendation: We recommend the Department implement procedures to ensure compliance with required monitoring of its subrecipients, including review of financial reporting provided by its subrecipients. Additionally, we recommend the Department review the Federal Regulations to ensure the required elements are included in the subaward agreements. In general, the Department could benefit from improved processes over identification of entities at subrecipients or contractors and related tracking/monitoring of those entities identified as subrecipients. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: To ensure this does not occur again, the Family Support and Early Intervention Division (FSEI) Director and Deputy Director will implement procedures for program managers to ensure adequate compliance with required monitoring of its subrecipients, including review of financial reporting provided by its subrecipients. The FSEI Director and Deputy Director will ensure that program staff are adequately trained on subrecipient monitoring. The FSEI Director and Deputy Director will work with the Administrative Services Division (ASD) Director, Chief Financial Officer (CFO) and Grants Manager to verify subrecipient status and to ensure required elements are included in subaward agreements. Furthermore, the FSEI Director and Deputy Director will implement an internal review process to ensure program and financial monitoring is aligned and involves a third level of review by ASD Director, CFO and Grants Manager and other program personnel. Name(s) of the contact person(s) responsible for corrective action: Mayra Gutierrez, FSEI Director; Johanna Kehoe, FSEI Deputy Director; Ron Lucero, ASD Director; Carmel Pacheco-Aragon, Chief Financial Officer. Planned completion date for corrective action plan: June 30, 2023

Management agrees with this finding and is in the process of developing internal controls to ensure timely and appropriate actions are made on the deficiency noted.

Recommendation: We recommend that the County 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 and that appropriate monitoring is performed for each subrecipient. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will ensure that all subrecipients of American Rescue Plan (APRA) funds are monitored by using appropriate subrecipient monitoring procedures to ensure compliance with the grant awarded throughout the contract period. Name(s) of the contact person(s) responsible for corrective action: Sherri Crow, Interim Director of Budget and Finance Planned completion date for corrective action plan: January 1, 2024

Temporary Assistance for Needy Families (TANF) ? Assistance Listing No. 93.558 Recommendation: We recommend the County determine whether an entity receiving payment under TANF is a subrecipient or a contractor prior to entering into an agreement with the entity and to include all guidance under 2 CFR 200.331 when making this determination. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Prior to the finding we have been working to properly classify entities that receive TANF fund as subrecipients versus contractors. We will continue to implement a process to analyze the entities that are receiving payments through TANF and make sure that we properly determine them as a subrecipient or a contractor. Once the determination is made, we will work with Legal and enter into the correct agreement with the entity. We will also perform the required monitoring for the TANF subrecipients. Name of the contact persons responsible for corrective action: Eddie Valdez ? Deputy Director, Candace Cadena ? Executive Strategist, Nick Beston ? Accounting Manager. Planned completion date for corrective action plan: July 1, 2024

Views of Responsible Officials: The Center will update their policies and procedures regarding monitoring of sub-recipients to ensure they are complying with 2 CFR 200.331. The Center will also enhance the documentation around monitoring of sub-recipients.

The National Healthcare for the Homeless Council (NHCHC) will develop and implement a compliance checklist and procedure document for all sub agreements of federal funds. The compliance checklist will include the reference to the applicable CFR requirements including CFR 200.331(a(1).

The City of Boston?s Mayor?s Office of Emergency Management (OEM) will add an event to the departmental annual calendar on the first business day of the month of May of every year indicating that pre-risk assessment forms for the upcoming fiscal year beginning on July 1st are to be sent out to subrecipients of federal funds. The addition of this even to the calendar will ensure that all appropriate Admin and Finance staff at OEM are aware of this annual requirement and follow up with subrecipients to receive completed pre-risk assessments in advance of the new fiscal year. OEM?s Director of Admin and Finance will be the primary point of contact for pre-risk assessment-related inquiries from subrecipients, with the Assistant Deputy Chief of Administration serving as a backup point of contact. An event will also be added on the final business day of May each year to ensure that OEM staffs follow up with subrecipients that were not responsive to the initial request. OEM will also institute a policy of requiring a written response following receipt of a SEFA letter from OEM detailing the previous fiscal year?s expenditures on behalf of a subrecipient. This written response will contain confirmation that the subrecipients have recorded the same expenditures in their accounting systems as OEM reported in the SEFA letter. Should there be any discrepancy between the information provided in the SEFA from OEM and the expenditures reported by the subrecipient, OEM will schedule a meeting to reconcile any differences and resolve discrepancies within 30 days of being notified of said discrepancies. The Director of Admin and Finance and the Assistant Deputy Chief of Administration will represent OEM in this meeting with the appropriate staff from the subrecipient reporting a discrepancy. Confirmation of resolution of any discrepancies will be documented in writing and attached to SEFA letters for record keeping purposes. Anticipated Completion Date: June 30, 2023 Responsible Contact Person: Scott Finn, Assistant City Auditor, Grants Monitoring Unit scott.finn@boston.gov

