Corrective Action Plans

FISCAL YEAR OF FINDING: 2023 AUDITOR FINDING: 1. At the time of the award – County did not make subrecipients aware of Federal Assistance Listing Number or title. 2. Risk Assessment could not be provided for 2022 or 2023 to support the level of monitoring. 3. Audited financials for family tree for 2022 or 2023 were not obtained by the County. 4. Family Tree did not have any case review monitoring performed during 2023 – October 15, 2022. Criteria: Condition: During testing, we noted the following: - The Assistance Listings number and Title were not provided to the County's two subrecipients in accordance with 2 CFR Part 200.332(a) - The County did not have a formal documented risk assessment completed for either of the County's two subrecipients in accordance with 2 CFR Part 200.332(b) - The County did not obtain or review one of the subrecipients single audit reports in accordance with 2 CFR Part 200.332(f) Effect: The subrecipient may be unaware whether the funds are federal or what compliance requirements they are responsible for. In addition, The County may not perform the adequate level of monitoring as formal risk assessments were not completed. Finaly, the County did not review the single audit report and while any finding would not directly be related to the subaward program, failure to review such reports and take appropriate action could result in non-compliance by the subrecipient continuing for an inappropriate length of time. Cause: The County does not have adequate internal controls over subrecipient monitoring to ensure that the County is in compliance with subrecipient monitoring requirements. Recommendation: We recommend that the County develop a risk assessment template or form to be completed over each federal subrecipient. The County should provide training to those administering grants over the development risk assessment template or form and the associated monitoring to be performed based on each assessed risk. In addition, the County should develop a subrecipient grant template to help ensure all required information is included within each award. Finally, the County should establish a policy or procedure over obtaining and reviewing audits completed over each of their subrecipients. CLIENT PLANNED ACTION: 1. On 4/8/24, Jefferson County sent the two ERA subrecipients the Federal Assistance Listing Number. The County policy is to include the Subaward Data Form, which includes the Federal Assistance Listing Number (see attached), as an Exhibit in all subrecipient contracts. This was inadvertently not included in the ERA contract. 2. On 4/8/24, Jefferson County completed a formal Risk Assessments for both The Action Center and Family Tree and placed in the files. The two subrecipients are long-time partners and federal fund recipients and have undergone continuous scrutiny through regular monitoring, and a rigorous draw reimbursement process. Due to this history and knowledge, both partners were determined to be very low risk at the time of ERA awards. Moving forward, the County will complete a formal Risk Assessment for the records prior to the execution of a contract or within 6 months of execution of a contract. 3. The County has now collected the audited financial statements for the two subrecipients and retained them in the files. Subrecipient audits are regularly reviewed as part of the monitoring process to assess for any findings or concerns. Moving forward, the County will obtain the most recent audit reports and place them in the files prior to the execution of a contract or within 6 months of execution of a contract. 4. The County performed a monitoring including the scrutiny of 20% of all case files during the 2022 ERA Program and there were no findings. The County had plans to monitor the ERA2 Program at the time of this audit, after the program was running at full capacity. The County has now moved up this time frame according to the above feedback and is currently undergoing a monitoring of the 2023 cases from the two subrecipients. This process aligns with the previous year, as the program has more time during the early spring months when cases are slower. Monitoring of subrecipients began the week of April 8th. CLIENT RESPONSIBLE PARTY: Kat Douglas, Community and Workforce Development Director COMPLETION DATE: 6/25/24

Sandra Dalida, CFO September 30, 2024 AL# 2 1.027 - Coronavirus State and Local Recovery Funds; 2023 Pursuant to CFR Section 200.332(b), pass-through ent1t1es must evaluate each subrecipient's risk of noncompliance with Federal statutes, regulations, and the tenns and conditions of the subaward for purposes of determining the appropriate subrecipient monitoring. The Unity Council did not perform a risk assessment of subrecipients. Management is in agreement with the finding and is in the process of developing and documenting a risk assessment process. Chief Financial Officer, Sandra Dalida Chief Operating Officer Chief Program Officer September 30, 2024

Views of Responsible Officials and Planned Corrective Actions: AL has a long-standing preassessment Questionnaire (sample attached) that we require each potential subgrantee to complete before they can receive any financial remuneration from us. In response to this finding, we will require all subgrantees to complete this questionnaire on an annual basis. In addition we have included the following questions to the questionnaire:  Does the organization perform an annual audit of financial statements?  Annual amount of US Government Funds received?  Is the organization subject to a US compliance audit under 2 CFR 200 Subpart F?  If the organization is subject to a compliance audit under 2 CFR 200 Subpart F, please provide a copy of your most recent 2 CFR 200 Subpart F audit report. Anticipated Completion Date: We will submit the questionnaire to all subgrantees during the month of June 2024 and then perform it annually. Responsible Officials: Chief Innovation and Operations Officer and Finance Manager.

