Corrective Action Plans

Dear Mr. Waguespack, Please find enclosed the Louisiana Workforce Commission's response to the above-mentioned finding. On behalf of Secretary Susana Schowen, we thank your staff for their guidance and technical assistance throughout this process. If you have any questions or need additional information, please do not hesitate to give me a call at (225) 342-3474 or email at swilliams@lwc.la.gov. LWC Response: LWC concurs with this finding concluding that five close out letters were issued 111 to 183 days after monitoring report issuance and that four close out letters were not issued as of January 2024 while the monitoring reports for these reviews were issued more than 195 days prior. LWC's policy has established timelines for the monitoring process, which should be followed by all monitoring staff. As established in policy, a subrecipient has 45 days of issuance of the monitoring report to submit their corrective action plan (CAP). An extension may be granted for an additional 15 days per approval of the monitoring director. Failure to submit the CAP within the allowable timeline will result in the issuance of an initial determination letter. The subrecipient has 30 days to respond. At this point, the monitoring staff works diligently back and forth with the subrecipient in an attempt to resolve the findings. This process can be a lengthy process and may extend beyond the established timelines within the policy. Staff’s goal is to resolve each finding to re-establish compliance. However, not all efforts may resolve each finding. At the conclusion of this process and when all avenues have been exhausted, LWC makes a final determination and issues a letter. Additionally, The Louisiana Workforce Commission is currently implementing changes within the structure of the agency's executive leadership. During this transition, deficiencies and neglect of internal controls has been discovered within the Office of Workforce Development leading to non-compliance of monitoring policy and procedures. The individuals responsible for most of the neglect are no longer employed with the agency. With the onboarding of new leadership, LWC will ensure compliance with all federal and state regulations, internal controls and policies, and transparency within all levels of management. The agency will provide timely and meaningful monitoring actions and provide continuous staff training and development. LWC is currently reviewing our monitoring policy and will make updates to implement all necessary changes ensuring compliance by March 1, 2024. Staff will be re-trained on the required monitoring process and will be required to incorporate the learned information in their monitoring review process. Staff will participate in continuous trainings each quarter to identify any deficiencies in the process or in its implementation. LWC concurs with this finding concluding three Single Audit reports with findings affecting the WIOA cluster of programs, management decision letters were issued 66 to 264 days after the due date set by federal regulations. LWC staff responsible for the issuance of the management decision letters has since reviewed the policy to ensure an understanding of the submission timelines has been received and will apply this knowledge when processing the letters. For the two reports, LWC incorrectly issued management decisions letters noting no WIOA affected findings, LWC staff has performed a second review of the audit reports and management letters have been drafted and are currently under review. We expect that these management letters will be finalized and emailed to the two subrecipients within the month of February 2024, and will include follow-up requests for corrective actions on the identified findings where necessary. LWC will develop and issue a policy that requires the appointing authority to issue management decisions on Single Audit reports within six months of the acceptance of the audit report by the Federal Clearinghouse. The policy will also include second level approvals to ensure audit findings are properly identified and follow up procedures are established to ensure subrecipients take prompt and appropriate action on all audit findings. Staff will train on the proper review and submission of the single audit reports, what constitutes a finding for LWC/WIOA purposes and the work that should be completed to close out the review. A process has been implemented that requires the LWC staff responsible for the review and submission of the single audit reports to obtained an approval of all work performed prior to the issuance of the letters to the subreceipents'.

Identifying Number: 2023-001, 2023-002; Agency: internal; Name of Contact Person: Eric Kool, director of Polk County Community, Family and Youth Services; Anticipated completion date: Effective immediately/December 2023; Agency's response: Concur: We agree with this finding. The Community Family and Youth Services (CYFS) team will obtain detailed reporting data and request supporting documentation from subrecipients to reconcile/review expenses quarterly. In addition, CFYS will have other personnel and Central Accounting assist in reviewing data to ensure accuracy.

Finding Number 2023-222: Supporting documentation to demonstrate the completion of subrecipient risk assessments for the Activities to Support State, Tribal, Local and Territorial (STLT) Health Department Response to Public Health or Healthcare Crises program was not available for review. Federal Programs: 93.391 - Activities to Support State, Tribal, Local and Territorial (STLT) Health Department Response to Public Health or Healthcare Crises Related to Prior Finding: N/A Agency’s view: The Department agrees with this finding. Corrective Action: The division will ensure new staff receive training related to awarding grants, to include components on appropriate internal controls, identifying required grant elements, detailing the grant process, and outlining record retention requirements. All current employees have been trained as of March 2024. All newly hired employees will be trained beginning April 2024. Anticipated Corrective Action Date: April 2024 Responsible for Corrective Action: Elke Shaw-Tulloch, Division Administrator Division of Public Health Elke.Shaw-Tulloch@dhw.idaho.gov 208-354-5950 Kelly Combs, Bureau Chief, Compliance Kelly.Combs@dhw.idaho.gov 208-334-5814

