Corrective Action Plans

Finding Number: 2023-004 Finding Name: Failure to Establish Subrecipient Monitoring Procedures Finding Condition(s): The Illinois Department of Human Services (IDHS) did not perform a risk assessment or subrecipient monitoring procedures for the subrecipient of the COVID-19 – Homeowner Assistance Fund (HAF) program. Name of Contact Person(s): Joseph Wellbaum, Chief Financial Officer – Illinois Department of Human Services Corrective Action(s): On September 10, 2024, the IDHS completed a fiscal and administrative review of the Illinois Housing Development Authority. Additionally, on March 5, 2024, the IDHS will complete a thorough programmatic review of the HAF program. Proposed Completion Date: September 10, 2024 – Completed

Finding Number: 2023-002 Finding Name: Inadequate Monitoring of Subrecipient Single Audit Reviews Finding Condition(s): The State of Illinois did not establish adequate controls to monitor the completion and documentation of the single audit reports reviews for its subrecipients of the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), Child and Adult Care Food Program (CACFP), Crime Victims Assistance Program (CVA), WIOA Cluster (WIOA), Highway and Planning Construction (Highway), Emergency Rental Assistance Program (ERAP), Homeowner Assistance Fund Program (HAF), Coronavirus State and Local Fiscal Recovery Funds (SLFRF), Twenty-First Century Community Learning Centers (Twenty-First), Title I Grants to Local Education Agencies (Title I), Supporting Effective Instruction State Grants (SEISG), Education Stabilization Funds (ESF), Epidemiology and Laboratory Capacity for Infectious Diseases (ELC), Temporary Assistance for Needy Families Cluster (TANF), Child Support Enforcement (CSE), Low-Income Home Energy Assistance Program (LIHEAP), CCDF Cluster (CCDF), Social Services Block Grant (SSBG), and Block Grants for Prevention and Treatment of Substance Abuse (SAPT) in the State's Grant Accountability and Transparency Act (GATA) Audit Report Review Management System (ARRMS). Name of Contact Person(s): Keyria Rodgers, Grant Accountability and Transparency Unit Director – Illinois Governor’s Office of Management and Budget Corrective Action(s): The Grant Accountability and Transparency Unit (GATU) provides a centralized, uniform process and a system which State grant-making agencies are required to adhere to throughout the life cycle of the grant. The Illinois Governor’s Office of Management and Budget (GOMB) will develop and implement monitoring procedures to ensure the system is updated by agencies and accurate as to the completeness of the agencies’ report reviews, letter issuances, and desk reviews. Proposed Completion Date: December 31, 2025

Finding 2023-041 Program Information Program Name: Child Support Enforcement CFDA Number: 93.563 Summary of Finding Subrecipient Monitoring Significant Deficiency in Internal Control over Compliance Agency Response Agency agrees with this finding. Corrective Action Plan DSS contracts staff will formally communicate to the Child Support Enforcement (CSEP) Chief the annual requirement to update the Subrecipient Federal Award Funding attachment with the current FAIN and Federal Grant Award date. A structured follow-up process will be implemented to confirm timely completion of the updated template and distribution to both the Subrecipient and DSS contracts staff for official records. These procedures will ensure that all subawards consistently include the required elements. Contact Person(s) Responsible Karen Stoycoff, Social Services Program Specialist Phone: 775-684-7436 Email: kstoycoff@dss.nv.gov Anticipated Completion Date September 30th, 2025.

Finding Number 2023-002 Contact Person(s): Brianna Mariani – BriannaMariani@housinghope.org Kathryn Opina - KathrynOpina@housinghope.org Explanation and specific reasons for disagreement with the audit finding or that corrective action is not required (if applicable): N/A Corrective action planned: This was the first and only grant Housing Hope has administered that required subrecipient monitoring. The grant has since ended and the organization does not anticipate entering any future agreements that would require subrecipient monitoring. To ensure compliance should such an agreement arise again, Housing Hope will adopt a Subrecipient Monitoring Policy. This policy will outline the criteria for identifying subrecipient relationships and establish a standardized process for monitoring subrecipients, if any are engaged in the future. Anticipated completion date: The Subrecipient Monitoring Policy will be adopted by October 2025 Board meeting.