EXECUTIVE OFFICE OF HOUSING AND LIVABLE COMMUNITIES 2023-028 Low-Income Home Energy Assistance, COVID-19 – Low-Income Home Energy Assistance - Assistance Listing No. 93.568 Action taken in response to the finding: The Executive Office of Housing and Livable Communities (EOHLC), which was formerly the Department of Housing and Community Development (DHCD or Department), has implemented the recommended measures and will continue them going forward. EOHLC has reviewed their internal controls and procedures and is committed to making any enhancements that are necessary to ensure that required information is included in its subawards. EOHLC notes that the Federal Award Identification Number (FAIN) and the Federal Award Date are included in the HHS award notices and other HHS guidance, which EOHLC incorporates by reference into its LIHEAP subaward contracts with its subrecipients. In an effort to ensure compliance with these requirements going forward, EOHLC will include a direct reference to the FAIN and the Federal Award Date in its LIHEAP subaward contracts with its subrecipients beginning with its FFY 2025 LIHEAP contracts. Name of the contact person responsible for corrective action: Edward Kiely Planned completion date for corrective action plan: October 1, 2024

DEPARTMENT OF PUBLIC HEALTH 2023-025 Refugee and Entrant Assistance State Administered Programs (Refugee), Opioid-STR Block Grants for Prevention and Treatment of Substance Abuse, COVID-19 - Block Grants for Prevention and Treatment of Substance Abuse (SABG) - Assistance Listing No. 93.566, 93.788, 93.959 Action taken in response to the finding: DPH will continue to automatically generate a subrecipient notification whenever federal funding amounts change. However, because FAIN# and grant award date information is not currently available through our automated systems, we will require bureaus to include a contract attachment that includes this information. The state’s current accounting system is being replaced by a new system, with improved grant functionalities. If the FAIN# and grant award information is available through this system, DPH will be able to add these data to our automatically generated subrecipient notification in the future. Name of the contact person responsible for corrective action: Sharon Dyer, Director Purchase of Service Office Planned completion date for corrective action plan: September 30, 2024

OFFICE FOR REFUGEES AND IMMIGRANTS 2023-024 Refugee and Entrant Assistance State Administered Programs - Assistance Listing No. 93.566 Action taken in response to the finding: ORI will provide the Federal Award Identification Number (FAIN) to the subrecipient in the contract document. ORI will update internal controls and procedures to confirm FAIN number is included in contract documents going forward. Name of the contact person responsible for corrective action: Kelvin Pham Planned completion date for corrective action plan: July 1, 2024

EXECUTIVE OFFICE OF ELDER AFAIRS 2023-022 COVID-19 – Aging Cluster - Assistance Listing No. 93.044, 93.045, 93.053 Action taken in response to the finding: EOEA will review internal processes to ensure that all required information is included in all subaward agreements, including reviewing FFY25 and subsequent Title III subaward agreements to ensure that the required federal award information is present. Name of the contact person responsible for corrective action: Sheila Tunney, EOEA CFO Planned completion date for corrective action plan: EOEA will complete this corrective action plan for the re-issuance of FFY24 subawards following receipt of additional federal awards, anticipated for June/July 2024.

MASSACHUSETTS EXECTIVE OFFICE OF EDUCATION 2023-019 COVID-19 – Governor’s Emergency Education Relief (GEER) Fund - Assistance Listing No. 84.425C Action taken in response to the finding: EOE will review and enhance internal controls and procedures to ensure that all required information is included in all subawards including: RFQ postings and contracts. This documentation will be included in our updated internal control process which is underway as required by the Comptroller’s Office. Name of the contact person responsible for corrective action: Joanne Puopolo Planned completion date for corrective action plan: July 1, 2024

EXECUTIVE OFFICE OF HOUSING AND LIVABLE COMMUNITIES 2023-015 COVID-19 – Emergency Rental Assistance Program – Assistance Listing No. 21.023 Action taken in response to the finding: The Emergency Rental Assistance Program (ERA or ERAP) was a temporary program relating to the COVID-19 emergency which was administered by the Executive Office of Housing and Livable Communities (EOHLC), formerly the Department of Housing and Community Development (DHCD or Department). Most of the ERA contracts that are still in place will be ending as of 6/30/2024. In the event that EOHLC’s ERA contracts are extended or renewed before the performance period ends, EOHLC will amend the contracts to include a reference to the required information. EOHLC is committed to reviewing internal controls and procedures and making the enhancements that are necessary to ensure that required information is included in its subawards going forward. Name of the contact person responsible for corrective action: Henok Teffera Planned completion date for corrective action plan: July 1, 2024