Finding Number 2023-221: The Department did not review subrecipient application information for the Coronavirus State and Local Fiscal Recovery Funds at a sufficient level to identify missing information. Federal Programs: 21.027 – Coronavirus State and Local Fiscal Recovery Fund Related to Prior Finding: 2022-210 Agency’s view: The Department agrees with this finding. Corrective Action: The Division of Public Health and Idaho Council on Domestic Violence and Victim Assistance (ICDVVA) will take steps to ensure new staff receive training related to awarding grants, to include components on appropriate internal controls, identifying required grant elements, detailing the grant process, and outlining record retention requirements. All current employees have been trained as of March 2024. All newly hired employees will be trained beginning April 2024. Anticipated Corrective Action Date: April 2024 Responsible for Corrective Action: Elke Shaw-Tulloch, Division Administrator Division of Public Health Elke.Shaw-Tulloch@dhw.idaho.gov 208-354-5950 Dana Wiemiller, Executive Director ICDVVA Dana.Wiemiller@icdv.idaho.gov 208-332-1545 Kelly Combs, Bureau Chief, Compliance Kelly.Combs@dhw.idaho.gov 208-334-5814

Finding Number 2023-213: The Department erroneously determined that two recipients of Temporary Assistance for Needy Families (TANF) funding were contractors instead of subrecipients resulting in noncompliance with the subrecipient monitoring requirements. Federal Programs: 93.558 – Temporary Assistance for Needy Families Related to Prior Finding: N/A Agency’s view: The Department agrees with this finding. Corrective Action: The Department has revised our training of personnel involved in subrecipient and contractor determinations. These contract managers and monitors completed grant training on March 12th-13th, 2024 which included sections about subrecipient and contractor determinations, risk assessment and documentation. All newly hired employees will be trained beginning April 2024 with an on-line module. For the impacted vendor, an updated Risk Assessment was completed and submitted to LSO. Additionally, the Department has started the work to effectively change the designation of the vendor and ensure all required information is provided to this subrecipient. This process will be completed by April 30th, 2024. The Department will develop internal control procedures to ensure all required information is provided to the subrecipients at the time of the subawards. These updated internal control procedures will be completed by June 30th, 2024. Anticipated Corrective Action Date: June 30, 2024 Responsible for Corrective Action: Cameron Gilliland, Division Administrator Cameron.Gilliland@dhw.idaho.gov 208-334-0641 Kelly Combs, Bureau Chief, Compliance Kelly.Combs@dhw.idaho.gov 208-334-5814

Finding Number 2023-206: The Department did not fully disclose required information to subrecipients, document subrecipient risk assessments, or ensure subrecipient audits were received for the Coronavirus State and Local Fiscal Recovery Fund. Federal Programs: 21.027 – Coronavirus State and Local Fiscal Recovery Fund Related to Prior Finding: N/A Agency’s view: The Department agrees with this finding. Corrective Action: The department agrees with the lack of certain required subrecipient information datapoints for the CSLFRF projects. • The department had an imperfect implementation of the initial subawards for CSLFRF documentation for subrecipients. Our general practice includes providing the identified federal award identification datapoints; however, this was not the case with the initial CSLFRF subrecipients. As an example, the period of performance was truncated to ensure that we were able to meet the aggressive timeline outlined in the American Rescue Plan Act; we will include both the true period of performance as set forth in the grant and the budgetary period in which the subrecipient will need to complete their work. Carrie Champlin, Contracts Manager, and Rob Sepich, Chief Financial Officer will implement these changes by April 15, 2024. • The department had processes for evaluating the risk of subrecipients, however it could be improved and made clearer for auditors and we will implement a process used by other agencies to memorialize the risk factors outside of email in a clear and concise manner. Additionally, the department is currently implementing a new software system, Amplifund, to aid in registering subrecipients, monitoring them, and closing out subawards. This system will include all of the relevant information necessary for both the subrecipient and the department in one location and will provide consistency across the department. Amplifund implementation is currently underway and will be used department- wide by August 2024. Doug McRoberts, Grants Manager, Jeri Ann Fogg, Accounting Manager, Carrie Champlin, Contracts Manager are working on the integration of Amplifund. Anticipated Corrective Action Date: April 15, 2024 Responsible for Corrective Action: Rob Sepich, Chief Financial Officer Rob.Sepich@deq.idaho.gov 208-373-0292

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

HSEM concurs with the finding. Condition A: NH HSEM Mitigation and Recovery leadership has updated the award letter templates to ensure the necessary information is included as outlined in the condition. Conditions B – D: NH HSEM Mitigation and Recovery leadership updated the Risk Assessment Quick Reference Guide (QRG) and Subrecipient monitoring QRG. A two hour in-person training was conducted on January 31, 2024, to Mitigation and Recovery staff which focused on conducting risk assessments and subrecipient monitoring. This will be reviewed with staff again during an upcoming Section meeting in March 2024.

