Corrective Action Plans

The newly hired CFO has Federal Grant Compliance experience and will implement a process for identification and oversight of subrecipients in line with Uniform Guidance 2 CFR § 200.331. The Organization will ensure there are written policies to comply with this provision and will monitor its subrecipients on a quarterly basis and will obtain written agreements by and between the Organization and its subrecipients.

FINDING 2023-002 Finding Subject: COVID-19 – Education Stabilization Fund – Subrecipient Monitoring Summary of Finding: The School Corporation received and passed through to subrecipients $495,386 of ESF funds. The School Corporation is to clearly identify the award and applicable requirements to the subrecipients, evaluate the risk of noncompliance related to the subrecipients to determine appropriate monitoring of the subaward, and monitor the activities of the subrecipients to ensure that the subaward is used for authorized purposes, complies with the terms and conditions of the subaward, and achieves performance goals. Contact Person Responsible for Corrective Action: Dr. Judi Hendrix, Director of WVEC and Michelle Cronk, CFO of West Lafayette Schools Contact Phone Number and Email Address: Dr. Judi Hendrix Michelle Cronk 765-894-0333 765-746-1602 judi.hendrix@esc5.k12.in.us cronkm@wl.k12.in.us Views of Responsible Officials: We concur with the finding regarding the informing and monitoring of subrecipients for federal grants. Description of Corrective Action Plan: We concur with the findings from the State Audit regarding the 3E grants funds; 2023-002. Our Corrective Action Plan would consist of the following:  Before ESF funds are dispersed to school districts (subrecipients), the WVEC Grant Director will ask districts for proper documentation such as receipts, college entrance letters, staff documented timesheets to support their request for funding.  The WVEC Grant Director will monitor the activities of the subrecipients to ensure that the financial subaward is used for authorized purposes, complies with the terms and conditions of the subaward, and achieves performance goals of the grant.  Once the school district’s information and documentation is received and approved, grant funding will be dispersed. Both the Service Center Executive Director and WVEC Grant Manager will approve and sign off on any payment made to a subrecipient.  On a biannual basis (periods ending June 30 and December 31), West Lafayette School Corporation will request the monitoring documentation from WVEC to ensure that proper monitoring is taking place. The WVEC Grant Director will create a sub-grantee reporting procedure:  Monthly spreadsheet with district allowable expense and sign off by Grant Manager, WVEC Executive Director and WVEC Treasurer approval.  This will take place every pay period to monitor the disbursement of any federal funds and to ensure that they are used for allowable expenditures under the grant.  This monitoring will begin in the month of March 2024 and continue until the end of the grant or Final Report, December 31, 2024. This procedure will also be used for other federal grants received.  On a biannual basis (periods ending June 30 and December 31), West Lafayette School Corporation will request the monitoring documentation from WVEC to ensure that proper monitoring is taking place. Anticipated Completion Date: Monthly monitoring will begin promptly (March 2024) and end with the final report of 3E grant activities on December 31, 2024.

Responsible Contact Person(s): Diana Clark, Associate Director Senior Corrective Action Planned: A spreadsheet to track monitoring activities by the BP SRM Coordinator was developed and implemented to ensure that Program Consultants adhere to the developed schedule. The BP SRM Coordinator reviews the completed audit documents to ensure that all required audit documents are uploaded to the system timely and that reviews are conducted in accordance with the SRM Plan. A SRM monitoring desk tool will be created for Practice Consultants as a quick reference to the SRM Plan. Training for all Program Consultants conducting SRM will be provided on the new updated monitoring plan as well as ongoing training for newly hired Program Consultants. Estimated Completion Date: 8/1/2023

Responsible Contact Person(s): Diana Clark, Associate Director Senior Corrective Action Planned: SRM for the TANF Federal grant program will be included in the SFY2024 SRM Plan. Inclusion of Risk Assessment criteria have been made and are being incorporated into the Monitoring Plan. Estimated Completion Date: 8/1/2023

Responsible Contact Person(s): Diana Clark, Associate Director Senior Corrective Action Planned: A risk assessment tool was developed as part of the State Fiscal Year 2024 SRM Plan and will be implemented with the new plan. Estimated Completion Date: 8/1/2023