2023-002 Compliance and Internal Controls over Subrecipient Fiscal Monitoring (Significant Deficiency) Corrective Action: In accordance with 2 CFR Section 200.332, The Resource Group as the pass-through entity will ensure subrecipient fiscal monitoring is completed in 2024 to ensure compliance with federal and state requirements. The Finance Director is responsible for oversight and administration of fiscal monitoring. Fiscal monitoring will be conducted at least annually in accordance with HRSA Monitoring Standards 45 CFR 74.51 and 45 CFR 75.352. As a pass-through entity, fiscal monitoring will include at minimum reviews of financial performance and compliance with federal and state statues, regulations and terms and conditions. The process will include desktop/remote verification of applicable financial policy and procedures and an onsite review. A standardized monitoring tool will be used to evaluate financial compliance. The fiscal monitoring observations will result in a monitoring report, disseminated to the subrecipient within 60 days of the onsite review. Progress to date: 1. To support the financial monitoring efforts, technical assistance was received on February 5-7, 2024, from the DSHS Fiscal Support and Oversight Department. The primary objective of the visit was to discuss financial monitoring requirements as it applies to state and federal regulations, statues and terms and conditions. The standardized monitoring tool was also evaluated for compliance. 2. The Finance Director developed and implemented a comprehensive fiscal monitoring schedule for calendar year 2024. In alignment with strengthened oversight practices, onsite fiscal reviews of subrecipients commenced in February 2024. As part of the enhanced monitoring approach, the testing period for subrecipient fiscal reviews was expanded beyond the standard scope to include transactions and activities from both Fiscal Year 2022 and Fiscal Year 2023. 3. As of September 2024, the Finance Director completed 100% of fiscal monitoring visits. a. Support Documentation: to establish additional guidelines for fiscal monitoring, the Fiscal Monitoring Policy was drafted and approved by the Board on November 18, 2024. 3 Responsible Party: Finance Director, Garland Thompson Date Complete: November 18, 2024

The Board of County Commissioners, with the cooperation and participation of all elected officials, reviews, develops and implements policies and procedures to create a strong internal control environment. The Board of County Commissioners will work with all elected officials, the third-party administrator, and federal, state and local partners to develop policies, procedures, and internal controls designed to accurately track grants, including the application process, verification, oversight, and reporting of grant requirements. To assist in this process, the Board of County Commissioners engaged a third-party administrator to oversee the grant process, including application, eligibility, review, requirements, contracting, recipient tracking and oversight, and documentation and reporting. The Board of County Commissioners will work with the third-party administrator to ensure proper grant administration.

Planned Corrective Action: Update Financial Policies and Procedures to reflect language surrounding areas of deficiency, specifically listed in 2 CFR 200.332(b). New subrecipients awards will include: subrecipient’s unique entity identifier, federal award identification number, federal award date, assistance listing title, assistance listing number, dollar amount available under each federal award and assistance listing number at the time of disbursement, and approved indirect cost rate. Planned Implementation Date of Corrective Action: 7/14/25, will be included in Financial Policies revisions in December 2025. Person Responsible for Corrective Action: Director of Finance

