Corrective Action Plans

Dear Mr. Waguespack:The Department of Children and Family Services (DCFS) has reviewed the finding ?Control Weakness Relating to Foster Care Subrecipient Monitoring.? The finding states DCFS did not adequately review subrecipient Foster Care Invoices submitted by the Office of Juvenile Justice (OJJ) for reimbursement of administrative expenditures to ensure billings were accurately calculated. DCFS concurs with the finding.DCFS will establish a secondary level of review to ensure accuracy of OJJ administrative invoices prior to reimbursement. The Child Welfare Consultant will review OJJ?s IVE Administrative Expenditure Invoice for accuracy. Upon verification of an accurate OJJ invoice, the Federal Programs Manager will conduct a secondary level review to confirm accurate calculation of administrative expenditures.If discrepancies are noted, the Consultant will contact OJJ for clarification and request corrections, if necessary. OJJ will be required to submit a corrected invoice. Upon receipt of the corrected invoice, the Consultant will conduct a review of the invoice to ensure accuracy. The Consultant will submit the invoice to the Federal Programs Manager for a secondary level review. This secondary level reviewer will ensure no additional issues exist and will confirm the accuracy of the calculations for administrative expenditures.Secondary level reviews of OJJ administrative expenditure invoices will begin immediately and DCFS is working with OJJ to recover the overpayment through deduction from the next FY22 Quarterly invoice submitted by OJJ.If you have any additional questions, please reach out Sharla Thomas, Child Welfare Manager 2, at Sharla.Thomas.DCFS@la.gov.

Mr. Waguespack,Please accept this response to the audit conducted by your office on the Acadiana Area Human Services District (AAHSD). There were two findings listed: 1) Inadequate Controls over Sub - Recipient Agreements; 2) Untimely Billing of Patient Services.Please find the response for each under separate letter attached.We appreciate the feedback and comments from your team and will use this information to improve our systems and processes.Finding:Inadequate Controls over Subrecipient AgreementsComment:We concur with this finding. AAHSD works closely with the Louisiana Department of Health (LDH) regarding interagency transfers (IAT) and other grant funding, including TANF and Block Grant funds. Much of the information required to demonstrate compliance with this element is maintained by LDH and was not always accessible to us in a timely manner. Additionally, we have worked with LDH to revise the documentation regarding risk assessment for the subrecipients.Corrective Action:? AAHSD will develop and implement an appropriate checklist of required information regarding:o identification of Federal award informationo a risk assessment of the subrecipients' non-compliance? AAHSD has revised our contract template to include the necessary information regarding audits of subrecipient organizations? AAHSD will request all necessary information from subrecipient organizations at the initiation of the contracting process rather than waiting on notification from LDHPerson(s) Responsible:The Executive Director is ultimately responsible for ensuring all corrective action. Specific duties may be delegated to other senior managers, specifically: the Chief Financial Officer; the Director of Behavioral Health; and the Corporate Compliance/Accreditation Officer.Timeframe:All action points implemented within 90 calendar days of receiving the final audit report.