Responsible Contact Person(s): Ross McDonald, Director of Compliance Ousman Kah, Subrecipient Monitoring Coordinator Corrective Action Planned: The final version of the agency's Monitoring Plan was completed. Estimated Completion Date: 8/1/2023

Responsible Contact Person(s): Ross McDonald, Director of Compliance Ousman Kah, Subrecipient Monitoring Coordinator Kevin Platea, Chief Information Officer Corrective Action Planned: A Grants Management solution is being pursued by DSS in anticipation that it can be deployed with Subrecipient Monitoring capabilities needed to comply with these requirements. A new budget request has been submitted for funding of a contingent Subrecipient Monitoring System solution. This will help bridge the deficiencies noted until an integrated permanent solution is implemented. Additionally, an interim solution is being considered where these subrecipients will be reviewed and tracked through a manual system. Estimated Completion Date: 3/31/2025

Responsible Contact Person(s): Ross McDonald, Director of Compliance Ousman Kah, Subrecipient Monitoring Coordinator Corrective Action Planned: A Grants Management solution is being pursued by DSS in anticipation that it can be deployed with Subrecipient Monitoring capabilities needed to comply with these requirements. A new budget request has been submitted for funding of a contingent Subrecipient Monitoring System solution. This will help bridge the deficiencies noted until an integrated permanent solution is implemented. Estimated Completion Date: 3/31/2025

Condition: The College did not have a control system in place to monitor performance measures as outlined in the subrecipient and grant agreements. The College was also not completing any site visits of the subrecipients or requiring annual financial reporting be submitted. Planned Corrective Action: Below are three items implemented to address the subrecipient monitoring requirement: 1. To address the finding of noncompliant subrecipient agreements, Grand Rapids Community College has implemented a new Grants Administration Guide. This guide can be found on the Grand Rapids Community College website. 2. To address the finding of lack of progress monitoring, subrecipient partners have been given monthly metric reports which include planned vs actual outcomes as a means of outlining their progress. The reports also include historical data for each category. This information is broken down by month and to be reviewed with subrecipients on a bi-weekly basis. This bi-weekly monitoring will provide oversight and help manage performance. Each grant partner will submit quarterly outreach plans that will be balanced against planned vs actual outcomes. These outreach plans will consist of detailed information highlighting the purpose of the event, target audiences, and updates from previous events. 3. To address the finding of lack of subrecipient monitoring, Grand Rapids Community College has scheduled formal site visits with subrecipients. Within the meetings they will discuss the following topics: Narrative Visit Overview, Financial Status Discussions, Metrics Verification, Narrative Overview, Participant Records and Revenue and Evaluation. Contact person responsible for corrective action: C. Dennis Triggs II- Program. Manager – One Workforce Grant. Anticipated Completion Date: 7/31/2023

FINDING 2023-001 Finding Subject: Research and Development Cluster – Subrecipient Monitoring Summary of Finding: Audit Finding 2023-001 states that Indiana State University did not have an effective internal control system in place in order to ensure that subrecipient Federal Audit Clearinghouse reports are reviewed in a timely manner for the Research & Development Cluster. Contact Person Responsible for Corrective Action: Hope Waldbieser, Executive Director of Finance Contact Phone Number and Email Address: 812-237-3524 - hope.waldbieser@indstate.edu Views of Responsible Officials: We concur with the finding that Indiana State University should have completed the Federal Audit Clearinghouse review in a more timely manner. Indiana State University conducted the required review, but it was completed later than allowed by the excerpt of 2 CFR 200.521(d) below. 2 CFR 200.521(d) states in part: “The federal awarding agency or pass-through entity responsible for issuing a management decision must do so within six months of acceptance of the audit report by the FAC. . . . “ Indiana State University did have other aspects of subrecipient monitoring in place related to the review of financial and programmatic reports for the subrecipients. Explanation and Reasons for Disagreement: Description of Corrective Action Plan: Effective January 2024, Indiana State University will update its Subrecipient Monitoring procedures in the following ways to ensure the Federal Audit Clearinghouse is reviewed in a timely manner and that appropriate documentation is maintained. 1. Subrecipient Federal Audit Clearinghouse reviews for prior fiscal year audits will be completed quarterly (July, October, January & April) during each fiscal year. The final Subrecipient Federal Audit Clearinghouse review for prior fiscal year audits will be completed in July after all current fiscal year payments have been made. 2. In order to ensure there is a segregation of duties the Office of Contracts & Grants Director will provide the Executive Director of Finance a report of the completed review each quarter including INDIANA STATE BOARD OF ACCOUNTS 20 the final review in July for their review and approval. The Executive Director of Finance will confirm the following: a. There is adequate documentation to support each quarterly review. b. Any deficiencies pertaining to the subrecipients Federal Audit Clearinghouse findings related to an award from Indiana State University are addressed in a timely manner. 3. Any identified issues during these reviews will be appropriately addressed by management as required by 2 CFR 200.332 and 2 CFR 200.521(d). Anticipated Completion Date: Indiana State University will ensure that the revised timeline for these procedures is in place during January 2024.