Condition A: DHHS partially concurs. The review of expenditure details is an integral part of DHHS’ Subrecipient Monitoring and standard language is included in the templates for legal agreements. These five subrecipients were deemed low or no risk, examination of expenditure detail is considered sufficient monitoring. All five of these subrecipients had the inclusion of the monthly detail requirement in the contracts and this was performed prior to the invoice being submitted to AP for payment. DHHS will re-evaluate current practices to ensure that the documentation is sufficient for the current subrecipient monitoring process. Regarding the two selections identified as having risk assessments which did not specify recommended monitoring procedures: The Risk Assessment Tool for one subrecipient was performed after the subaward award. However, as indicated on the Tool, programmatic monitoring activities were included in the contract. DHHS reviewed the monthly back-up documentation provided with the submitted invoices prior to sending them to AP for payment. The risk assessment tool for the second selection was performed after the subaward award. However, as indicated on the tool, programmatic monitoring activities were included in the contract. We reviewed the monthly back-up documentation provided with the submitted invoices prior to sending them to AP for payment. Condition B: DHHS partially concurs. The review of expenditure details is an integral part of DHHS’ Subrecipient Monitoring and standard language is included in the templates for legal agreements. The subrecipients were deemed low or no risk, therefore, examination of expenditure detail is considered sufficient fiscal monitoring. DHHS employs the review of expenditure details, as allowed under 200.332 (d)(1), as an integral part of the Departments Subrecipient Monitoring. A review of the expenditures provides monitoring for the following concerns: • The familiarity a subrecipient has utilizing Federal funds • The subrecipient management teams’ familiarity with Federal funding • Single Audit findings • Any prior return of funding due to non-compliance • The subrecipient’s compliance with the requirements of 200.300 and 302 • Whether the subrecipient has a new financial system DHHS will re-evaluate the risk response parameters to determine that the level of documentation is sufficient to ensure that the procedures performed would be able to identify noncompliance at the subrecipient level. Condition C: DHHS concurs. DHHS will be updating procedures to include contacting vendors to remind them of the deadline regarding the submission of their single audit in the Federal Audit Clearinghouse.

The Department Concurs with paragraph A – Since this same finding was reported in March of 2023 for FY22, items a, c, and d are now included on all federal subaward contracts and policies have been updated to reflect this. The Department will ensure b is also included going forward. The Department concurs with paragraph B - The finding was a result of personnel turnover and medical issues. The Department has hired and trained additional program staff and updated policies to ensure programmatic monitoring and subsequent reports are done in a timely manner. The Department partially concurs with paragraph C. Fiscal monitoring was done for all 3 subrecipients during the federal program year. However, 1 subrecipient monitoring fell outside the state fiscal year so was not covered during the audit period. The Department has changed the wording on its risk assessment procedures to ensure no misinterpretation of the timeframe each subrecipient will be monitored in accordance with its risk assessment. The Department has also changed the requirements of the frequency of fiscal monitoring in each of the risk assessment categories. The Department Concurs with paragraph D – The Department is reviewing policies and procedures and will update them to ensure compliance with 2 CFR section 200.332(a), 2 CFR section 200.332(b) and 2 CFR section 200.521. The Department also created a tracking mechanism to ensure we receive, review, and issue management decisions (if required) in a timely manner. The Department concurs with Paragraph E - The Department is reviewing policies and procedures for both reporting and subrecipient monitoring to ensure data is tested and verified. The Department has already gained increased access to data in current software and is in the process of selecting a vendor for new software that will provide more testing and enhanced internal controls.

Condition A: DHHS concurs. Pursuant to the Subrecipient Monitoring Policy, the risk assessment and determination of subrecipient monitoring activities is performed during the procurement process with the Grants Administrator and the Program Lead. It is the responsibility of Program to perform the requested subrecipient monitoring. The Department provides annual training on the Subrecipient Monitoring Policy. We will reinforce the requirements of the Policy and the ramifications for the Department for the non-compliance in this year’s annual training. Regarding the incomplete Risk Assessment Tool, we will update the Subrecipient Monitoring Policy to include a secondary review of the Tool prior to implementation, as part of our internal controls. Condition B: DHHS does not concur. The Department employs the review of expenditure details, as allowed under 200.332 (d)(1), as an integral part of the Departments Subrecipient Monitoring. The Department’s review of the expenditures provides monitoring for the following concerns: • The familiarity a subrecipient has utilizing Federal funds • The subrecipient management teams’ familiarity with Federal funding • Single Audit findings • Any prior return of funding due to non-compliance • The subrecipient’s compliance with the requirements of 200.300 and 302 • Whether the subrecipient has a new financial system Standard language for the submission of expenditure detail is included in all templates for legal agreements. These subrecipients were deemed low or no risk, therefore, examination of expenditure detail is considered sufficient monitoring. Subrecipient monitoring activities are memorialized in the legal agreements. The Risk Assessment Tool provides a space for the monitoring activities to be selected, however, the Subrecipient Monitoring Policy does require the memorialization of the activities on the Tool for compliance, only to be memorialized in the legal agreement. Condition C DHHS partially concurs. As the subrecipient’s audit report had no findings, we are not required to issue a management decision letter. However, we will be updating our procedures to include contacting the vendors to remind them of the deadline regarding the submission of their single audit in the Federal Audit Clearinghouse.

