Corrective Action Plans

Assistance listing number and program name: 21.027 COVID-19 - Coronavirus State and Local Fiscal Recovery Funds Agency: Arizona Department of Economic Security (DES) Name of contact person and title: Jim Whallon, DES Deputy CFO Anticipated completion date: June 30, 2026 Agency’s response: Concur The Department of Economic Security will address the audit recommendations as follows: 1. Perform required monitoring of its subrecipients and their compliance with the award terms and program requirements. The Department will revise its agency-wide policies and procedures related to single audit requirements for pass-through entities to include guidance regarding how to establish effective subrecipient monitoring procedures. The Department will also offer additional subrecipient monitoring guidance for programs administered by divisions with existing subrecipient monitoring findings. 2. Properly classify and report subrecipient expenditures on the State’s SEFA. The Department will revise its procedures related to single audit requirements to include steps detailing the instructions for classifying and reporting subrecipient expenditures on the State’s SEFA. The updated procedures will include actions needed to be taken to ensure each pass-through relationship is appropriately determined and that every subrecipient relationship is communicated to the staff responsible for compiling the State’s SEFA. 3. Develop, implement, and train all divisions on entity-wide written subrecipient-monitoring policies and procedures requiring all divisions to: a. Assess the risk of each subrecipient’s noncompliance and carry out monitoring activities based on those risk assessments such as reviewing financial and performance reports, providing training or technical assistance on program-related matters, and performing on-site reviews, selective audits, and/or other monitoring procedures. b. Verify subrecipients receive timely single audits, if required; follow up on and ensure that corrective action is taken on any audit findings that could potentially affect the program; and issue management decisions for any audit findings pertaining to the federal award. c. Maintain documentation of monitoring procedures demonstrating they were performed, including the monitoring procedures’ results and any Department actions taken, if appropriate. In addition to the revisions in policy and procedures outlined in Recommendation #1 above, the Department will train staff responsible for administering compliance requirements for pass-through entities. This training will include instructions to formulate a risk assessment, review controls related to compliance requirements, review timely single audit submittal, follow up on audit findings, issue management decisions for findings, and maintain adequate documentation of monitoring procedures. The training will be provided to all staff responsible for administering programs with pass-through entities. 4. Allocate sufficient resources, such as staffing, to comply with the award terms and program requirements, and designate individuals within each division to perform necessary subrecipient-monitoring procedures. The Department will conduct analyses to determine resources needed, including staffing, to ensure compliance with applicable requirements. For example, the Department will assess the efficiency of its subrecipient-monitoring procedures, estimate future workloads, determine staffing needed to meet those workloads, and assign sufficient staff the responsibility for ensuring compliance with each requirement outlined in the federal award. The Department will also ensure the staff responsible for administering the compliance requirements prioritize this responsibility and communicate anticipated compliance deficiencies to management. 5. Update the form it uses to determine whether other parties receiving program monies have the role of a subrecipient or contractor to include guidance for how to determine each characteristic of a subrecipient and contractor relationship and require a conclusion to be documented. In addition, train staff to properly complete the form and perform supervisory reviews of it. The Department will revise its Contractor/Subrecipient Determination form to clearly identify the final determination of a pass-through entity. The Department will also provide guidance to accompany the form that shows how to determine each characteristic of a subrecipient and contractor as well as how to make the final determination regarding the contractor versus subrecipient relationship. The Department will then provide training to staff responsible for using this form as part of the training outlined in Recommendation #3 above.