A risk assessment questionnaire will be completed prior to funding being awarded to a subrecipient. The City of Boston?s Age Strong Commission?s policies and procedures will be updated to reflect this. Anticipated Completion Date: June 30, 2023 Responsible Contact Person: Scott Finn, Assistant City Auditor, Grants Monitoring Unit scott.finn@boston.gov

The City of Boston?s Age Strong Commission has revised the addendum that is attached to their award letters to include whether or not the award is R&D and a section on indirect cost rate. Anticipated Completion Date: June 30, 2022 Responsible Contact Person: Scott Finn, Assistant City Auditor, Grants Monitoring Unit scott.finn@boston.gov

Recommendation: The Organization should strengthen and organize the policies and procedures for administering the CoC program and work with the Department of Housing and Urban Development to draft a Subrecipient Manual that includes all regulatory requirements and citations. View of Responsible Officials: Responsible officials agree with the recommendation and will organize all policies and procedures and work with the Department of Housing and Urban Development to draft a Subrecipient Manual.

Finding: 2022-003 Material Weakness in Internal Control over Compliance and Material Noncompliance U.S. Department of Labor Federal Financial Assistance Listing 17.258/17.259/17.278 WIOA Cluster Subrecipient Monitoring 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. Responsible Individuals: Dana Aschenbrenner, Finance Director Corrective Action Plan: Johnson County disagrees with the underlying premises of this finding. This finding is due in part to the fiscal agent agreement with Iowa Workforce Development (?IWD?) which does not state that subrecipient monitoring has to be done. Recently, IWD received a finding from the Department of Labor stating that the template fiscal agent agreements imposed upon fiscal agents by IWD improperly placed liability of disallowed costs onto the fiscal agents. According to DOL, IWD?s form of fiscal agent contract was incorrect, i.e., the liability was to stay with the local CEOs. In the wake of the finding, IWD is reissuing the contracts out to the regions to create compliant subrecipient entities within each, and then new fiscal agent agreements will be issued. Additionally, Johnson County will be ending it fiscal agent agreement, and no longer continue to be the fiscal agent as of June 30, 2023. Anticipated Completion Date: Ongoing

Planned Corrective Action: Management agrees with the finding. Policies and procedures are being updated to address the material weakness identified. A monitoring calendar has been developed to use to monitor and track when the necessary monitoring is scheduled and performed for all subrecipients. We have worked with the Division of Aging Services to ensure that the most up to date guidelines and forms are used during the monitoring process. Training will also be provided to staff to ensure that they are aware of the monitoring requirements and the forms to be used by the staff during the process. We have also implemented procedures to perform risk assessments of subrecipients prior to awarding the contract to the provider. Documentation of the risk assessments and monitoring will be reviewed quarterly by the Executive Director and properly stored and maintained. Name of Contact Person: Laura M. Mathis, Executive Director Anticipated Completion Date: December 31, 2022

Management of Josephine County has acknowledged that evidence of subrecipient monitoring and risk assessments were not retained in the file. While vetting was done on subrecipients a risk assessment form was not formally written. We have addressed it by providing training to central staff as well as department staff who have responsibility over grants. Further, a dedicated staff member will be responsible for monitoring grant compliance and completing risk assessments that were not done based on the vetting process that did occur. Anticipated Completion date is June 30, 3023. The responsible contact person is Sandy Novak, Finance Director.

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.