Corrective Action Plan FINDING 2023-002 - Subrecipient Monitoring (Partially Repeated from Prior Year Findings 22-002, 21-003, 20-004, 19-005, 18-004, and 17-003) CONDITION: The Regional Office of Education #47’s internal controls over subrecipient monitoring do not include timely and adequate risk assessment procedures. Furthermore, the Regional Office of Education #47 did not properly monitor subrecipients in accordance with the Uniform Guidance standards. During audit testing procedures it was determined that ROE #47: McKinney Education for Homeless Children – for three (3) of three (3) subrecipients tested, ROE #47: • Did not evaluate the risk of noncompliance with Federal statutes, regulations, and the terms and conditions of the subaward. • Did not conduct subrecipient monitoring procedures during the year ended June 30, 2023. • Did not determine whether the subrecipient met the 2 CFR 200 Subpart F Audit requirements criteria for a single audit. COVID-19 ARP - McKinney Education for Homeless Children – for three (3) of three (3) subrecipients tested, ROE #47: • Did not identify the subaward and applicable requirements in the agreements. • Did not evaluate the risk of noncompliance with Federal statutes, regulations, and the terms and conditions of the subaward. • Did not conduct subrecipient monitoring procedures during the year ended June 30, 2023. • Did not determine whether the subrecipient met the 2 CFR 200 Subpart F Audit requirements criteria for a single audit. PLAN: Moving forward, The Regional Office will formally identify the subaward and applicable requirements in our agreements. We will conduct subrecipient monitoring procedures. We will determine if the subrecipient met the requirement criteria of 2 CFR 200 Subpart F Audit requirements for a single audit. ANTICIPATED DATE OF COMPLETION: Fiscal Year 2025 CONTACT PERSON: Mr. Chris Tennyson, Regional Superintendent for Lee, Ogle, and Whiteside Counties.

VIEWS OF RESPONSIBLE OFFICIALS ADSEF will provide training to personnel on the requirements and regulations related to subrecipient monitoring. Recommendation to management will be implemented, internal controls and compliance measures that allow for the identification, reporting, and monitoring of subrecipient activities Prevention Activities/TANF. IMPLEMENTATION DATE During Fiscal Year 2025-2026. RESPONSIBLE PERSON Administration for Socioeconomic Development of the Family (ADSEF, by its Spanish Acronym)

Finding 2023-001 Information on the federal program: Federal Agency: Department of the Treasury Pass-Through Entity: N/A – Direct Grant Federal Program: Coronavirus State and Local Fiscal Recovery Funds (CSLFRF) Assistance Listing Number: 21.027 Compliance Requirement: Subrecipient Monitoring Audit Findings: Material Weakness, Noncompliance Condition: The City of Bloomington was unable to identify subrecipients of CSLFRF funding for the purposes of financial reporting and compliance with requirements under 2 CFR 200.332. The City could not distinguish between a subrecipient and a general vendor. Management misreported subrecipient activity on the SEFA, failed to include required contractual language for subrecipient awards in executed agreements, and did not perform monitoring procedures over the subrecipients management identified during audit testing procedures. Context: The 10 subrecipients represent approximately 18%, $1,025,070, of the total award expenditures of $5,590,828, in 2023. The condition reported was prevalent for each subrecipient participating in the award. Views of Responsible Officials and Planned Corrective Actions: Management agrees with the finding and will draft a policy and develop an internal controls process regarding subawards and the monitoring of subrecipients to ensure the compliance requirements are met. Responsible party and timeline for completion: The City’s Controller will be responsible for overseeing the implementation of the corrective action plan, which will be implemented starting during calendar year 2025.

Chairman of the Board of County Commissioners: Oklahoma County will comply with federal laws and regulations and grant agreements by creating award agreements that are designed and implemented to ensure Subrecipient Monitoring is performed. Anticipated Completion Date: 6/30/2025 Responsible Contact Person: Myles Davidson, BOCC Chairman

Statement of Condition: Compliance over subrecipient monitoring. Entity did identify the award and applicable requirements, however entity did not evaluate each subrecipient’s risk of noncompliance nor did it monitor subrecipient activities as listed in the contracts “Subaward Performance Reporting” and monitoring procedures per 2 CFR Sections 200.332 (b) and (d) through (f). Criteria: National Association of Wetland Managers’ internal control policies and procedures, and the Uniform Guidance 2 CFR Sections 200.332 (b) and (d)-(f). Cause: Management’s lack of understanding of criteria. Corrective Action Plan: Contact person: Marla Stelk, Executive Director Corrective action to be taken: NAWM will finalize and implement our subrecipient policies and procedures for current subawards, including documentation of how NAWM evaluated each subrecipient’s risk of noncompliance. NAWM will continue to monitor subrecipient activities through the grant period for each subaward as applicable. For future subawards, NAWM will evaluate and document each subrecipient’s risk of noncompliance and will monitor subrecipient activities as stated in our subrecipient policies and procedures. Anticipated completion date: End of current fiscal year (December 31, 2025)

