Corrective Action Plans

Finding 2023-002 - Department of Health and Human Services – Research & Development Cluster- Subrecipient Monitoring Statement of Condition: No formal documentation existed to indicate that the Foundation performed the required monitoring of its subrecipient’s activity and no written policy exists to establish procedures to document the monitoring of the subrecipient. Management Response: The RTOG Foundation Inc. has adopted the subrecipient monitoring policy of NRG Oncology that comports with the “Subrecipient Compliance With Uniform Administrative Requirements, Cost Principles, and Audit Requirements.” Additionally, activity of subrecipients of the Foundation, including the American College of Radiology (ACR) is monitored under the Management Services Agreement with the NSABP Foundation, via routine analysis and documentation of ongoing activities as well as inspection of ACR financial statements to ensure compliance with 2 CFR 200.322. Lastly, RTOG has created an SOP and document templates to assist in the monitoring of subrecipients.

2023-004: U.S. Department of Agriculture - Soil and Water Conservation - Assistance Listing #10.902 Subrecipient Monitoring: Significant Deficiency in Internal Control over Compliance and Non-Compliance Finding Summary: Several required elements per 2 CFR 200.331 being absent from the subrecipient agreements, including: Subrecipients’ unique entity identifier, Federal award date of award to Wallowa Resources by the USDA, and ALN number and dollar amount made available by the USDA Wallowa Resources was unable to provide support that subrecipients were assessed for suspension and debarment during the risk assessment. Corrective Action Plan: Wallowa Resources will implement a formal subrecipient monitoring policy using the guidance of 2 CFR 200.332. We are aware of this policy and have used it before. It was an oversight in this case – due in part to the fact that the subrecipients were recommended to us by NRCS staff and were in good standing with NRCS. Responsible Individual(s): Joni Maasdam, Finance Manager. Anticipated Completion Date: October 2024.

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

Corrective Action Plan: To ensure compliance with 2 CFR Part 200, Uniform Administrative Requirements, Post Federal Award Requirements, the county (Human Services Agency) will follow Kings County’s subrecipient monitoring policy and procedure. In addition, it will establish a procedure and checklist that is specific to FFA, GH, and STRTP subrecipients, due to the unique structure and involvement of CDSS. The County (Human Services Agency) will draft written policies and procedures for monitoring identified subrecipients receiving Foster Care Title IV-E funds that will include the following steps: •Annually, the County (Human Services Agency) will request from each placement agency utilized a copy of their audited financial statements and complete an annual risk assessment of each FFA, GH, and STRTP agency receiving Foster Care Title IV-E funds to determine the agency’s risk of non-compliance withFederal statutes and regulations. The risk level determined for each agency will determine the appropriate level of subrecipient monitoring. •To ensure compliance with the management decision letters and audit findings of CDSS, the County (Human Services Agency) will follow up with each agency with a request for their corrective action plan. This will be done promptly after receipt of the subrecipient’s audit report, ensuring that subrecipients are aware of any issues and can take appropriate and timely corrective action. Contact Information of Responsible Official: Atonya Moore Deputy Director – Fiscal Kings County Human Services Agency 559-852-2214

COMMONWEALTH OF PUERTO RICO CORRECTIVE ACTION PLAN MUNICIPALITY OF NARANJITO FOR THE FISCAL YEAR ENDED JUNE 30, 2023 Audit Report: Reports on Compliance and Internal Control in Accordance with Government Auditing Standards and 2 CFR 200 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards Audit Period: July 1, 2022 – June 30, 2023 Fiscal Year: 2022-2023 Principal Executive: Hon. Orlando Ortíz Chevres - Mayor Contact Person: Mrs. Belinda Álvarez, Finance Director Phone: (787) 869 – 2200 Original Finding Number: 2023-004 Statement of Concurrence or Nonconcurrence: We concur with the finding. Corrective Action : The Municipality appointed a person to work on all the required reports. Implementation Date: August 31, 2024 Responsible Person: Mrs. Belinda Álvarez - Finance Department Director

