Corrective Action Plans

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.

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