Assistance listing numbers and program names: 21.027 COVID-19 - Coronavirus State and Local Fiscal Recovery Funds 84.425C COVID-19 Education Stabilization Fund –Governor’s Emergency Education Relief (GEER) Fund Agency: Arizona Governor’s Office of Strategic Planning and Budgeting (Office) Name of contact person and title: Sarah Brown, Director Anticipated completion date: July 31, 2025 Agency’s response: Concur During fiscal year 2024, the Office took significant corrective action to improve subrecipient monitoring by developing and implementing a comprehensive subrecipient monitoring plan. This plan includes the following: • Financial Report-Reimbursement Requests—The Office reviews the grantee's financial reports to ensure costs align with the approved budget, program objectives, and federal cost principles. • Performance Reports—The Office reviews the submission of programmatic reports. The timelines for submission and frequency of the programmatic activity reports are defined in the terms and conditions of each award. The program activity reports document that all program requirements are being satisfactorily fulfilled. Grantee outreach is conducted when performance activity is lagging. Grantee check-ins and/or additional milestones are set to ensure goals are met. The Office may amend or terminate the grant award if sufficient progress is lacking. • Single Audit Reports—The Office confirms any required Single Audits and reviews a copy of the most recent report. • A Single Audit Questionnaire is distributed to grantees annually to confirm if the entity is subject to this federal audit requirement. • The Office also reviews total payments issued to an entity by the Office in the prior year to confirm if disbursements met the audit threshold. • The Office requests grantees submit their Single Audit Reporting Package (SARP) with any findings and the required Corrective Action Plan. In addition, the Office collects SARPs from the federal clearinghouse. • The Office reviews SARPs for any findings and conducts follow-up monitoring of CAPs that impact any grant funding managed by the Office. Management decisions are issued to grantees as required for specific grant findings. • Risk Assessment (RA)—The Office conducts a Risk Assessment (RA) of grantees when applying for grants to inform the grant award decision and possible grantee oversight or restrictions. Additionally, the Office conducts an annual RA of any grantee currently awarded funding. • The RA contains a self-assessment for the grantee to complete and an internal review conducted by the Office. Scores from both are weighted and used to calculate the overall risk score for each grantee as high, medium, and low risk. • The Office utilizes the RA results to prioritize high-risk grantees, which are reviewed through a desk or on-site monitoring. Medium-risk grantees will receive additional support and be referred to our Compliance and Reporting team for further review if additional concerns arise. Office staff now attend ongoing internal and external training to improve their understanding of compliance requirements, identify noncompliance, and actively reduce the risks of waste, fraud, and abuse of federal dollars through our subrecipient monitoring process. The Office has developed and implemented processes for requirements such as single audit review and corrective action follow-up, risk assessment, and subrecipient monitoring to address the specific findings. During the time frame corresponding to this audit finding, the pace and volume of grants management administrative duties required to be executed exceeded staffing capacity, contributing to the findings noted. As of this date, the Office has achieved stability in both manager and staff positions. In addition, the Office has allocated sufficient resources to comply with the award terms and program requirements by establishing a Grants Compliance and Reporting Team dedicated to performing necessary subrecipient monitoring procedures. Furthermore, the Office has implemented all recommendations and would like to specifically highlight efforts to work with subrecipients to resolve the potential disallowed costs of $1,903,858 of program monies that may have been spent in violation of its federal award terms by conducting on-site monitoring visits, desk reviews, and facilitating subrecipient technical assistance. OSPB is committed to continuing these efforts.

Assistance listing number and program name: 14.267 Continuum of Care Program Agency: Arizona Department of Housing (DOH) Name of contact person and title: Keon Montgomery, DOH Assistant Deputy Director of Programs Anticipated completion date: January 30, 2025 Agency’s Response: Concur The Department resumed monitoring duties and developed a monitoring schedule to ensure subrecipients maintain program compliance. The Department also established a risk assessment tool that assess risk associated with each subrecipient. Records of subrecipient monitoring will be kept for a period of time to demonstrate monitoring activities were performed.

Assistance listing number and program name: 14.267 Continuum of Care Program Agency: Arizona Department of Housing (DOH) Name of contact person and title: Keon Montgomery, DOH Assistant Deputy Director of Programs Anticipated completion date: January 30, 2025 Agency’s Response: Concur The Department is no longer reimbursing the subrecipient for unsupported or ineligible costs and is pursuing repayment of funds from the subrecipient. Written policies for reviewing and approving subrecipient reimbursements, as well as, risk assessment were reviewed, updated and amended to ensure ongoing compliance. Staff has been trained and new policies were implemented in FY 2024 subsequent to the period reviewed in this audit. Contract Specialists in the Special Needs Division have received additional training through HUD TA support on CoC standards to ensure all request for reimbursement from subrecipients are eligible, reasonable and appropriately documented, including any allocations and purchasing requirements.