Individual Responsible for Corrective Action Plan: Ashley Prow, Alliance Director Corrective Action: The Alliance performed site visits as required, and will maintain documentation of these going forward to provide verification that these occurred in accordance with the contract and our documented subrecipient monitoring procedures. Anticipated Completion Date: December 31, 2024

Corrective Action Plan: Trillium Place will update the sub-award contracts to include all required elements, including: FAIN, ALN number and title, name of the federal awarding agency, UEI, indirect cost rate, Single Audit requirements, and a suspension and debarment clause. Contact Person(s): Ann Campen Anticipated Completion Date: 12/31/2024

2023- 007 - Material Weakness in Internal Control and Material Noncompliance – Sub-recipient Monitoring and Management WPHW understands this finding and recognizes that correction that were planned for FY23 were not able to be fully implemented. One of the significant challenges WPHW had over the past couple of year, in addition to IT system challenges, is staffing. WPHW has hired three individuals to develop our contracting process and had performance issues with all three individuals. In addition to the difficulties with the NetSuite implementation, we have had to re-evaluate our sub-recipient monitoring and management business process. The following process will address this finding: 1) Director of Accounting and the Accounting Manager will review CFR 200.332 and develop a revised business process for the WPHW contract system a. Accounting Team will hire 2 Accounting Specialists who will each have specific sub-recipient monitoring responsibilities 2) Director of Accounting and the Accounting Manager will review all current contract to ensure the following: a. Ensure that every subaward is clearly identified to the subrecipient as a subaward and includes: i. Federal, State or other award identification. ii. Subrecipient name (which must match the name associated with its unique entity identifier); iii. Subrecipient's unique entity identifier; iv. Award Identification Number (FAIN/SAIN); v. Award Date of award to the recipient by the Federal agency; vi. Subaward Period of Performance Start and End Date; vii. Subaward Budget Period Start and End Date; viii. Amount of Federal Funds (if applicable) Obligated by this action by the pass-through entity to the subrecipient; ix. Total Amount of Federal Funds Obligated, if applicable, to the subrecipient by the pass-through entity including the current financial obligation; x. Total Amount of the Federal Award committed to the subrecipient by the pass-through entity; xi. Federal award project description, as required to be responsive to the Federal Funding Accountability and Transparency Act (FFATA); xii. Name of Federal awarding agency, pass-through entity, and contact information for awarding official of the Pass-through entity; xiii. Assistance Listings number and Title; the pass-through entity must identify the dollar amount made available under each Federal award and the Assistance Listings Number at time of disbursement; xiv. Identification of whether the award is R&D; and xv. Indirect cost rate for the Federal, State, or other award (including if the de minimis rate is charged) per § 200.414. b. All requirements imposed by the pass-through entity on the subrecipient are in accordance with Federal, State, Local statutes, regulations and the terms and conditions of the award; c. Determines and ensure completion of required financial and performance reports; d. Has an approved federally recognized indirect cost rate negotiated between the subrecipient and the Federal Government or utilizes the de minimus. e. States that subrecipient permit the pass-through entity and auditors to have access to the subrecipient's records and financial statements as necessary for the pass-through entity to meet the requirements of this part f. Details appropriate terms and conditions concerning closeout of the subaward. g. Subrecipient risk assessment that accesses: i. prior experience with the same or similar subawards; ii. previous audits iii. personnel or substantially changed systems iv. Prior monitoring results 1. Subaward conditions will be placed if issues arise 3) Implement sub-recipient monitoring process. a. Conduct invoice review monthly i. All invoices must include full back up and support for expenses ii. All invoices will be reviewed as they are received to ensure expenses are allowable iii. Any issues that arise will be addressed prior to invoice payment b. Conduct contract monitoring visit annually i. Hold a meeting with the sub-recipient to review the following: 1. Reviewing financial and performance reports 2. Following-up and ensuring that the subrecipient takes timely and appropriate action on all deficiencies detected through audits, on-site reviews, and written confirmation from the subrecipient, highlighting the status of actions planned or taken to address Single Audit findings related to the subaward. 3. Training and technical assistance on program-related matters 4. Determine corrective action for any deficiencies or findings and determine risk 5. Discussion of enforcement action against noncompliant subrecipient This process will be reviewed, and implementation will begin during Q4 FY24. All current FY24 contracts will be reviewed, and monitoring visits scheduled. For FY25, all contracts will be in compliance with requirements.