EXECUTIVE OFFICE OF LABOR AND WORKFORCE DEVELOPMENT 2023-012 WIOA Cluster, Employment Service Cluster – Assistance Listing No. 17.258, 17.259, 17.278, 17.207, 17.801 Action taken in response to the finding: The corrective action plan (CAP) for this finding was implemented and completed in Fiscal Year 2023 with the addition of the FAIN numbers to the subawards and the completion of FY23 CommCorp monitoring. MDCS continues to include FAIN as part of the revised documented process and monitoring is current and timely performed. MDCS therefore considers this item to be completed and closed. Name of the contact person responsible for corrective action: Michael Williams, Director of Field management and Oversight Planned completion date for corrective action plan: December 31, 2022

DEPARTMENT OF ELEMENTARY AND SECONDARY EDUCATION 2023-005 Child and Adult Care Food Program – Assistance Listing No. 10.558 Action taken in response to the finding: The Office for Food and Nutrition Programs (FNP) has moved from a paper based permanent agreement to a web form that exists on the DESE Security Portal. All existing and new Child Nutrition Sponsors will continue to sign off on the document via the web-based portal allowing for a more efficient collection and document retention process. A change will be made in the portal to automatically apply a DESE signature upon submission of the permanent agreement to avoid a late DESE signature. Name of the contact person responsible for corrective action: Rob Leshin, Director of FNP Planned completion date for corrective action plan: July 1, 2024

DEPARTMENT OF ELEMENTARY PUBLIC HEALTH 2023-004 WIC Special Supplemental Nutrition Program for Women, Infants, and Children – Assistance Listing No. 10.557 Action taken in response to the finding: DPH will continue to automatically generate a subrecipient notification whenever federal funding amounts change. However, because FAIN# and grant award date information is not currently available through our automated systems, we will require bureaus to include a contract attachment that includes this information. The state’s current accounting system is being replaced by a new system, with improved grant functionalities. If the FAIN# and grant award information is available through this system, DPH will be able to add these data to our automatically generated subrecipient notification in the future. Name of the contact person responsible for corrective action: Sharon Dyer, Director Purchase of Service Office Planned completion date for corrective action plan: September 30, 2024

FINDING 2023-002 Individuals Responsible for Corrective Action Plan: Romero Brown/Alliance staff Corrective Action: The Organization will properly monitor the subaward disbursed to provide reasonable assurance the subrecipient used the subaward for authorized purposes. Anticipated Completion Date: December 31, 2024

Views of Responsible Officials: The Organizations concur with the auditor's assessment and are in the process of implementing a pre-award risk assessment procedure.

Views of Responsible Officials: Management is aligned with these observations and notes that a Subaward Manual was finalized for use by the Prime (JGI-Tanzania) as of February 2024. The Manual addresses the auditor’s findings around subaward selection and monitoring policies. Preaward procedures were performed that signaled that the subrecipients were low risk. The Prime will retroactively document the pre-award risk assessment for the two subawards in 2023 and any future subaward. The Prime will perform monitoring procedures according to the assessed level of risk. Additionally, subawards will be assigned a Federal Assistance Listing Number as required by §200.332.

Finding 2023 – 006 CONDITION During the current audit period, the Cook County Department of Public Health (DPH) did not perform adequate monitoring of its subrecipients as required by Federal regulations. CORRECTIVE ACTIONS DPH will implement procedures to ensure that the subrecipient monitoring process is adequately documented to ensure financial monitoring is performed, the subrecipient’s risk of noncompliance is evaluated, and the process includes the review of single audit reports. Management Approval of the Policy and Tools have been shared with the auditors. Implementation Phase includes but will not be limited to 1) identifying designated personnel team/consultant, 2) training staff, and 3) monitoring plan to ensure that the policy is followed. Anticipated completion of the corrective action is estimated to be December 31, 2024. The corrective action will be coordinated by the Director of Grants Accounting.