Recommendation: We recommend the Center establish a formal monitoring process to review the activities on each of its recipients. This should include site visits, review of annual external audits when applicable and training when deemed necessary. Action Taken: Tri-County OIC has developed and begun implementing a comprehensive Sub recipient Monitoring Plan to ensure compliance and accountability. Actions taken include: Development of Sub recipient Monitoring Policies and Procedures, which outline expectations, responsibilities, and steps for oversight. Creation of a Sub recipient Risk Assessment Tool to categorize sub recipients based on risk level and determines appropriate monitoring frequency. Scheduling of Annual On-Site or Virtual Monitoring Visits, including programmatic and fiscal reviews. Formal Collection and Review of Annual External Audits or Financial Statements from sub recipients, as applicabie. Documentation Protocols to maintain records of all monitoring activities, communications, findings, and corrective actions. Anticipated Completion Date: May 31, 2025 Contact Person Responsible: Christina Johnson, Executive Director

Recommendation: We recommend the Center review its contracts against the criteria set forth in the Uniform Guidance to ensure that all sub-awards in the future contain the required information for subrecipients. Action Taken: Tri-County 010 has taken the following corrective steps: Reviewed and Updated the Subrecipient Contract Template to include all required elements as outlined in Pennsylvania Department of Education. Implemented a Pro-Award Contract Review Checklist to ensure each contract is verified for compliance prior to execution. Established a Documentation Process for storing all subrecipient agreements and related compliance materials in a centralized location. Anticipated Completion Date: March 31, 2025 Contact Person Responsible: Christina Johnson, Executive Director

Recommendation: CLA recommends adding a review and approval process for all the reimbursement requests and obtaining the support for the payments made in advance for the subawards and review whether subrecipient used the subaward for authorized purposes in compliance with federal statutes, regulations, and the terms and conditions of the subaward. Additionally, CLA recommends modifying the subaward agreements to include the award information required by CFR 200.332 (b). There is no disagreement with the audit finding. Action taken in response to finding: ICEDC appreciates the identification of a gap in subrecipient monitoring. In response, we are strengthening our monitoring procedures by implementing a formal subrecipient monitoring program. ICEDC will implement a formal review and approval process for all reimbursement requests and will enhance monitoring procedures to better assess utilization of the subaward funds for their intended, authorized purposes. This will include regular reviews of subrecipient activities and financial reports to ensure compliance with federal statutes, regulations, and the terms of the subaward. ICEDC will ensure subaward agreements include all necessary award information as required by CFR 200.332 (b). Name(s) of the contact person(s) responsible for corrective action: Kristina Hines Planned completion date for corrective action plan: 8/31/2025