The City agrees with the finding. The City's Grant Administrator will provide training to each City department which currently oversees subrecipients, ensuring that all department staff understand general and ARPA-specific subrecipient requirements. Additionally, the Grant Administrator will review City departments' subrecipient management checklists to ensure all required documentation is obtained from subrecipients and reviewed as required. This will be complete by June 30, 2024.

SUBRECIPIENT MONITORING School Building Authority (SBA) Assistance Listing Number 97.036, COVID-19 97.036 The SBA will ensure and review audits of all subrecipients yearly effective February 2024. The SBA will implement policies and procedures to monitor all subrecipients to ensure compliance with federal requirements. This will include, but is not limited to, performing a yearly risk assessment as required by 2 CFR 200.303. This assessment will take into consideration results from the yearly audit of each subrecipient as well as other criteria listed in 2CFR 200.303 paragraphs (b), (d) & (e).

SUBRECIPIENT MONITORING West Virginia Community Advancement and Development (WV CAD) Assistance Listing Number 93.568, COVID-19 93.568 Between the years 2022 and 2023, the Weatherization Assistance Program (WAP) experienced a significant turnover in its staff. As a result of this turnover, the proper adherence to the requirement of 2 CFR 200.332(f) for verifying subrecipients was not followed during the auditing process. To ensure that this requirement is met in the future, WV CAD has taken measures to document the policies and procedures related to the financial audit requirements of 2 CFR 200.332(f) in the current WAP State Plan. A designated team member has been assigned the responsibility of maintaining a comprehensive tracking list, which includes the due dates of audits, their review dates, any necessary subrecipient corrective action plans, the dates of letter correspondence, and the uploading of all relevant documents into the divisions Shared Drive. Additionally, this team member is also responsible for downloading the audits from the Federal Audit Clearinghouse and submitting the information to the Fiscal Monitor for a thorough accounting review. These measures aim to ensure proper compliance and accountability within the Weatherization Assistance Program. This action will be implemented in February 2024.

SUBRECIPIENT MONITORING Department of Education (DOE) Assistance Listing Number 93.558, COVID-19 93.558 Program management will implement policies and procedures to ensure that the subrecipient monitoring is updated to “ensure that every subaward is clearly identified to the subrecipient as a subaward and includes the following 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 passthrough entity must provide the best information available to describe the federal award and subaward.” The timeline for the development and initiation of the process is tentatively set for February 1, 2024.

SUBRECIPIENT MONITORING Department of Environmental Protection (DEP) Assistance Listing Number 15.252 Effective April 2024, DEP will prepare and implement a written risk assessment policy containing monitoring and compliance review standards. DEP will also prepare and implement written standard operating procedures to assist in measuring subrecipient risk.