Finding 2023 – 005 CONDITION During the current audit period, the Cook County Department of Public Health (DPH) did not adequately comply with its subrecipient monitoring requirements in accordance with federal regulations. CORRECTIVE ACTIONS DPH will implement prior corrective action plan for future subrecipients awarded with federal funds. The corrective measure will include adequately documenting financial monitoring and review of single audit reports. Management Approval of the Policy and Tools have been shared with the auditors. Implementation Phase includes but will not be limited to 1) identifying designated personnel team/consultant, 2) training staff, and 3) monitoring plan to ensure that the policy is followed. Anticipated completion of the corrective action is estimated to be December 31, 2024. The corrective action will be coordinated by the Director of Grants Accounting.

Corrective Action Plan – Subrecipient Risk Assessment Fiscal Year Ended September 30, 2023 Program name: Research and Development Audit Contact: Jennifer Kennedy Title: Director, Sponsored Programs Finance Telephone: 617-638-2852 E-mail address: Jennifer.Kennedy@bmc.org Audit Report Reference: 2023-003 Anticipated Completion Date: September 30, 2024 Corrective Action Planned: The primary cause of the identified issue was due to personnel changes within Sponsored Programs Administration (SPA). This turnover led to a gap in recording and establishing the subrecipient risk assessment process before finalizing subaward agreements. However, SPA reviewed subrecipient single audit reports prior to issuing subaward agreements. 1) Review of Risk Assessments for current active subawards: SPA will conduct a review of all current subrecipients and document a risk assessment for each by the end of FY24. All new active subawards beginning October 1, 2024, will follow the updated SOPs and policies to ensure compliance and consistency. 2) Updating SOPs: SPA will update the Standard Operating Procedures (SOPs) pertaining to Subaward Issuance (Risk Assessments, Monitoring, Reporting, etc.) to ensure continuity and consistency, regardless of personnel changes. The updated SOPs will include specific steps for subaward issuance and will be reviewed and updated annually as necessary. In addition to the above actions, SPA is in the process of opening a new role for a Subaward Specialist who will be a dedicated FTE for subaward management. The new employee will pair with the SPA Associate Director as they onboard. This role will oversee subrecipient risk assessments, subaward issuance, and FFATA reporting. A centralized role will allow for consistency and expertise on all subrecipient management pre-award and non-financial post-award processes. This role will contribute to maintaining and updating current SOPs pertaining to subaward management and monitoring. By implementing these measures, we are confident in our ability to manage personnel changes effectively and ensure that critical functions, such as subrecipient risk assessments, are carried out with the highest level of accuracy and compliance.

COVID-19 Coronavirus State and Local Fiscal Recovery Funds– Assistance Listing No. 21.027 Recommendation: The County should review and enhance internal controls and procedures to ensure that evaluation of independent audits is performed. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Division of Grants Management requires annual reports from all SLFRF subrecipients. We will be requesting a copy of all annual audits from the subrecipients for the most recent completed year. The accountant team will review audit reports for any findings of note. We recognize that some subrecipients will not have their most recent audit completed and will allow those who need extra time to submit their audits by the fall. Name(s) of the contact person(s) responsible for corrective action: Ashley Meyer Planned completion date for corrective action plan: 6/30/2024

Action Plan: Upon learning of this finding during the FY2022 audit, we worked with our external consultant, our Council auditors and our external auditor to reperform and review the base year and subsequent year calculations of revenue, using financial information in our final audit reports. These corrected calculations of lost revenue have been clearly documented and will be reported going forward. We will continue to work to ensure that all controls for grants be documented with written procedures. The procedures will include the title of the positions responsible for each control (preparation, review, reconciliation, etc.) and will require that the performance of the controls be documented in a clear, reperformable manner including the name of each responsible individual, the specific control they performed over compliance for the grant and the date(s) the controls were performed. Contact Names responsible for the plan – Marcia Saulo Anticipated completion date of the plan – September 30, 2024

The contracts between the Board and its subrecipients did not include all the required elements as prescribed by 2 CFR Section 200.332. Management Response: The Board has taken immediate corrective action. We have implemented templates for fiscal reporting and introduced comprehensive checklists for the contracts and procurement and finance departments. These measures are designed to ensure full compliance with 2 CFR Section 200.332 requirements and enhance our subrecipient source reporting protocols.