The County Child and Youth Services department started requiring a corrective action plan for all subrecipients with findings as a result of their on-site monitoring in 2023 that include the entity’s plan to correct the errors noted, individual responsible and timeline for corrections to be implemented. Finding noted are for monitoring completed in January and March 2023, prior to the requirement of written corrective action plans being implemented.

Management agrees with the recommendation and has added this report filing requirement to the grant onboarding checklist. The FFATA report was submitted and uploaded by the Director of Grants & Compliance on August 28 2024. This process will be overseen by the Director of Grants & Compliance and is in place as of the date of this corrective action plan.

CORRECTIVE ACTION PLAN September 26, 2024 Clarion County respectfully submits the following corrective action plan for the year ending December 31, 2023. MaherDuessel 503 Martindale Street, Suite 600 Pittsburgh, PA 15212 Audit period: January 1, 2023 to December 31, 2023 The finding from the schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. Finding 2023-001 Subrecipient Monitoring U.S. Department of Health and Human Services, Foster Care Title IV-E - ALN 93.658 Recommendation: We recommend that procedures be implemented to ensure all subrecipients are notified of subawards and implement a process to ensure all subrecipients audits are reviewed and deficiencies be followed up on. In addition, we recommend implementation of procedures to formally document and complete a risk assessment of subrecipients. Based on the risk assessment performed, the County should develop monitoring procedures to address the risks noted, which should be include a documented review of subrecipients audits. Action Taken: The Children and Youth Agency will require that all placement providers (all providers who have to potential to receive federal funds) submit their latest audit for review. We will develop a risk assessment tool with the help of our auditors and document the results. The agency will also develop a letter to notify those providers of any federal funds that they may have received for the fiscal year, the letter will be sent no later than October 31st.

Individual Responsible for Corrective Action Plan: Alliance Director – Brian Dennis Corrective Action: The Organization will enhance its procedures and internal controls with respect to monitoring over subrecipient activities and reimbursement payments by working with the State of Montana grantor to ensure local clubs are using subawards for authorized purposes. Anticipated Completion Date: December 31, 2024

Individual Responsible for Corrective Action Plan: Alliance Director and staff – Brian Dennis Corrective Action: The Organization will enhance its procedures and internal controls with respect to monitoring over subrecipient activities and reimbursement payments by working with the State of Montana grantor to ensure local clubs are using subawards for authorized purposes. Anticipated Completion Date: December 31, 2024

Views of Responsible Officials: Management acknowledges a noncompliance with FFATA Reporting requirements and a need to establish and document a policy and procedure. FFATA reporting was subsequently completed for one of the two subawards requiring FFATA reporting in 2023 and the other is in process. The Global Center has updated its “Subaward Methodology and Guidelines” to include FFATA reporting requirements and is distributing those guidelines to all project managers, finance, and other staff to ensure FFATA reporting is completed when required by the end of the month following the month in which any subcontract greater than $30,000 is awarded. Responsible Officials: Jason Ipe, Chief of Operations Anticipated Completion Date: September 27, 2024

Finding 2023-004 – Subrecipient Monitoring Contact Person Responsible for Corrective Action: Danny Yost Contact Phone Number: 812-285-6221 Views of Responsible Official: We concur with the finding Description of Corrective Action Plan: The County will obtain all subrecipient audit reports and formally document their review of each subrecipient’s audit report. Anticipated Completion Date: October 2024.