Dear Mr. Waguespack,The Louisiana Workforce Commission (LWC) respectfully submits its response to the Single Audit Report finding of Inadequate Controls Over and Noncompliance with Subrecipient Monitoring Requirements.First and foremost, it is important to note that the Compliance and Monitoring Unit of LWC has been working very diligently to comply with the requirements of the Workforce Innovation and Opportunity Act (WIOA) of annual monitoring reviews of subrecipients. LWC recognizes the importance of monitoring our subrecipients and in doing so performs their due diligence to ensure that compliance with all legal requirements within WIOA are met. Enormous strides are being made towards improving and sustaining the great work that has already been done. We will continue our efforts to ensure that we remain on track in accomplishing full compliance with subrecipient monitoring at the close of the current fiscal year.Should you have any questions or need additional information, please feel free to contact my office at (225) 342-3001.? Two monitoring reports were not issued timely by LWC. The monitoring reports were issued 74 and 75 days after the completion of the monitoring review. LWC?s policy requires monitoring review reports to be issued 60 days after the completion of the monitoring review.? LWC concurs with this portion of the finding that 2 out of the 15 monitoring reports were issued more than 60 days after the conclusion of the monitoring review. We find it important to note that the late issuance of the 2 monitoring reports is a direct result of the many challenges LWC faced during the monitoring cycle. As a result of these challenges, LWC undertook a review of its internal policy and has made revisions to the policy with regard to, among other things, the timeliness of the issuance of monitoring reports.? For four monitoring reports, close out letters were issued 145 to 191 days after monitoring report issuance. For six monitoring reports, close out letters were not issued as of January 2023 while the monitoring reports for these reviews were issued over 200 days prior. The monitoring reports include findings with possible questioned cost totaling $3.1 million. LWC policy does not specifically address timeliness requirements for closeout letters.? LWC concurs in part with this finding concluding that four close out letters were issued 145 to 191 days after monitoring report issuance and that six close out letters were not issued as of January 2023 while the monitoring reports for these reviews were issued over 200 days prior. However, LWC does not concur with the overarching conclusion that its policy does not specifically address timeliness requirements for closeout letters.A closeout letter is not generated to a subrecipient unless all findings identified in the monitoring report have been resolved. When findings are identified in the monitoring report, subrecipients are given the opportunity to clear those findings by submitting a Corrective Action Plan (CAP). A CAP is the subrecipient?s opportunity to address the cause of the findings and provide LWC with a well thought-out plan not only address the cause of the finding but to implement steps to prevent findings of that nature in the future. Until the CAP is submitted, all steps executed, and a determination that the finding has been resolved, a closeout letter will not be issued.If a subrecipient submits a CAP, LWC periodically reviews the CAP with the subrecipient to determine whether sufficient steps are being taken toward resolution of the finding(s). If at some point, it is determined that resolution is not attainable, an initial determination is then issued.For the time period covering the Single Audit, LWC?s policy provided for the following:? Within 45 days of issuance of the monitoring report, the subrecipient must submit a corrective action plan for all findings listed in the monitoring report.? Within 30 days of receiving the corrective action plan from the subrecipient, LWC would notify the subrecipient of acceptance or rejection of the corrective action plan.The next step in the process, as articulated in LWC?s policy is the initial determination.? Three subrecipients had findings on the monitoring reports stemming from a lack of documentation supporting the subrecipients? drawdowns of WIOA funds and drawdowns of federal funds could not be reconciled by LWC to the subrecipients accounting records. The monitoring reports noted potential questioned cost associated with these drawdowns. These reviews are included in the six monitoring reports not issued as of January 2023, noted in the bullet above. Timely resolution would allow LWC to quickly address any compliance issues at the subrecipients? level. According to LWC, it is working with the subrecipients to reconcile the federal funds drawdowns and close out the reports.? LWC received unorganized data from the subrecipients. In response to LWC?s request for financial documentation such as general ledgers, balance sheets, expenditure reporting, invoices, etc., subrecipients basically did a data dump. There was no legend or other identifying information associated with the data that was submitted and opening each unidentified file, reviewing it and trying to identify it with thousands of transaction for 15 subrecipients proved tedious, time-consuming and confusing. In an effort to stick as closely as possible to very tight timelines, LWC issued a finding within the monitoring report anticipating that the finding would compel the subrecipients to work with LWC to resolve the differences. As a result of issuing these findings the subrecipients developed corrective action plans to resolve the differences in the drawdown reconciliations. LWC created internal control documents to assist in the organization of material received from the subrecipients. The documents will be utilized when performing the review of the financial portions of the monitoring.Documents that were created include:REQUEST FOR DOCUMENTS - The ?Request for Documents? is a document that details for the subrecipient how documents are to be submitted and labeled. Attached is a copy of the Request for Documents and a detail of the new layout of how the documents are to be uploaded. Portions of the corrective action plan were omitted due to character limitations; See Corrective Action Plan for attachment.INTERNAL CONTROL QUESTIONNAIRE - The ?Internal Control Questionnaire? is a series of queries that helps LWC understand the structure and workflow of the subrecipient. Attached is a copy of the Internal Control Questionnaire. Portions of the corrective action plan were omitted due to character limitations; See Corrective Action Plan for attachment.The new format has significantly reduced the amount of time to complete the financial monitoring of the subrecipient.