Assistance listing numbers and program names: 14.231 Emergency Solutions Grant Program 14.231 COVID-19 - Emergency Solutions Grant Program 93.558 Temporary Assistance for Needy Families 93.558 COVID-19-Temporary Assistance for Needy Families Agency: Arizona Department of Economic Security (DES) Name of contact person and title: Molly Bright, DES CCSD Assistant Director Anticipated completion date: June 30, 2025 Agency’s Response: Concur The Department will stop the reimbursement of costs to all nonprofit and contracted subrecipients for items that are disallowed and/or restricted by the regulations of the federal Emergency Solutions Grant (ESG) program and Temporary Assistance for Needy Families (TANF) grant, including payments to personnel that violate the conflict-of-interest disclosure requirements. The Department will revise its expenditure review procedures to ensure compliance with these regulations prior to disbursing any ESG and/or TANF funding to any subrecipient for any purpose. These revisions will include review and approval by applicable management personnel prior to disbursement of federal funding. The Department is also in the process of establishing a divisional Monitoring and Compliance Policy and Procedure Manual which will establish procedures specific to subrecipient monitoring. The Department will continue to assess the risk of noncompliance violations for each subrecipient and establish a plan of action to address noncompliance. The plan of action will include an array of training and educational processes to ensure applicable personnel are knowledgeable of programmatic compliance requirements and Department contracts. The Department will also monitor subrecipients per its updated policies and procedures and will ensure proper oversight of federal expenditures as required by federal regulations. The Department has amended its contracts with the applicable subrecipients to more clearly outline the regulatory requirements and expectations for expenditures under the ESG and TANF grants. The Department will also continue to resolve the unallowable costs reimbursed to subrecipients as deemed appropriate by the applicable federal agencies.

Auditor’s Recommendation: Procedures for subrecipient monitoring to meet federal statutes, regulations, and terms and conditions of the awards should be developed and documented. Internal controls should be designed, implemented, and documented within the subrecipient monitoring procedures to ensure compliance with 2 CFR section 200.332. Subrecipient monitoring activities should be performed and documented. Corrective Action: Implement Policy A10 – “Grant Management Protocols.” Utilize Donor Database for managing subawards. Responsible for Corrective Action: Finance Team (Outsourced accounting firm, Operations Manager, Executive Director) Anticipated Completion Date: December 31 2024

Auditor’s Recommendation: Internal controls over compliance for allowable activities and cost principles should be documented and design and document procedures over allowable cost principles. Corrective Action: Implement new software (bill.com) for processing accounts payable and receivable. Responsible for Corrective Action: Finance Team (Outsourced accounting firm, Operations Manager, Executive Director) Anticipated Completion Date: Completed as of September 2024

COVID-19 Coronavirus State and Local Fiscal Recovery Funds (SLFRF) – Assistance Listing No. 21.027 Recommendation: CLA recommends 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. This process was started in 2024 as part of the 2022 Corrective Action plan and many of the subrecipients were in compliance for 2023. Due to a change in personnel early in 2024 this was not followed up on until later in the year. Name of the contact person responsible for corrective action: Sherri Crow, Director of Budget and Finance Planned completion date for corrective action plan: December 1, 2024

Subrecipient Monitoring Name of Contact Person: Tamara Colden, Assistant Director Housing and Community Services Department Corrective Action: The Subrecipient Monitoring policy and procedures were updated in August 2022 to include the procedures for evaluating risk for subrecipients and revise monitoring procedures. These procedures were updated to include checking the Federal Awards clearinghouse annually to assess audit requirements for all subrecipients and ensure the monitoring policy includes procedures when those audits result in any concerns or findings for subrecipients. A revised risk assessment will be conducted for each subrecipient. A new subrecipient monitoring policy was implemented in March 2023 to address this finding and staff has followed this policy since that time and will continue to do so. Proposed Completion Date: 06/30/2023

The Alliance team will enhance its procedures to execute subaward agreements in advance of awarding funds.