FINDING 2023-005 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Subrecipient Monitoring Summary of Finding: Both of the County’s subrecipients submitted quarterly reports for Quarter 2 of 2023, covering the time period from April 1st through June 30th. No other quarterly financial and performance reports were submitted to the County during the fiscal year. As part of the monitoring the County performed on the subrecipients in March 2023, they noted the subrecipients had been missing quarterly reports. Despite communications made by the County to obtain the missing quarterly reports, no other quarterly reports were submitted by the subrecipients. Contact Person Responsible for Corrective Action: Don Lopp, Director of Operations and County Planning Contact Phone Number and Email Address: 812-948-4110 and dlopp@floydcounty.in.gov Views of Responsible Officials: We concur with the finding Description of Corrective Action Plan: Staff will continue to work with Water companies regarding audit of projects and submission of all required quarterly reports. Anticipated Completion Date: Quarterly Reports will be collected until final December 2024 reporting. All subrecipient awards are required to be completed by December 2024.

Condition: The Organization did not clearly communicate the required federal award information and applicable requirements to the subrecipients. The Organization did not evaluate the risk of non-compliance of the subrecipients in order to identify the appropriate monitoring procedures. Statistical sampling was not used in making sample selections. Response: The Organizations’ Board and Chief Executive OGicer (CEO) and key HCEDC StaG recognize the need to further refine subrecipient monitoring. Subrecipients within the identified project are all school districts already under single audit with associated levels of financial controls and reporting. Participating districts, via their appropriate elected boards, were informed the conditions of the grant and individually voted to accept obligations and requirements. Some subrecipients in Fall 2023 did attempt to submit unauthorized expenses, the controls were adequate for management to identify these discrepancies, which were in turn not submitted for reimbursement to the state, and appropriate amendments were made prior to any expense being reimbursed. HCEDC management, in alignment with outsourced controller services via CliftonLarsonAllen LLP, have now further increased controls and monitoring activity. Through the onboarding of a new Grants Management System (GMS) in Fall 2024, subrecipient monitoring activity and profiles are now created for each eligible award. In 2024, the HCEDC has also been much more active in communicating reporting and grants management requirements to subrecipients, including multiple amendments to the ESSER grant program. The new GMS system is built specifically to assist organizations with single audit compliance and has multiple features specific to subrecipient reporting and monitoring.

In 2024, the Corporation implemented a process to obtain single audit affirmation letters annually from subrecipients, if applicable, and confirm as per current understanding and discussions with subreceipients during due diligence process that their funding from US federal government sources during the agreement period will not exceed $750,000 annually. These steps will ensure proper subrecipient monitoring in alignment with federal regulations.

Before we can enter into any agreement, Program and Fiscal will thoroughly review all grant agreements and develop a check list based on the grant requirements. • Both Fiscal and Program read through the grant agreement thoroughly to come up with a plan for all information required to obtain from Sub-recipients getting more than 30k o As of right now those are  FFATA  Single Audit Evaluation  Any Additional Subrecipient issues • When program is developing a scope with the organization we would send them a check list mutually agreed upon based on the fiscal and program review of requirements the subrecipient must adhere to along with any required forms o Collect FFATA  Program Uploads and tracks o Collect Single Audit if eligible  Fiscal reviews and brings attention to any subrecipient issues with program o Additional items for review as it pertains to sub recipient will be assigned as they arise

Before ACHD can enter into any agreement, Program and Fiscal will thoroughly review all grant agreements and develop a check list based on the grant requirements. • Both Fiscal and Program read through the grant agreement thoroughly to come up with a plan for all information required to obtain from Sub-recipients getting more than 30k o As of right now those are  FFATA  Single Audit Evaluation  Any Additional Subrecipient issues • When program is developing a scope with the organization we would send them a check list mutually agreed upon based on the fiscal and program review of requirements the subrecipient must adhere to along with any required forms o Collect FFATA  Program Uploads and tracks o Collect Single Audit if eligible  Fiscal reviews and brings attention to any subrecipient issues with program o Additional items for review as it pertains to sub recipient will be assigned as they arise