Corrective Action Planned (Condition A): The DAS analyzed the six items erroneously reported as subawards and noted the errors were isolated to two specific agencies, the Department of Health and Human Services and the Department of Environmental Services. In response to the prior year finding 2022-002, the DAS had strengthened internal controls related to the review and validation of amounts reported by individual state agencies as pass through expenditures. This included an additional control specifically verifying SLFRF pass through expenditures reported by each agency. The DAS will offer additional training relative to identification and reporting of subaward expenditures in its annual statewide Single Audit training and re-evaluate the precision of execution of controls over the validation of pass through reporting in assembling the SEFA for fiscal year 2024. Corrective Action Planned (Conditions B through E): The State largely concurs with the findings and recommendations and has implemented procedures to address the identified conditions already or will do so. With regards to condition B, The State will work with the individual agencies to ensure that individual agencies entering into such agreements clearly indicate the terms required by Uniform Guidance, including permitted indirect cost rates and whether the award is for R&D. The State has already begun this corrective action plan with the agencies. With regards to condition C, for a. and b. for payments by agencies, there are standard procedures for review and authorization of invoices and payments and those payments are documented. For c. The State has already implemented an agency wide framework for subrecipient monitoring. The State will provide re-training for those agencies that had not properly documented monitoring as outlined by the subrecipient risk assessments and ensure monitoring reports are documented. With regards to condition D, The State has already implemented an agency wide framework to help ensure policies and procedures are in place concerning Uniform Guidance Reports. We will work those agencies that had not documented the date received and the review of the Uniform Guidance Reports to ensure written documentation occurs. Where findings have been reported in the Uniform Guidance Report, ensure timely Management Letters are documented and provided with the summary review of Uniform Guidance Report.

The Agency agrees with the finding. It has been seeking qualified fiscal staff to address the staffing needs. A new fiscal staff member has been hired and will start employment on 4/2/24. The requisite fiscal reviews of subrecipients has been initiated with the intention of completing them as soon as practical.

Federal Agency Name: U.S. Department of Transportation, Federal Highway Administration Pass‐Through Entity: Nebraska Department of Transportation Assistance Listing Number: 20.205 Program Name: Highway Planning and Construction Finding Summary MAPA is the pass-through entity for several subrecipients. MAPA does not appear to have a formal policy to evaluate each subrecipient’s risk of noncompliance for appropriate subrecipient monitoring. Further, MAPA does not have a formal policy to monitor the activities of the subrecipients to the extent deemed necessary by the federal government, including the verification that subrecipients are audited when they reach Uniform Guidance spending levels and evaluation of those audits. However, the current procedures require a review of the subrecipients’ invoices, including all detailed costs by an appropriate individual at MAPA prior to payment. This process helps reduce risk of inappropriate funding to subrecipients. Corrective Action Plan MAPA will establish written internal procedures and complete a compliance risk determination for every federal subaward to evaluate subrecipient risk of noncompliance in accordance with the guidance provided in 2 CFR 200.332: Requirements for pass-through entities. In particular with regard to this finding, MAPA will verify whether every subrecipient is audited as required by the conditions cited in 2 CFR 200.332(f), and MAPA will evaluate such audits for compliance risk as part of its internal procedures. Responsible Individual Matthew Eash, Director of Finance Anticipated Completion Date June 30, 2024

Program: COVID-19 Aging Cluster Assistance Listing No.: 93.041, 93.042, 93.043, 93.044, 93.045, 93.052, 93.053 Federal Grantor: U.S. Department of Health and Human Services Passed-through: California Department of Aging Award No. and Year: Various Compliance Requirements: Subrecipient Monitoring Type of Finding: Significant Deficiency in Internal Control over Compliance and Instance of Non- Compliance Department’s Management Response: The Area Agency on Aging (AAA) management agrees that all required award information needs to be communicated to subrecipients at the time of the subaward and a subrecipient’s risk assessment needs to be completed and documented in accordance with 2 CFR section 200. View of Responsible Officials and Corrective Action: Beginning July 1, 2023, AAA merged with Human Services Agency (HSA). Administrative and fiscal functions have been integrated into HSA's administrative and fiscal management. The fiscal team has been working with AAA management to identify and address internal control and non-compliance issues, implementing procedures and policies to improve operational efficiency and internal controls. Risk assessment of subrecipients was performed in December 2023 to determine the level of monitoring needed. Federal award identification number (FAIN) will be provided to subrecipients, and the unique entity identifier (UEI) will be obtained from subrecipients by March 31, 2024. Once monitoring is complete, a monitoring report will be issued, any findings with be communicated with subrecipients. In the future, the FAIN and subrecipient’s UEI will be included in contract agreements. Name of Responsible Persons: Bernadette Heredia, Accounting Manager II Helina Wu, Chief Financial Officer, Human Services Agency Implementation Date: December 1, 2023, related to documenting risk assessments March 31, 2024, related to providing require award information to the subrecipient