The CDSS agrees with the finding. The Child Care and Development Division's Program Quality Improvement Branch (PQIB) recognized the need for tracking monitoring procedures starting from risk assessment identification to closing out of Continuous Improvement Plans (CIP) to ensure that contractors with the highest risk factors are prioritized and agencies requiring follow up received a CIP. • Tracking Use of the Risk Assessment: Annually, the PQIB identifies risk criteria for the upcoming Fiscal Year (FY) monitoring through the Contract Monitoring Protocols Agreement document. Using the Consultant Caseload Cohorts spreadsheet staff identify the agencies they will monitor using the FY Monitoring Priorities criteria (risk assessment criteria). The PQIB Travel Team and Administrators review the monitoring schedules for each consultant to ensure the risk assessment criteria has been followed. The risk assessment criteria are reviewed and updated annually based on trends and support needs of the field. In FY 2023-2024 PQIB implemented a cohort review cycle to apply the risk assessment criteria to all contracted programs subject to monitoring reviews. • Maintaining Monitoring Reports: Each Contract Monitoring Report includes a “Monitoring Summary Page” containing all items reviewed during a Contract Monitoring Review (CMR). Any item from the Program Integrity Monitoring Tool identified during a review as unmet and/or identified for a CIP is automatically tracked by the analysts for follow-up and resolution. A spreadsheet with all the reviews scheduled for any contract monitoring visit are maintained by FY and the findings are recorded for each item on the tool. The PQIB analysts track the review dates, reports, findings, and CIPs. The analysts meet with the administrators monthly to track missing reports. All reports are filed by individual agency. • Continuous Improvement Plan (CIP): The PQIB analysts use the Contract Monitoring Report to determine if a CIP is required. A standard CIP template was developed, and all staff are required to use the same document. Every CIP has a 45-day corrective action period; however, programs may be granted extensions if requested in writing. Programs can request up to an additional 180 days to complete corrective actions. To receive an extension, a plan must be submitted in writing detailing how the program will address the actions by the end of the extension period. The PQIB analyst conducts follow-up with the consultant until the CIP is received. The CIP is not closed until all items identified for corrective action are resolved. A completed CIP and Resolution Letter are sent to the contractor and filed in the Common Folder in the agency’s folder. All spreadsheets, agreements, forms, and records of completed monitoring reports referenced above are maintained in the Common Folder and on the PQIB SharePoint page. Furthermore, CDSS is actively working to fully adopt audit report monitoring responsibilities of Local Education Agencies (LEA) and certain non-LEAs receiving Child Care and Development Fund (CCDF) Cluster program funds by July 1, 2025. Estimated Implementation Date: July 1, 2025 Contact: Jeff Fowler, Staff Services Manager III Child Care and Development Program California Department of Social Services

Public Health agrees with the recommendation. Public Health will develop a process for conducting risk assessments of subrecipient funding, develop and implement procedures for obtaining single audit reports from subrecipients, as well as a system to monitor and track compliance with the single audit mandate among subrecipients. Public Health will ensure each subaward includes all requirements imposed on the subrecipient so that the federal award is used in accordance with Federal Statutes, regulations, and terms of conditions of the federal award. Estimated Implementation Date: May 2025 Contact: Melissa Relles, Assistant Deputy Director Division of Operations, Center for Preparedness and Response California Department of Public Health

The Chancellor’s Office established and implemented SLFRF emergency financial assistance grants policies and procedures. The policies and procedures can be found on the following website: State Fiscal Recovery Funds - Emergency Financial Assistance for California Community College Students. These policies and procedures included a self-certification process to certify that students met SLFRF eligibility requirements, expenditure tracking and management information system data reporting, a monitoring plan, and state compliance procedures through the annual Contracted District Audit Manual for the 2021-22, 2022-23, and 2023-24 fiscal years. The Chancellor’s Office intends to include SLFRF compliance procedures in the upcoming 2024-25 fiscal year Contracted District Audit Manual. The intent of both the policies and procedures as well as the Audit requirements are intended to address the Chancellor’s Office need to: (1) maintain effective internal controls regarding its use of the applicable SLFRF Federal award funding, (2) assess each community college’s risk of potential noncompliance with SLFRF subaward federal statutes, regulations and terms and conditions, and (3) validate that community colleges expended the SLFRF resources in accordance with federal statutes, regulations and terms and conditions. The Chancellor’s Office will coordinate with the Department of Finance as needed to revise the funding source of expenditures that are determined to be ineligible to be supported by SLFRF resources. The Chancellor’s Office will also work with community college districts to ensure any SLFRF funds awarded to ineligible students are adjusted in districts’ accounting records to the proper state funding source. The Chancellor’s Office will continue to communicate the SLFRF emergency financial assistance grants policies and procedures to California Community districts as needed. Additionally, the Chancellor’s Office will continue to receive copies of each district’s annual audit and audit findings as determined through the Contracted District Audit Manual process. The Chancellor’s Office will also continue to review and revise the SLFRF policies and procedures, and memorandums as needed to ensure the required federal award identification information and retention process information is available to community college districts. In conclusion, the Chancellor’s Office appreciates the focus toward ensuring the successful implementation of the emergency financial assistance grant program and in support of our students’ success. The SLFRF grants provided low-income students who were disproportionately impacted by the COVID-19 pandemic emergency support to continue with their enrollment, improve their economic mobility, complete their educational goals, and contribute to California’s economy in a meaningful way. Estimated Implementation Date: December 15, 2025 Contact: Chris Ferguson Executive Vice Chancellor of Finance and Strategic Initiatives California Community Colleges Chancellor’s Office