Dear Mr. Waguespack,Please find below our management response to the audit finding "Noncompliance with Subrecipient Monitoring Requirements".The University does not concur that this is a second consecutive year finding, but in fact the same one from FY2021.The completion of FY2021 audit and the start of FY2022 audit did not allow the University time in between to correct the FY2021 finding.The following is timeline for the FY2021 finding.? Notification of potential finding was issued on 5/26/22.? Preliminary response request was issued on 5/26/2022.? Preliminary finding response was submitted on 6/2/2022.? Audit response request letter was submitted on 6/6/22.? Audit response was submitted on 6/13/22.Sponsored Programs Finance Administration and Compliance (SPFAC) will continue the following corrective action provided in FY2021 and it will be overseen by Director of SPFAC.1. Continue with our procedures to adequately monitor subrecipients.2. Implement a risk assessment questionnaire and have Senior SPFAC staff complete one for every sub recipient per 2 CFR 200.332 (f).

Finding Number 2022-206: The Department did not complete required subrecipient monitoring of the Elementary and Secondary School Emergency Relief (ESSER) Fund of the Education Stabilization Fund.Federal Programs:84.425U - Education Stabilization Fund ? ARPA ESSER III84.425D - Education Stabilization Fund - Elementary and Secondary School Emergency Relief Fund84.425W - Education Stabilization Fund - ARPA ESSER - Homeless Children and Youth84.425R - Education Stabilization Fund - Emergency Assistance for Non-Public SchoolsRelated to Prior Finding: 2021-204Agency?s view: The Department agrees with this finding.Corrective Action: It was not until the end of the 2022 legislative session that spending authority was given to the State Department of Education to use ARP ESSER Sincerely, administrative funds to hire additional staff to meet the robust requirements identified by the U.S. Department of Education. Up to that point, only one full-time person was handling all of the needs associated with ESSER funds. Since then, two positions have been hired. The ESSER Data and Reporting Coordinator began in April 2022, and the ESSER Monitoring Coordinator began in June 2022. While developing the monitoring procedures began in July 2022, it was after the audit timeframe. The Department now has in place all ESSER monitoring policies and procedures and will complete year one monitoring before May 5, 2023.Anticipated Corrective Action Date: May 2023Responsible for Corrective Action: Gideon Tolman, Chief Financial Officergtolman@sde.idaho.gov 208-332-6874

Finding Number 2022-210: The Department did not review subrecipient application information for Coronavirus State and Local Fiscal Recovery Funds at a sufficient level to identify missing information from required documentation.Federal Program: 21.027 - Coronavirus State and Local Fiscal Recovery FundsRelated to Prior Finding: N/AAgency?s view: The Department agrees with this finding.In the rush to respond to emergency needs during the pandemic and the non-traditional format these funds were distributed, the Department neglected to properly review and hold incomplete attestation applications. The attestation application process was specifically developed under the pandemic, was a new process for staff, and was during the time period of transitioning from DUNS to Unique Identifier. Additionally, staff not typically involved in the subrecipient process approved the applications for payment and did not know to hold payments if the unique identifier field was blank. Finally, attestation documents did not route through the traditional internal processes where controls would have identified the gap. After funds were distributed and the misstep was realized, the Department verified Unique Identifiers through SAMS registration or by reaching out directly to the hospitals for documented proof. At the time of the audit, we did not have documentation of a unique identifier for two (2) hospitals out of the forty-three (43) awarded, but that information has subsequently been obtained.The attestation process has since been discontinued. Internal controls are in place as the Department procurement policy; staff are trained to check SAM.gov on all subrecipients. Additionally, internal forms needed to execute a subrecipient agreement require documentation of the Unique Identifier. If the Unique Identifier field is left blank, the Department Contracts and Procurement Unit will not process the agreement request. This finding was a result of a new process and untrained staff pulled into the rapid dispersal of COVID funds.Corrective Action: Corrective action is complete. Internal controls are in place as the Department procurement policy; staff are trained to check SAM.gov on all subrecipients. Additionally, internal forms needed to execute a subrecipient agreement require documentation of the Unique Identifier. If the Unique Identifier field is left blank, the Department Contracts and Procurement Unit will not process the agreement request. This finding was a result of a new process and untrained staff pulled into the rapid dispersal of COVID funds.Anticipated Corrective Action Date: Corrective action has been taken as of April 2023Responsible for Corrective Action: Kelly Combs, Bureau Chief, Compliancekelly.combs@dhw.idaho.gov 208-334-5814