The Alliance will implement internal controls and administrative oversight to ensure subrecipient monitoring requirements are being followed and adequately documented.

U.S. Department of Health and Human Services AL No. 93.940 HIV Prevention Activities Health Department Based Material Weakness in Internal Controls and Noncompliance over Subrecipient Monitoring Repeat Finding: No Auditee’s Corrective Action Plan: BCHD has updated its subrecipient monitoring policy to ensure compliance with Federal standards for monitoring of subawards. BCHD will use the contract unit’s internal contract tracker via Smartsheet to develop the subrecipient monitoring schedule. The contract tracker now includes a column to identify if an agreement is a subaward, which will ensure all subrecipients are included in the monitoring schedule. Contact Person: Chief Financial Officer – Unyime Ekpa Completion Date: December 2024

U.S. Department of Health and Human Services AL No. 93.914 HIV Emergency Relief Project Grants Material Weakness in Internal Controls and Noncompliance over Subrecipient Monitoring Repeat Finding: No Auditee’s Corrective Action Plan: BCHD has updated its subrecipient monitoring policy to ensure compliance with Federal standards for monitoring of subawards. BCHD will use the contract unit’s internal contract tracker via Smartsheet to develop the subrecipient monitoring schedule. The contract tracker now includes a column to identify if an agreement is a subaward, which will ensure all subrecipients are included in the monitoring schedule. Contact Person: Chief Financial Officer – Unyime Ekpa Completion Date: December 31, 2024

U.S. Department of Health and Human Services AL No. 93.686 Ending the HIV Epidemic: A Plan for America Material Weakness in Internal Controls and Noncompliance over Subrecipient Monitoring Repeat Finding: No Auditee’s Corrective Action Plan: BCHD has updated its subrecipient monitoring policy to ensure compliance with Federal standards for monitoring of subawards. BCHD will use the contract unit’s internal contract tracker via Smartsheet to develop the subrecipient monitoring schedule. The contract tracker now includes a column to identify if an agreement is a subaward, which will ensure all subrecipients are included in the monitoring schedule. Contact Person: Chief Financial Officer – Unyime Ekpa Completion Date: December 2024

S. Department of Housing and Urban Development (HUD) AL No. 14.241 Housing Opportunities for Persons with AIDS Material Weakness in Internal Controls and Noncompliance over Subrecipient Monitoring Repeat Finding: Yes Auditee’s Corrective Action Plan: Condition #1 Response MOHS acknowledges the finding that 3 out of 3 subrecipient files did not disclose the federal award identification number of unique entity identifier on the sub award. Corrective Action: MOHS will follow the City’s Grant Management office’s established process of establishing and maintaining a hardcopy audit file. This file will include: a. Federal System Registrations: SAM; DUNS #s, Grants.gov information; b. Federal Financial Accountability and Transparency (FFATA) information; c. FFR Submissions (SF-425 Federal Financial Report); d. Grant Agreements; and, e. Prior Year Single Audits/Monitoring Reports Condition #1 Response MOHS acknowledges the finding that 3 out of 3 subrecipient files did not have evidence that prior year audit was verified. Corrective Action: MOHS will follow the City’s Grant Management office’s established process of establishing and maintaining a hardcopy audit file. This file will include: a. Federal System Registrations: SAM; DUNS #s, Grants.gov information; b. Federal Financial Accountability and Transparency (FFATA) information; c. FFR Submissions (SF-425 Federal Financial Report); d. Grant Agreements; and, e. Prior Year Single Audits/Monitoring Reports Contact Person: Lakeysha Williams – 410-396-4887 or Lakeysha.williams@baltimorecity.gov Completion Date: July 2024

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.