Pacific University acknowledges the importance of an effective control environment and closely monitors activities of subrecipients under federal awards. Pacific was able to demonstrate that the selected subrecipients had appropriate audits under Subpart F (or were not subject to such audits). However, the University will enhance controls related to tracking such compliance

Recommendation We recommend updating internal policy over subrecipient monitoring and recommend implementation of effective internal controls and procedures over subrecipient monitoring and tracking that allow for compliance with all applicable federal laws, regulations, and compliance requirements of various federal grants. It seems likely that additional monitoring activities are being performed that are not currently being documented in a central location, and therefore we recommend standardizing the documentation of such activities. Management Response Corrective Action: We concur with this finding and the auditor’s recommendation. The Department is in the process of implementing policies and procedures to ensure proper monitoring of subrecipients. This will also include training for both the financial and the grants departments. Subrecipient monitoring tools, such as excel worksheets and checklists are being reviewed and modified to fit the Department’s needs. The complete implementation of the subrecipient policies and processes is expected to be completed June 2024. Due Date of Completion: June 30, 2024 Responsible Person(s): Chief Financial Officer, Grants Unit Manager

CORRECTIVE ACTION PLAN (Concerning Finding 2023-001) December 21, 2023 Finding: 2023-001 Subrecipient Monitoring Federal Program Information: U.S. Department of Education Passed through the State of Vermont Agency of Education ALN: 84.425 - Education Stabilization Fund Contact Person Responsible for Corrective Action: Cheryl Hammond, Business Manager Corrective Action: The Two Rivers Supervisory Union will take the following actions to address finding 2023-001:  Review 2 CFR 200.332(a)  Create a temple subreceipient form  Complete the form annually and create a new form with any chance to the sub granted amount  Begin this process immediately Anticipated Completion Date: December 21, 2023

2023-002 - Noncompliance and Significant Deficiency in Internal Controls over Compliance for Subrecipient Monitoring Corrective Action Plan: Wellbeing Initiative has reviewed subrecipient monitoring criteria and updated the Internal Controls Policy and Procedure Manual to include the following policy. The appropriate measures have been taken to ensure these requirements are met in the coming years. Item 10.8.b.i-xv. Subrecipient monitoring requirements for pass-through entities, include the requirement that pass-through entities ensure that every subaward is clearly identified to the subrecipient as a subaward and includes the following 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. Required information includes but is not limited to: i. Subrecipient name (which must match the name associated with its unique entity identifier); ii. Subrecipient's unique entity identifier; iii. Federal Award Identification Number (FAIN); iv. Subaward Period of Performance Start and End Date; v. Subaward Budget Period Start and End Date; vi. Total Amount of Federal Funds Obligated to the subrecipient by the pass-through entity including the current financial obligation; vii. Total Amount of the Federal Award committed to the subrecipient by the pass-through entity; viii. Federal award project description, as required to be responsive to the Federal Funding Accountability and Transparency Act (FFATA); ix. Name of Federal awarding agency, pass-through entity, and contact information for awarding official of the Pass-through entity; x. 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; xi. Indirect cost rate for the Federal award (including if the de minimis rate is charged) per § 200.414. xii. All requirements imposed by the pass-through entity on the subrecipient so that the Federal award is used in accordance with Federal statutes, regulations and the terms and conditions of the Federal award; xiii. Any additional requirements that the pass-through entity imposes on the subrecipient in order for the pass-through entity to meet its own responsibility to the Federal awarding agency including identification of any required financial and performance reports; xiv. A requirement that the 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; and xv. Appropriate terms and conditions concerning closeout of the subaward Anticipated Completion Date: Completed 11/16/2023 Responsible: Chief Executive Team: Danielle Smith and Sadie Thompson

Federal Program Name: • Coronavirus State and Local Fiscal Recovery Funds – ALN 21.027 Recommendation: The Organization created a Subrecipient Monitoring Policy in fiscal year 2023 to include performing subrecipient risk assessments on all subrecipient relationships entered into by the Organization. As part of the Organization’s subrecipient monitoring process it received an incomplete audit report from a subrecipient and as a result the Organization was not aware of the audit findings the subrecipient had received. Our auditor’s recommended the Organization utilize the federal audit clearinghouse to verify the audit reports the subrecipients are providing. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Management’s response: Management concurs with the audit finding. Subrecipient monitoring was performed per the existing policy but the subrecipient provided inaccurate information on the monitoring questionnaire and incomplete audit information. The information provided by the subrecipient was not verified against the Federal Audit Clearinghouse. The risk assessment policy will be updated to ensure that information provided by subrecipients is verified against the Federal Audit Clearinghouse to ensure a complete risk assessment is performed. Planned completion date for corrective action plan: Will implement in fiscal year 2024. If the U.S. Department of Health and Human Services has questions regarding this plan, please call Brent Amfahr, CFO at 303-443-8500