Department staff has reviewed the Legislative Audit Bureau’s (LAB) interim audit memo for Finding 2023-301: Social Services Block Grant – Subrecipient Contracts. This is the department’s Corrective Action Plan.  Recommendation (2023-301): Social Services Block Grant – Subrecipient Contracts We recommend the Wisconsin Department of Health Services update its procedures for contract development to ensure information provided in its subrecipient contracts identifies the Social Services Block Grant as the federal funding source for the basic county allocation of the community aids program related to the transferred Temporary Assistance for Needy Families funds. Wisconsin Department of Health Services Planned Corrective Action: DHS will change the Assistance Listing Number (ALN) for Temporary Assistance for Needy Families funds transferred to the Social Services Block Grant (SSBG) to the SSBG’s ALN, 93.667, for future Basic County Allocation contracts. Anticipated Completion Date: July 31, 2024 Person responsible for corrective action: Rebecca Mogensen, Section Chief Managerial Accounting, Bureau of Fiscal Services, Division of Enterprise Services rebeccaj.mogensen@dhs.wisconsin.gov

Planned Corrective Action: The DCF Bureau of Finance will update current subrecipient contracts containing Social Services Block Grant (SSBG) funds to include information required under 2 CFR section 200.332. The bureau will incorporate the SSBG fund source into existing procedures which identify the federal assistance listing numbers for subrecipient contracts. Anticipated Completion Date: The bureau will complete this work by June 30, 2024. Person responsible for corrective action: Rachelle Armstrong, Director Bureau of Finance Rachelle.Armstrong@wisconsin.gov

Finding 2023-201: Refugee and Entrant Assistance State / Replacement Designee Administered Programs – Subrecipient Monitoring Planned Corrective Action: The DCF Bureau of Finance currently performs risk assessments for subrecipients meeting either the state single audit threshold or federal single audit threshold. The bureau will review and update subrecipient risk evaluation procedures to ensure all subrecipients receive a risk assessment, even in cases of lower dollar amount subawards. The DCF Bureau of Refugee Programs (BRP) monitors all subrecipients for compliance with state and federal requirements pertaining to the grants they receive. In certain cases during State Fiscal Year 2023, BRP made decisions to differentiate monitoring activities of certain partners according to bureau established priorities, which included but were not limited to programs related to refugee employment, distribution of benefits, and reduction of refugees’ use of public benefits. These programs received BRP’s highest degree of formal monitoring (on- site case file reviews), while other programs were monitored through program desk reviews of subrecipient reports and direct communication with subrecipients in accordance with the results of those reviews. During SFY 2023 and the beginning of SFY2024, BRP piloted and then implemented a new comprehensive program desk monitoring plan and annual monitoring schedule. BRP will continue to review these tools to ensure that all subrecipients are appropriately monitored and that all monitoring activities are appropriately documented. In addition, BRP will review existing subrecipient contracts to ensure appropriate monitoring plans are in-place and customized as needed according to subrecipient risk assessments, administered as planned, and that ongoing monitoring activities are adequately documented.Anticipated Completion Date: The bureaus will complete this work by June 30, 2024. Persons responsible for corrective action: Rachelle Armstrong, Director Bureau of Finance Rachelle.Armstrong@wisconsin.gov Bojana Zoric Martinez, Director Bureau of Refugee Programs Bojana.ZoricMartinez@wisconsin.gov