Reference Number: 2023-001 - Material Weakness, Subrecipient Monitoring Recommendation: We recommend· that the Board improve policies and procedures to ensure communication identifies available funding for program services provided in a timely and efficient manner to the program providers. Concerning monitoring its sub-recipients, policies and procedures should be enhanced to ensure that oversight of its sub-recipients is more frequent, timely, and responsive to findings. Management Response: In response to the identified material weakness regarding subrecipient monitoring, the Board has been placed on a Corrective Action Plan by the Texas Workforce Commission to address and rectify the issues. The key actions and improvements are as follows: 1. Implementation of New Dashboards and Projection Tools: Action Taken: The Board has developed and integrated advanced dashboards that provide real-time insights into programmatic decisions and their financial impacts. These tools facilitate continuous monitoring and alignment of the budget with program activities. Expected Outcome: Enhanced ability to manage budget variances promptly, ensuring that future expenditures are consistently within approved funding limits. 2. Strengthening Subrecipient Monitoring: Action Taken: The Board has established more frequent and systematic oversight mechanisms, including bi-weekly meetings and comprehensive data analysis to track and manage enrollment and expenditures. Expected Outcome: Improved compliance with federal regulations, timely identification of potential over-enrollments, and prevention of budget overruns. 3. Active Oversight and Continuous Communication: Action Taken: The Board has instituted regular bi-weekly conference calls and progress reporting with Texas Workforce Commission (TWC) staff to review and support implementing the corrective action plan. Expected Outcome: Enhanced transparency and accountability, ensuring all stakeholders are informed and aligned with the implemented corrective measures. 4. Development of Standard Operating Procedures (SOPs): Action Taken: The Board is in the process of developing formal SOPs for enrollment and financial management to standardize and document all processes. Expected Outcome: Clear guidelines and consistent practices that ensure efficient and compliant program management. 5. Benchmark and Progress Monitoring: Action Taken: Specific benchmarks have been established to reduce the average number of children served per day and to monitor the active oversight of the Child Care Services (CCS) program. Expected Outcome: Achievement of performance targets and improved management of program resources. 6. Implementation of Strong Budgetary Oversight: Action Taken: Robust budgetary oversight measures have been implemented to monitor financial activities closely and ensure adherence to budget constraints. This includes integrating stronger projection tools and regular variance analysis. Expected Outcome: Improved fiscal discipline and proactive identification of financial risks, preventing budgetary shortfalls and ensuring sustainable program funding. Conclusion: The Board is committed to addressing the issues identified in the audit and ensuring that all subrecipient activities are monitored effectively to comply with federal requirements. The corrective action plan and the new tools and procedures will strengthen our financial oversight and program management capabilities. The Board will continue to work closely with TWC to ensure the successful implementation of these measures and to prevent future occurrences of such issues.

The County will require departments receiving federal funding to complete a subrecipient and contractor relationship checklist based on the Uniform Guidance prior to entering into a contract with any vendor. This checklist will ensure proper identification of subrecipients and serve as documentation of this procedure. This checklist will be part of our Grants Acknowledge form implemented by our Grants department that recipient departments are required to complete at a grant’s inception. Completed checklists will be retained and reviewed by the Finance department prior to SEFA compilation to ensure subrecipient expenditures are being properly recorded on the SEFA. For awards identified as being passthroughs to subrecipients, the County has developed additional procedures to document this relationship. This includes a subrecipient package requiring signatures from the County and subrecipient to acknowledge the subrecipient relationship. This package will include relevant award identifiers such as award date, period of performance and Federal awarding agency and Assistance Listing Number and title. Recipient departments will also be required to perform monitoring procedures on identified subrecipients including assessing the subrecipient’s risk of noncompliance with Federal statutes, regulations and the terms and conditions of the subaward. The County has developed a questionnaire for biannual monitoring meetings with the subrecipient that is intended to further document the subrecipient is utilizing funds for authorized purposes, in compliance with Federal statutes, regulations, and the terms and conditions of the subaward, and that subaward performance goals are achieved. This questionnaire also requests obtaining copies of the subrecipients financial statements and single audit to verify the subrecipient is audited as required by Subpart F - Audit Requirement under the Uniform Guidance

Views of Responsible Officials: HIAS management accepts this comment and has instituted a subrecipient risk assessment and ongoing monitoring policy and procedure which will be adhered to during FY 2024. HIAS will conduct sub award pre-risk assessments and determine appropriate level of ongoing monitoring for new sub awards, and will determine and document appropriate ongoing monitoring procedures for existing sub awards on an annual basis.

The Department of Housing and Community Development (DHCD) concurs with the conditions and recommendations of this finding. DHCD will create a subrecipient monitoring plan and submit final reports to all Homeowner Assistance Fund subrecipients promptly. Contact - Lesley Edmond, DHCD Housing Compliance Officer Estimated Completion Date - July 5, 2024 for submission of finalized reports to subrecipients; and July 28, 2024 to develop a revised monitoring plan for fiscal year 2024. See Corrective Action Plan for chart/table