Corrective Action Plans

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

NEED FROM CLIENT…...

President and operations team will carefully review each contract to ensure that all subaward contracts are prepared with all of the required information. Anticipated Completion Date: June 30, 2024. Responsible Contact Party: Martine Miller, President

Finding 2023-006-Subrecipient Monitoring Recommendation: We recommend implementation of procedures to formally document and complete a risk assessment of subrecipients. Based on the risk assessment performed, the City should develop monitoring procedures to address the risks noted, which should include a documented review of subrecipient audits and deficiencies to be followed up on, if applicable. Action Taken: The City will develop and implement procedures to perform formal risk assessments of all subrecipients. The City will also implement procedures and processes to ensure that subrecipients are monitored throughout the duration of their grant cycle. Audit documents will be obtained annually and reviewed. Concerns will be noted, and formal follow-up will be conducted by the Grants team. The target implementation date is March 30, 2025.

CONDITION: The Regional Office of Education No. 39 did not have adequate controls over subrecipient monitoring in compliance with the Code. PLAN: The ROE drafted subrecipient monitoring policies and procedures for FY24 after receiving the FY22 audit finding December 2023. Policies and procedures will include required reporting, monitoring, and award notification for the subrecipients of the ARP- Social Emotional Learning grant. ANTICIPATED DATE OF COMPLETION: Implemented April 2024 CONTACT PERSON: Jill Reedy, Regional Superintendent

Reference Number: 2023-002 Prior Year Finding: Yes, 2022-023 Federal Agency: U.S. Department of Labor Department Name: Mississippi Department of Employment Security Federal Program: WIOA Cluster Assistance Listing Number: 17.258, 17.259, 17.278 Award Number and Year: 7/1/22 – 6/30/23 Compliance Requirement: Subrecipient Monitoring Type of Finding: Material Weakness in Internal Control over Compliance, Material Noncompliance Criteria or specific requirement: Compliance – Per 2 CFR section 200.332(a), all pass-through entities must ensure that every subaward is clearly identified to the subrecipient as a subaward and includes information at the time of the subaward and if any of these data elements change, include the changes in subsequent subaward modification. When some of this information is not available, the pass-through entity must provide the best information available to describe the Federal award and subaward. 2 CFR section 200.332 also states that pass-through entities must: (d) Evaluate each subrecipient's risk of noncompliance with Federal statutes, regulations, and the terms and conditions of the subaward for purposes of determining the appropriate subrecipient monitoring described in paragraphs (d) and (e) of this section, which may include consideration of such factors as: 1) The subrecipient's prior experience with the same or similar subawards; 2) The results of previous audits including whether or not the subrecipient receives a Single Audit in accordance with Subpart F - Audit Requirements of this part, and the extent to which the same or similar subaward has been audited as a major program; 3) Whether the subrecipient has new personnel or new or substantially changed systems; 4) The extent and results of Federal awarding agency monitoring (e.g., if the subrecipient also receives Federal awards directly from a Federal awarding agency). (e) Monitor the activities of the subrecipient as necessary to ensure that the subaward is used for authorized purposes, in compliance with Federal statutes, regulations, and the terms and conditions of the subaward; and that subaward performance goals are achieved. Pass-through entity monitoring of the subrecipient must include: (1) Reviewing financial and performance reports required by the pass-through entity. (2) Following-up and ensuring that the subrecipient takes timely and appropriate action on all deficiencies pertaining to the Federal award provided to the subrecipient from the pass-through entity detected through audits, on-site reviews, and other means. (3) Issuing a management decision for audit findings pertaining to the Federal award provided to the subrecipient from the pass-through entity as required by § 200.521 Management decision. (f) Verify that every subrecipient is audited as required by Subpart F - Audit Requirements of this part when it is expected that the subrecipient's Federal awards expended during the respective fiscal year equaled or exceeded the threshold set forth in § 200.501 Audit requirements. Control – Per 2 CFR section 200.303(a), a non-Federal entity must: Establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States or the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). Condition: The Mississippi Department of Employment Security (MDES) was unable to provide documentation of subaward agreements and monitoring activities performed. Context: Six subrecipients were selected for testing and the following exceptions were noted:  1 of 6 subawards was not available for audit. Auditors were unable to verify if the subaward contained all required information nor if it was reviewed and approved by appropriate program staff prior to issuance.  For 3 of 6 subrecipients, MDES was unable to provide documentation that it performed monitoring activities nor that it ensured the subrecipients were audited as required by Subpart F. Questioned costs: Undetermined. Cause: Internal controls were not sufficient to ensure that copies of subaward agreements were maintained and available for audit, nor that it maintained documentation of subrecipient monitoring activities performed. Effect: Auditors were unable to verify that subawards were issued in accordance with Federal requirements nor that the subrecipients had been adequately monitored and were audited as required by Subpart F. Recommendation: MDES should review and enhance internal controls and procedures to ensure that it maintains copies of all subaward agreements, that proper subrecipient monitoring is conducted, and that evaluation of independent audits is performed for all subrecipients. Copies of subawards and documentation of subrecipient monitoring activities should be readily available for audit. Views of responsible officials: MDES Response MDES concurs with this finding. Corrective Action Plan: a. MDES Plan: MDES will establish a checklist to verify receipt of the documents responsive to this compliance requirement. Using the checklist, MDES will ensure that all documents indicated in this finding will be readily available for the auditors as early as possible in the audit process. Additionally, MDES will develop a timeline and plan for the submission of documentation to ensure timely review. b. Contact Person Responsible: Director of Grant Management. c. Anticipated Corrective Action Plan Completion Date: July 31, 2024.