Department staff has reviewed the Legislative Audit Bureau’s (LAB) interim audit memo for Finding 2023-305: Activities to Support State, Tribal, Local and Territorial (STLT) Health Department Response to Public Health or Healthcare Crises – Subrecipient Monitoring. This is the department’s response.  Recommendation (2023-305): Activities to Support State, Tribal, Local and Territorial (STLT) Health Department Response to Public Health or Healthcare Crises – Subrecipient Monitoring We recommend the Wisconsin Department of Health Services: • Develop a written monitoring plan for the Health Disparities program that includes a description of the subrecipient monitoring expected for low-, moderate-, and high-risk subrecipients; procedures for completing and documenting desk reviews of subrecipient invoices; procedures for assessing and documenting the reliance that can be placed on review of subrecipient single audit reports; and procedures for documenting management oversight of the monitoring plan. Wisconsin Department of Health Services Planned Corrective Action: The Department of Health Services (DHS), Division of Public Health (DPH) Grant Managers and their designees are responsible for subrecipient monitoring. As part of the ongoing monitoring, DHS DPH recognized opportunities for improvement of this process and began developing a new Internal Controls Checklist during FY 2022-23. On February 15, 2024, DHS DPH Bureau of Operations provided training to DHS DPH staff who regularly work on financial, granting, and/or contracting items on a new Internal Controls Checklist for Federal Funding. This checklist provides DHS DPH federal Grant Managers and their designees a best practice tool for reviewing how their grant activities are carried out and to ensure their consistency with the terms and conditions of the federal award and with federal and state policies. The Internal Controls Checklist guides DHS DPH federal Grant Managers and their designees through a series of questions that, among other things, direct them to have knowledge of, follow, and maintain written policies for administering federal grant programs; document procedures for verifying invoices; archive relevant documentation; ensure financial reports are submitted timely; monitor subgrantees for fiscal and program requirements; document procurement authority; and monitor expenses against waiver and contract limits. The Internal Controls Checklist is to be signed by the Grant Managers or their designees in the last quarter of the grant. The policy states the Section Manager is accountable to make sure the Checklist is completed accurately. Using the Internal Controls Checklist will formalize management oversight as it will be signed by the Section Manager overseeing the grant. The Internal Controls Checklist will be updated to identify the need for subrecipient monitoring to be attributed to the risk levels of subrecipients. Also, it will include direction to document procedures for completing and documenting desk reviews of subrecipient invoices and procedures for assessing and documenting the reliance that can be placed on review of a subrecipient’s single audit report. Grant Managers and their designees are encouraged to use the Internal Controls Checklist as a monitoring plan by evaluating each item in the checklist and saving the procedures, documents, and emails associated with those steps in a folder, in addition to the program’s usual record keeping practice, to enhance the effectiveness of the information. Grant Managers and their designees may also produce a separate monitoring plan instead of using the Internal Controls Checklist, and if a separate document is produced, management oversight will be documented within the plan. We recommend the Wisconsin Department of Health Services: • Develop a central location to maintain documentation related to the subrecipient monitoring, including email correspondence. Wisconsin Department of Health Services Planned Corrective Action: Grant Managers and their designees maintain documentation related to subrecipient monitoring in various ways, and to provide better consistency, the newly created Internal Controls Checklist provides some recommendations. The Internal Controls Checklist recommends Grant Managers, and their designees develop plans for archiving relevant documents for program administration and maintain information to support subgrantee monitoring, including risk analyses and reporting. Individual units in DHS DPH will develop a central location to maintain documentation related to the subrecipient monitoring, including email correspondence. We recommend the Wisconsin Department of Health Services: • Provide sufficient training to the Department of Health Services staff administering the Health Disparities program to ensure all subrecipient monitoring responsibilities are completed consistently and are based on the risk assessment level determined. Wisconsin Department of Health Services Planned Corrective Action Current Grant Managers and their designees in DHS DPH who oversee federally awarded programs will be informed of the federal requirements as they relate to 2 CRF s. 200.331, through specific subrecipient monitoring training. DHS DPH will administer annual trainings to Grant Administrators and their designees on subrecipient monitoring requirements and policies for conducting risk assessments. Anticipated Completion Date: June 30, 2024 Person responsible for corrective action: Christina Isenring, Director Bureau of Operations, Division of Public Health christinam.isenring@dhs.wisconsin.gov

Department staff has reviewed the Legislative Audit Bureau’s (LAB) interim audit memo for Finding 2023-306: Public Health Emergency Response: Cooperative Agreement for Emergency Response: Public Health Crisis Response – Subrecipient Monitoring. This is the department’s response.  Recommendation (2023-306): Public Health Emergency Response: Cooperative Agreement for Emergency Response: Public Health Crisis Response – Subrecipient Monitoring We recommend the Wisconsin Department of Health Services: • Review the tracking spreadsheets completed in fiscal year 2022-23, and complete the assessment of the progress and fiscal reports and consideration of potential unallowable costs, document the conclusions, and return funding to the federal government if costs were determined to be unallowable; Wisconsin Department of Health Services Planned Corrective Action: Emergency Health Care (OPEHC) will create a workgroup that includes subject matter expert staff from all impacted areas that will be tasked with reviewing all the tracking spreadsheets for fiscal year 2022-2023. Staff will conduct the recommended assessment on all progress and fiscal reporting to determine any possible unallowable costs under the parameters of the cooperative agreement. The workgroup will coordinate efforts, as needed, with impacted health departments and workers. The workgroup will document all conclusions and, in coordination with leadership, will work with the correct federal agency to discuss and complete any necessary next steps. We recommend the Wisconsin Department of Health Services: • Develop a written monitoring plan for the Cooperative Agreements program that includes a description of the subrecipient monitoring expected for low-moderate-, and high-risk subrecipients; procedures for completing and documenting review of the progress and fiscal reports; procedures for completing and documenting desk reviews or on-site visits; procedures for assessing and documenting the reliance that can be placed on review of a subrecipient’s single audit report; and procedures for documenting management oversight of the monitoring plan. Wisconsin Department of Health Services Planned Corrective Action: The Department of Health Services (DHS), Division of Public Health (DPH) Grant Managers and their designees are responsible for subrecipient monitoring. As part of the ongoing monitoring, DHS DPH recognized opportunities for improvement of this process and began developing a new Internal Controls Checklist during FY 2022-23. On February 15, 2024, DHS DPH Bureau of Operations provided training to DHS DPH staff who regularly work on financial, granting, and/or contracting items on a new Internal Controls Checklist for Federal Funding. This checklist provides DHS DPH federal Grant Managers and their designees a best practice tool for reviewing how their grant activities are carried out and to ensure their consistency with the terms and conditions of the federal award and with federal and state policies. The Internal Controls Checklist guides DHS DPH federal Grant Managers and their designees through a series of questions that, among other things, direct them to have knowledge of, follow, and maintain written policies for administering federal grant programs; document procedures for verifying invoices; archive relevant documentation; ensure financial reports are submitted timely; monitor subgrantees for fiscal and program requirements; document procurement authority; and monitor expenses against waiver and contract limits. The Internal Controls Checklist is to be signed by the Grant Managers or their designees in the last quarter of the grant. The policy states the Section Manager is accountable to make sure the Checklist is completed accurately. Using the Internal Controls Checklist will formalize management oversight as it will be signed by the Section Manager overseeing the grant. The Internal Controls Checklist will be updated to identify the need for subrecipient monitoring to be attributed to the risk levels of subrecipients. Also, it will include direction to document procedures for completing and documenting review of the progress and fiscal reports, procedures for completing and documenting desk reviews or on-site visits, and for procedures for assessing and documenting the reliance that can be placed on review of a subrecipient’s single audit report. Grant Managers and their designees are encouraged to use the Internal Controls Checklist as a monitoring plan by evaluating each item in the checklist and saving the procedures, documents, and emails associated with those steps in a folder, in addition to the program’s usual record keeping practice, to enhance the effectiveness of the information. Grant Managers and their designees may also produce a separate monitoring plan instead of using the Internal Controls Checklist, and if a separate document is produced, management oversight will be documented within the plan. We recommend the Wisconsin Department of Health Services: • Develop a central location to maintain documentation related to the subrecipient monitoring, including email correspondence. Wisconsin Department of Health Services Planned Corrective Action: Grant Managers and their designees maintain documentation related to subrecipient monitoring in various ways, and to provide better consistency, the newly created Internal Controls Checklist provides some recommendations. The Internal Controls Checklist recommends Grant Managers and their designees develop plans for archiving relevant documents for program administration and to maintain information to support subgrantee monitoring, including risk analyses and reporting. Individual units in DHS DPH will develop a central location to maintain documentation related to the subrecipient monitoring, including email correspondence. We recommend the Wisconsin Department of Health Services: • Provide sufficient training to the Department of Health Services staff administering the Health Disparities program to ensure all subrecipient monitoring responsibilities are completed consistently and are based on the risk assessment level determined. Wisconsin Department of Health Services Planned Corrective Action: Current Grant Managers and their designees in DHS DPH who oversee federally awarded programs will be informed of the federal requirements as they relate to 2 CRF s. 200.331, though specific subrecipient monitoring. DHS DPH will administer annual trainings to Grant Administrators and their designees on subrecipient monitoring requirements and policies for conducting risk assessments. Anticipated Completion Date: June 30, 2025 Person responsible for corrective action: Natalie Easterday, Director Office of Preparedness & Emergency Health Care, Division of Public Health natalie.easterday@dhs.wisconsin.gov