California Department of Transportation (Caltrans) has determined that federal award information is not always disseminated to the project managers. Caltrans will review current policies and procedures of each division and revise, if necessary, so that best practices are followed. Caltrans Internal Audits Office will be working with Local Assistance’s single audit report monitoring process and take on the responsibility to monitor for all Caltrans divisions. Estimated Implementation Date: June 2025 Contact: Ben Shelton, Chief – Caltrans Internal Audits Office Division of Risk and Strategic Management

Consortium shall implement procedures to ensure quarterly reports are filed no later than the tenth calendar day of the second month following the quarter the report represents. In addition, all data reported thru these quarterly reports should be supported by the accounting system of the Fiscal Agent and County Financial Information System (CFIS). This practice was put into place on April 10, 2024.

Finding 2023-003: Subrecipient Monitoring (Significant Deficiency): The Organization erroneously recorded a prior year subaward expense as a 2023 subaward expense. This was missed during the Chief Financial Officer’s review of subaward invoices and during the Chief Executive Officer’s overall review of the Statement of Expenditure of Federal Awards. Name of Contact Person: Charles Xie, Chief Executive Officer email: charles@intofuture.org Corrective Action Plan: The Organization has a small accounting department, which consists of an outsourced bookkeeper. The bookkeeper works part time and did not timely reconcile certain accounts. The Organization has ensured all reconciliations are being done monthly and are reviewed, and that proper cutoff of invoices is implemented and reviewed at year-end. Anticipated Completion Date: Immediately

Views of Responsible Officials: Action Against Hunger - USA will update its subrecipient monitoring procedures to ensure a formalized process for obtaining, reviewing and documenting subrecipient audit reports in a timely manner. Key personnel involved in subrecipient oversight will receive additional training concerning the requirements for subrecipient monitoring in accordance with 2 CFR 200.332.

The Board of County Commissioners will take measures to ensure future compliance with all requirements of federal grants.

Management Response and Corrective Action Plan Finding 2023-002 – Subrecipient Monitoring Federal Agency: United States Department of Health and Human Services Program Name: Research and Development (R&D) Assistance Listing Number: 93.837 and 93.847 Responsible Individual: Roy Bourne, Director, Research Finance and Operations Contact Information: rbourne2@joslin.harvard.edu; 617-309-5741 Joslin Diabetes Center’s (Center) subrecipient monitoring process did not clearly indicate risk assessment procedures or the required monitoring activities in certain audited instances. While the Center has a Subrecipient Monitoring and Management policy, review suggests that a thorough evaluation of this plan, formal documentation, and secondary oversight will improve internal control. Management agrees with the recommendation and will evaluate the subrecipient monitoring process according to 2 CFR 200.332 and update established policy where applicable. Corrective Action Plan: - Management will review the Subrecipient Monitoring and Management policy for relevant updates and improvements to internal control - Results of risk assessment procedures and subrecipient monitoring will be formally documented within the tracking log - Log entries will be updated to reflect a reviewers note documenting material and date of review - Director of Research Finance and Operations will review log semi-annually for secondary oversight Expected Completion Date: June 30, 2025 Status of Completion: In Process

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