Finding: 2022-027 ? Department of Education and Early Development staff did not document risk assessments for non-Local Educational Agency (LEA) subrecipients.Questioned Costs: NoneAssistance Listing Number: 84.425D; 84.425UAssistance Listing Title: ESSER ? COVID-19; ARP ESSER Fund ? COVID-19Views of Responsible Officials (state whether your agency agrees or disagrees with the finding; if you disagree, briefly explain why): The department agrees with Finding 2022-027.Corrective Action (corrective action planned): Risk assessments for the FY2023 grant year are being done prior to grant payments for all grantees. Program staff have also implemented formal subrecipient monitoring in FY2023.Completion Date (list anticipated completion date): July 30, 2023Agency Contact (name of person responsible for corrective action): Deb Riddle, Division Operations Manager, Division of Innovation and Education Excellence

Finding: 2022-062 - For one of two subrecipients, DCCED staff did not identify all federally required information on the FY 22 Coronavirus State and Local Fiscal Recovery Fund (SLFRF) subaward or conduct a risk assessment.Questioned Costs: NoneAssistance Listing Number: 21.027Assistance Listing Title: SLFRFViews of Responsible Officials (state whether your agency agrees or disagrees with the finding; if you disagree, briefly explain why): The Department of Commerce, Community and Economic Development agrees with the finding.Corrective Action (corrective action planned): Staff administering the Coronavirus State and Local Fiscal Recovery Fund programs have been advised of the subrecipient status and provided guidance to ensure compliance with future federally funded subawards. TheSubrecipient was provided the federally required information, and a risk assessment was completed.Completion Date (list anticipated completion date): 04/30/2023Agency Contact (name of person responsible for corrective action): Jenny McDowell, Finance Officer

Finding: 2022-061 - DCCED staff did not issue timely management decisions for three of the four Coronavirus Relief Fund (CRF) single audit findings requiring follow-up during FY 22.Questioned Costs: NoneAssistance Listing Number: 21.019Assistance Listing Title: CRF - COVID-19Views of Responsible Officials (state whether your agency agrees or disagrees with the finding; if you disagree, briefly explain why): The Department of Commerce, Community and Economic Development agrees with the finding.Corrective Action (corrective action planned): The department has reviewed and revised the internal single audit tracking process.Completion Date (list anticipated completion date): January 1, 2022Agency Contact (name of person responsible for corrective action): Jenny McDowell, Finance Officer

Recommendation: The auditors recommend the University implement internal controls to assess the risk of the subrecipient and properly monitor any subrecipients of the University, such as reviewing single audits, financial and performance reports, or other necessary documentation of the subrecipient entity to help ensure the subrecipient is in compliance.Planned Corrective Action: In agreement with the auditor?s recommendation of internal controls to properly monitor any subrecipients of the University, such as reviewing financial and performance reports of the subreceipient entity including any single audit reports. Heritage University has finalized the new ?Grant Management Policy & Procedures? manual. The grant management manual section on subrecipient is explicit about the University?s policies and procedures to ensure documentation is maintained.Name of Responsible Party:1. Yolanda Maltos, Grant Accountant2. Alysia Stevens, Controller3. Tom Richter, VP of Administration/CFO4. Andrew Sund, PresidentAnticipated Completion Date: September 30, 2023

This payment was a one-time payment for a single project completed by the City of Meridian. Moving forward, Lauderdale County will document the completion of the project.