Department staff has reviewed the Legislative Audit Bureau’s (LAB) interim audit memo for Finding 2023-308: Aging Cluster – Subrecipient Monitoring. This is the department’s response. Recommendation (2023-308): Aging Cluster – Subrecipient Monitoring We recommend the Wisconsin Department of Health Services: • Create a centralized tracking process to monitor the receipt of the quarterly financial reports and semiannual financial reports from each Area Agency on Aging, including follow-up procedures when reports are not provided. Wisconsin Department of Health Services Planned Corrective Action: We will create a centralized tracking process that documents receipt of quarterly reports from each of the three Area Agencies on Aging, which we require to provide the basis for our annual federal reports. This tracking tool will also document any follow up measures taken if reports are late or not submitted. We recommend the Wisconsin Department of Health Services: • Implement procedures to document the review and approval of the quarterly financial reports and semiannual financial reports, including related follow-up and resolution. Wisconsin Department of Health Services Planned Corrective Action: The centralized tracking process will include documentation of the review and approval of the reports, including any follow up to address and resolve problems with the submissions. We recommend the Wisconsin Department of Health Services • Develop and maintain in a central location documentation related to the monitoring procedures performed, including email correspondence or documentation of oversight meetings such as agendas and significant discussion topics. Wisconsin Department of Health Services Planned Corrective Action: We will create and deploy standard agenda templates for our oversight meetings with Area Agency on Aging program management and fiscal management and will record minutes of these meetings including documenting attendance, topics address, and decisions requiring follow-up actions. The new tracking tools and the meeting agendas and minutes will be maintained in shared document storage space for ready access by all management and fiscal team members and will be monitored by leadership for completion. Anticipated Completion Date: June 1, 2024 Person responsible for corrective action: Cynthia Ofstead, Director Office on Aging, Bureau of Aging and Disability, Division of Public Health cynthia.ofstead@dhs.wisconsin.gov

Finding 2023-800: Geographic Programs -Great Lakes Restoration Initiative— Subrecipient Monitoring Planned Corrective Action: DNR will develop a written plan for monitoring subrecipients for the Geographic Programs-Great Lakes Restoration initiative program. This plan will include completing a documented risk assessment for each subrecipient and specific steps for monitoring subrecipients based on the assessed level of risk. In addition,DNR will develop a process to ensure that subrecipient audit reports are received, the review is documented and will follow-up with subrecipients to ensure all audit reports are received. Anticipated Completion Date:11/1/24 Name, Title: Wade Strickland, Director Office: Office of Great Waters Email address: wade.strickland@wisconsin.gov Person responsible for corrective action: Name, Title:Karen Van Schoonhoven,Finance Director Division or Unit (if applicable): Internal Services Division Email address: karena.vanschoonhoven@wisconsin.gov