2023-004 Federal Award Subrecipient Monitoring – Material Non-Compliance and Material Weakness in Internal Control over Compliance 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. Action Taken: Management concurs with the finding and has defined corrective action to address it. Staff have reviewed policies and procedures already in place to ensure compliance of subrecipient monitoring. The Fiscal department has subsequently conducted a fiscal desk review of the subrecipient in question for FY 22/23 and no findings were found. Standard Operating Processes were updated to ensure all subrecipients are fiscally monitored based on the Risk Assessment Determination level. The above identified corrective action was implemented in July 2024. Stacey Wilson, Fiscal Director, has implemented a monitoring calendar for fiscal and Program Director’s will be responsible for ensuring subrecipients are monitored.

U.S. Department of Health and Human Services, passed through Kansas Department of Aging Aging Cluster – ALN 93.044 - Special Programs for the Aging_Title III, Part B_Grants for Supportive Services and Senior Centers - 2301KSOASS ALN 93.045 – Special Programs for the Aging_Title III, Part C_Nutrition Services – 2301KSOAHD Management’s Response: The Aging Department will begin performing risk assessments in January 2025 for all subrecipients. All subrecipients will be required to submit monthly reports as well, which will be evaluated by the Aging Department staff to ensure compliance. Additionally, our current system includes a once-a-year compliance checklist with our subgrantee and is being updated for use in first quarter of 2025. Views of Responsible Officials and Corrective Action: The reason for recurrence is the finding was communicated late in the prior year and due to transition and turnover within the department's staff. Management will ensure this is addressed by December 31, 2025. Responsible Official: Dr. Shelley Kneuvean Chief Financial Officer Unified Government of Wyandotte County & Kansas City KS

The Agency agrees with the finding. When granting funds as a subaward to a pass-through entity, the Agency will update its master templates for subawards to include the required information. In addition, when the sub agreements are routed for signature and reviewed by the Chief Financial Officer, they will be double-checked to ensure compliance with this requirement.

The Agency agrees with the finding. When granting funds as a subaward to a pass-through entity, the Agency will update its master templates for subawards to include the required information. In addition, when the sub agreements are routed for signature and reviewed by the Chief Financial Officer, they will be double-checked to ensure compliance with this requirement.

The Agency agrees with the finding. When granting funds as a subaward to a pass-through entity, the Agency will update its master templates for subawards to include the required information. In addition, when the sub agreements are routed for signature and reviewed by the Chief Financial Officer, they will be double-checked to ensure compliance with this requirement.

Assistance listing numbers and program names: 84.010 Title I Grants to Local Educational Agencies 84.367 Supporting Effective Instruction State Grants (formerly Improving Teacher Quality State Grants) Agency: Arizona Department of Education (ADE) Name of contact person and title: Dr. Sarka White, ADE Deputy Associate Superintendent Anticipated completion date: December 15, 2024 Agency’s response: Concur The Arizona Department of Education (ADE) has already begun implementing a program to ensure accurate and quality programmatic monitoring for all ESEA programs which specifically requires LEAs to meet 100% of the requirements of all statutorily required items to be monitored regardless of CMO affiliation. This development of programmatic monitoring will design a system of integrity to allow each LEA to have unique monitoring findings and ensure they are treated as all other LEAs regardless of management status. The Arizona Department of Education (ADE) is finalizing all program policies and procedures along with field training and staff training on how this program is implemented. ADE began providing an assurance document to charters in May 2024 which asks the charters to assure that if they do business with a CMO, the CMO does not have fiscal or operational authority for the LEA. The charter is asked to submit to ADE a copy of their organizational chart, along with the assurances document. Grants Management has created a new user role in the Grants Management Enterprise (GME) system, called the LEA Contracted Update role. This role allows a CMO person the access to perform fiscal tasks for which they have been contracted but does not hold the final submit or approve capacity, that must be reserved for authorized employees of the LEA. Grants Management has provided the placeholder for the assurance and organizational chart in the LEA Document Library, along with the communication to eligible entities (charters in this case). Individual program areas within ADE who review and approve funding applications will be responsible for verifying the assurances have been signed and uploaded and only authorized people at the LEA are actioning funding applications in GME prior to the program area giving director approval to the application.