Condition and Context: ACT noted that it did not request and review audited financial statements for all subrecipients. Recommendation: ACT evaluates the policies and procedures to ensure appropriate monitoring is performed over all subrecipients and reviews audited financial statements for those subrecipients that are required to have an audit performed. Views of Responsible Officials and Planned Corrective Action: ACT accepts the auditors’ recommendation. We will review and update the monitoring policies and procedures to include requesting and reviewing the audited financial statements for those subrecipients that are required to have an audit performed.

All three of the subawards selected for testing, the recipient’s UEI number was missing from the subaward. Recommendation: ACT evaluates policies and procedures to ensure all required information is communicated with the subrecipient. Views of Responsible Officials and Planned Corrective Action: ACT accepts the auditors’ recommendation. We will review and update policies and procedures to ensure all required information is included in subaward agreements and communicated to subrecipients, including the recipient’s UEI numbe

Responsible: Denice Hairston, Chief Quality, Compliance and Accountability Officer Corrective Actions: Maintain the updated subrecipient award agreements to ensure the final approved scope of work and project description are specified. Completion Date: March 29, 2023 Explanation: Policies and procedures were updated in 2023 in response to an OJJDP/OCFO recommendation to ensure subaward files contain the requisite components for the award agreement. In addition to these updates, which include a master file checklist, National CASA/GAL has updated the subrecipient Terms & Conditions agreement to include CFR requirements as recommended. This finding was noted in the 2022 audit which was issued August 13, 2024. The 2023 audit, completed in September 2024, included in its scope, similar subrecipient awards from the same federal grant that had been reviewed in the 2022 audit and OJJDP/OCFO monitoring visit. National CASA/GAL did not have an opportunity between the 2022 and 2023 audits to cure this finding in practice until the issuance of new subrecipient awards in 2024.

Significant Deficiency in Internal Control and Compliance over Major Programs Funding Agency: Department of Defense ALN: 12.002 Recommendation: JSP recommends that the Organization includes all required elements in the subrecipient contracts. We also recommend that the organization reviews subrecipient's financial records and documentation for program expenses, prior to reimbursing the subrecipient with federal funds. There is no disagreement with the audit finding. Action planned in response to finding: An amendment to the subrecipient contracts ending March 31, 2025 shall be implemented to include language from the referenced CFR citations to reflect (1) the requirement of proper documentation of allowable expenditures attached to payment requests (2) the subrecipient permits the pass-through entity and auditors to have access to the subrecipient’s records and financial statements as necessary and (3) the closeout terms and conditions of the subaward. Names of the contact person(s) responsible for corrective action: Michael Cade (EDC Executive Director), Heidi McCutcheon (EDC Deputy Director), and Tiffany Scroggs (EDC APEX Accelerator State Director). Planned completion date for corrective action plan: September 30, 2024

2023-001 Conservation Research and Development Program – Assistance Listing #81.086 Recommendation: The Organization should establish written policies and procedures regarding the contracting and monitoring of subrecipients that are in line with Uniform Guidance requirements, as well as establish organizational controls to ensure that such policies and procedures are being followed. Explanation of disagreement with audit findings: there is no disagreement with the audit findings. Action Plan: We agree with the auditor’s comments and will implement the following action steps to improve the situation. We will create and document a procedure which ensures we obtain audits on an annual basis from our subrecipients. This procedure will be implemented by October 31, 2024. Name(s) of the contact people responsible for correction action: Gina Avalos-Limardo, Director of Finance & Operations and Cho Heide, Contracts & Compliance Manager Plan completion date for corrective action plan: October 31, 2024