Finding 2023-103: Emergency Rental Assistance Program—Subrecipient Monitoring Auditor Recommendation: Review its existing monitoring procedures and ensure adequate management oversight procedures are established, documented, and followed. Planned Corrective Action: The Wisconsin Department of Administration (Department) has reviewed its existing monitoring procedures, designed to ensure that subrecipients use the subaward for authorized purposes, take timely and appropriate action on all deficiencies detected through monitoring, and comply with the terms and conditions of the subaward, as required by 2 CFR s. 200.332 (d) through (f), and its own policies and procedures. The Department will improve the completeness and effectiveness of its monitoring program by ensuring that management oversight procedures are appropriately established, documented, and followed. Auditor Recommendation: Complete review and follow-up with the community action agencies or Energy Services, Inc. (ESI) identified by its existing monitoring procedures. Planned Corrective Action: The Department will complete review and follow-up with the community action agencies or Energy Services, Inc. (ESI) in accordance with its existing monitoring procedures.Auditor Recommendation: Consider if additional monitoring should be completed for the community action agencies or ESI for the months during FY 2022-23 when the Department of Administration paused monitoring for the Emergency Rental Assistance Program. Planned Corrective Action: To maintain the integrity of its Emergency Rental Assistance monitoring program, the Department will complete additional monitoring of the community action agencies and ESI during FY 2022-23, including during the period acceptance of new program applications was temporarily paused. Anticipated Completion Date: June 30, 2024. Persons responsible for corrective action: David Pawlisch, Administrator Division of Energy, Housing and Community Resources david.pawlisch@wisconsin.gov

CORRECTIVE ACTION PLAN February 15, 2024 The Tor Project, Inc. (the Organization) respectfully submits the following corrective action plan for the year ended June 30, 2023. Name and address of independent accounting firm: CohnReznick LLP 350 Granite Street, Suite 1200 Braintree, MA 02184 Audit period: July 1, 2022 – June 30, 2023 The findings from the June 30, 2023 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. Federal Award Findings and Questioned Costs Significant Deficiency Item #2023-001 - Subrecipient Monitoring International Programs to Support Democracy Human Rights and Labor – 19.345 Issue: The Organization did not fully monitor the subrecipients to ensure the subaward was 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. Recommendation: Management should 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 per 2 CFR 200.332. Action Taken: Subsequent to fiscal year end, the Agency implemented additional internal controls over subrecipient monitoring and retroactively performed these compliance procedures. The Tor Project, Inc. sampled monthly invoice periods for each active sub-recipient, per grant, in the period of the FY23 annual external audit. The Tor Project reviewed all supporting documentation for the cost reimbursements of the sample to ensure accuracy and completeness of all reimbursed costs. For all sub-recipients, The Tor Project performed the internal audit procedure selecting a sample of monthly invoices at random per sub-recipient, per grant, per year to verify the completeness and accuracy of all reimbursed costs. If there are any questions regarding this plan, please call Susan Abt at 781-307-8651.

SIGNIFICANT DEFICIENCY IN INTERNAL CONTROL OVER COMPLIANCE – U.S. DEPARTMENT OF EDUCATION, PASSED THROUGH MINNESOTA DEPARTMENT OF EDUCATION, CAREER AND TECHNICAL EDUCATION – BASIC GRANTS TO STATES – FEDERAL ALN 84.048 2023-001 Internal Control Over Compliance With Subrecipient Monitoring Requirements Finding Summary 2 CFR § 200.332 requires Intermediate District No. 287 (the District) as a pass-through entity, to have written subrecipient monitoring policies and procedures that include a written risk assessment of each subrecipient and documentation of the District’s monitoring of the subrecipient. Additionally, as a pass-through entity, the District is required to verify that every subrecipient is audited as required by 2 CFR § 200 Subpart F when it is expected that the subrecipient’s federal awards expended during the respective fiscal year equaled or exceeded the threshold for a federal Single Audit. During our audit, we noted that the District did have documented written controls to ensure compliance with the U.S. Office of Management and Budget’s Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) subrecipient monitoring requirements. The District did not maintain documentation of its evaluation of each subrecipient’s risk of noncompliance with federal statutes, regulations, and the terms and conditions of the subaward, nor did the District maintain documentation of the results of the subrecipients’ Single Audit, if any, for purposes of determining the appropriate subrecipient monitoring. Corrective Action Plan Actions Planned – The District will review its policies and procedures relating to subrecipient monitoring for its federal programs to ensure compliance with the Uniform Guidance in the future. Official Responsible – The District’s Executive Director of Business Services, Brian Schultz. Planned Completion Date – June 30, 2024. Disagreement With or Explanation of Finding – The District agrees with the finding. Plan to Monitor – The District’s Executive Director of Business Services, Brian Schultz, will assure appropriate internal controls and procedures are updated and in place to ensure compliance with subrecipient monitoring requirements.