Management Views and Corrective Action Plan: Management agrees with the finding and recommendation. Name and Title of Responsible Official: Rouba Anka, Chief Financial Officer Planned Completion Date: Immediately

University’s Response/Corrective Action Plan: Upon becoming aware of the issue, the University issued a Stop Work Order to the identified subrecipient to cease all work on the award until such time their invoicing and documentation complies with the terms and conditions of the subrecipient agreement. Since this issue was contained to a single award and a single department the University completed these steps: 1. Performed an audit of the subrecipients on the award to ensure all were following the requirements of the subrecipient award agreement. The audit was complete on October 13, 2023. 2. The Office of Research & Sponsored Programs (ORSP) and Grants Accounting (GA) completed a subrecipient monitoring training for the department to ensure that they were familiar with the requirements of the agreement and revised their processes for appropriate monitoring of subrecipients. This training was completed on November 7, 2023. This training will be made available to all OHIO principal investigators (PI) via the subrecipient webpage on the Office of Research & Sponsored Programs website by November 30, 2023. 3. ORSP and GA worked closely to develop a new checklist that was shared with all PIs on Tuesday, October 24, 2023, that outlines the PI responsibilities for monitoring subrecipients and reviewing any invoices before payment from the subrecipient to ensure that it complies with the subrecipient agreement terms and conditions. This checklist will also be added as resource for PIs as an additional tool for subrecipient monitoring by November 30, 2023. 4. Developed a subrecipient invoice template that includes all required information to comply with the subrecipient agreement. This invoice template will be sent to all subrecipients when the purchase order is issued to the subrecipient. This practice started on October 23, 2023. 5. Responsible Parties: Heidi Whitney, Director of Grants Accounting and Susan Robb, Assistant Vice President for Research & Sponsored Programs

Management’s Views and Corrective Action Plan 2023-001 – Subrecipient Information and Monitoring Grantor: Centers for Disease Control and Prevention (CDC) Passthrough Agency: Massachusetts Department of Public Health Program Name: Massachusetts Community Health Worker for Resilience Award Name: Community Health Workers for Public Health Response and Resilient Award Year: Various Award Number: INTF4207M03225031012 Assistance Listing Number: 93.495 The Alliance has implemented a template effective December 1, 2023 to be utilized for the communication of the subaward information as well as an initial risk assessment and a continuing reassessment template. Additionally, the Alliance will be developing formalized procedures to communicate with subrecipients. The Alliance will be using a checklist to formally review the initial and continuing agreements and will include high and low risk determinations. These will be implemented in February 2024 and be reviewed on an annual basis for any continued funding. Jill Batty Chief Financial Officer Cambridge Health Alliance 350 Main Street Malden, MA 02148

Failure to Properly Track Grant Expenditures Recommendation: We recommend that the Clinic maintains an effort to track federal and state funding and expenditures separate from regular program expenditures, inquiring of granting agencies if needed. Action Taken: Management is now properly tracking grant expenditures and can accurately state quantities of grant expenditures.

2023-003 Material Weakness over Subrecipient Monitoring; Emergency Rental Assistance Program (ERAP), Assistance Listing Number 21.023, U.S. Department of Treasury Recommendation: We recommend that the County create a subrecipient monitoring policy to monitor federal awards in accordance with the contract and Uniform grant guidance. The subrecipient monitoring policy should include performing a risk assessment to determine the level of subrecipient monitoring required. Additionally, we recommend the County conduct site visits and/or perform a random sampling of charges based on the results of the risk assessment. Corrective Action: An organization-wide documented policy is being developed by the newly established Grants Management program officers. The new policy will meet current Federal guidance on subrecipient monitoring and will include resources and recommendations for County Departments to perform a risk assessment, internal control assessment, onsite visits, and desk reviews as applicable. Proposed Completion Date: Upon completion and approval of the new subrecipient monitoring policy the County will implement the procedures within 180 days. Name of Contact Person: Patrick Flanary, Chief Financial Officer