Public Health’s Center for Preparedness and Response (CPR) agrees that it did not establish a formal risk assessment process over its subrecipients of ELC COVID-19 awards. CPR will establish and document formal procedures for conducting risk assessments of ELC subrecipients. Public Health will also develop and implement specific subrecipient monitoring procedures. CPR also agrees that it did not obtain single audit reports from ELC subrecipients. CPR will develop and implement procedures outlining the process for obtaining single audit reports from subrecipients, which will include a monitoring mechanism to track compliance with the single audit mandate. Estimated Implementation Date: December 2024 Contact: Melissa Relles, Assistant Deputy Director Division of Operations Center for Preparedness and Response California Department of Public Health

The County should establish policies and procedures to ensure risk assessment is documented. The County should also obtain the single audit reports for their subrecipients and issue management decision letters as part of their monitoring. Atonya Moore Deputy Director – Fiscal Kings County Human Services Agency 559-852-2214

EARPDC will amend subrecipient monitoring process to include a review of subrecipient's audit.

2022-002 Compliance and Internal Controls over Subrecipient Fiscal Monitoring (Significant Deficiency) U.S. Department of Housing and Urban Development 14.241- Housing Opportunities for Persons with AIDS Contract No. 537-17-0195-00001 and HHS001022300003 Texas Department of State Health Services State HIV Service Grants Contracts No. 537-18-0097-00001 and HHS001022300002 Recommendation: The Resource Group should follow its policies to perform fiscal monitoring of its subrecipients in accordance with 2 CFR Section 200.332. Corrective Action: In accordance with 2 CFR Section 200.332, The Resource Group as the pass-through entity will ensure subrecipient fiscal monitoring is completed in 2024 to ensure compliance with federal and state requirements. The Finance Director is responsible for oversight and administration of fiscal monitoring. Fiscal monitoring will be conducted at least annually in accordance with HRSA Monitoring Standards 45 CFR 74.51 and 45 CFR 75.352. As a pass-through entity, the fiscal monitoring will include at minimum reviews of financial performance and compliance with federal and state statues, regulations and terms and conditions. The process will include desktop/remote verification of applicable financial policy and procedures and an onsite review. A standardized monitoring tool will be used to evaluate financial compliance. The fiscal monitoring observations will result in a monitoring report, disseminated to the subrecipient within 60 days of the onsite review. Progress to date: 1. The Finance Director was hired in August 2023. To support the financial monitoring efforts, technical assistance was received on February 5-7, 2024, from the DSHS Fiscal Support and Oversight department. The primary objective of the visit was to discuss financial monitoring requirements as it allies to state and federal regulations, statues and terms and conditions. The standardized monitoring tool was also evaluated for compliance. 2. The Finance Director has developed a fiscal monitoring schedule for 2024. Onsite reviews started in February 2024. The testing period for subrecipient monitoring has been expanded to include a testing period from Fiscal Year 2022 and Fiscal Year 2023. Responsible Party: Finance Director, Garland Thompson Date to be Corrected: February-August 2024

Federal Program Community Programs to Improve Minority Health - 93.137, Contract 1 CPIMP211290-01-00 Condition The City did not perform a risk assessment or any additional monitoring of subrecipients beyond reviewing requests for payment. Cause This is a new grant for the City in 2022 and there was turnover in the grant director position during the year. Recommendation We recommend that the City continue developing standard operating procedures for subrecipient monitoring of grant activities. This is especially important for grants handled outside the community development office. Management Response City management agrees with this finding. We have an assessment tool from the ARPA Small business program that can be repurposed as a risk assessment for this program. Both the City’s Director and employee assigned to this Federal award understand subrecipient monitoring is required for sub awardees. There are monthly subgrant reports and quarterly HUD reports to back up all the work being done under the grant. The Director of Finance will oversee the work of these two City employees. Anticipated Completion Date - Ongoing

Finding 2022-002 - Department of Health and Human Services – Research & Development Cluster- Subrecipient Monitoring Statement of Condition: No formal documentation existed to indicate that the Foundation performed the required monitoring of its subrecipient’s activity and no written policy exists to establish procedures to document the monitoring of the subrecipient. Management Response: The RTOG Foundation Inc. currently utilizes a standard form “Subrecipient’s Compliance With Uniform Administrative Requirements, Cost Principles, and Audit Requirements For Federal Awards, Subpart F” with all federally-funded grants and cooperative agreements subject to the Uniform Guidance. Additionally, activity of the sole subrecipient of the Foundation, the American College of Radiology (ACR) is monitored under the Management Services Agreement with the NSABP Foundation Inc., via routine analysis and documentation of ongoing activities as well as the inspection of ACR financial statements to ensure compliance with 2 CFR 200.332.

The county added information to the Payment Request Form to ensure that sub recipients are aware of possible single audit requirements, active SAM registry and UEI.

Management concurs with this finding. As noted in the response to Subrecipient Monitoring – Improper Communication to Subrecipient, Subrecipient vs. contractor differentiation has been an area of continued improvement. Management believes recent efforts to properly differentiate between subrecipients and contractors has resulted in accurate determinations. However, documentation, ongoing monitoring, and communication are areas for further improvement. To that end, Management has implemented a new subrecipient/contractor determination form that includes both documentation of the determination and a checklist for ongoing compliance and monitoring for both subrecipients and contractors. This form requires that a subrecipient monitoring plan be put in place which will address compliance with all applicable federal award conditions including Single Audits. Management believes implementation of this form/process will reduce the risk of further noncompliance.

Recommendation: We recommend the Agency monitors its subrecipients regularly. Action Taken: In March 2023, the Agency hired a new Executive Director and in August 2023, a new Fiscal Officer. The new management team has implemented policies and procedures to comply with subrecipient monitoring requirements.

2022-006 Subrecipient Monitoring U.S. Department of Labor Assistance Listing Number 17.258/17.259/17.278 Recommendation: We recommend that the Board review its policies and procedures for sufficiency and commit the appropriate personnel to subrecipient monitoring to ensure that the Board is in compliance with all federal requirements. Action Taken: With the assistance of Workforce WV, the Board met with a private company representative (via Zoom) who made recommendations to the Board for fiscal monitoring of the Board’s subrecipient. A plan is in the process of accomplishing this action for both 21-22 and 22-23 Fiscal Years. The Board is planning on submitting a monitoring report within the next week. This process will be developed, and a six-month monitoring period is being developed to enter into the Board’s policies and procedures as a normal course of action.

Community Partners acknowledges that while subrecipient monitoring was performed for federal subrecipients by hiring third party CPAs, the monitoring was based on randomly selected samples and a risk assessment was not included in the monitoring plan. Current leadership has enhanced the subrecipient monitoring plan by ensuring that risk assessments are incorporated into any future subrecipient monitoring. The person responsible for the corrective action detailed above will be Joyce Williams, Chief Financial and Operations Officer, (213) 346‐3202. We anticipate corrective action will be completed by June 30, 2024.

The Board of County Commissioners will work with all County Officials to go over all grants. The Board of County Commissioners will take measures to ensure future compliance with all requirements of federal grants

The Logan County Commission will endeavor to put procedures in place to ensure subrecepient monitoring requirements are performed in compliance with all applicable, material compliance requirements of the Grant agreement.

CORRECTIVE ACTION PLAN September 28, 2023 Crawford County Human Services respectfully submits the following corrective action plan for calendar year ended December 31, 2022. Name and address of independent public accounting firm: Maher Duessel, CPA’s 503 Martindale Street, Suite 600 Pittsburgh, PA 15212 Audit period: January 1, 2022 – December 31, 2022 The finding from the December 31,2022 schedule of findings is discussed below: FINDING—SUBRECIPIENT MONITORING Dept. of Health and Human Services Passed through PA Dept. of Human Services Foster Care – Title IV-E – ALN 93.658 Finding 2002-002 Recommendation: We recommend that the County ensure adherence to the monitoring policy related to subrecipients and that these subrecipients be monitored on an annual basis in accordance with the policy. Action taken: Crawford County Human Services has created a Fiscal Technician position to aid in the monitoring process. The Fiscal Technician position has been approved by the County Commissioners and State Civil Service. Crawford County Human Services is activity recruiting for the position. The monitoring policy will be updated to insure inclusion of IV-E providers and will outline a set of criteria to determine the frequency of monitoring. Sincerely yours, Roberta Clark Fiscal Operations Officers Crawford County Human Services