Corrective Action Plans

Name of the Contact Person Responsible for the Corrective Action Plan: Jeremi Patterson, Deputy Finance Director. Corrective Action Plan: The City of Forest Park will take necessary steps in the future to ensure that our subrecipient agreements include all of the required federal compliance language and we will ensure that risk assessments are performed for future subrecipients. Anticipated Completion Date: December 31, 2023

The City has implemented steps to be more proactive in subrecipient monitoring and will perform additional testing to meets these requirements.

SUBRECIPIENT MONITORING Recommendation: We recognize the agency has established a policy over sub-grant recipient files effective June 29, 2017. We recommend the policy begin to be enforced in fiscal year 2023. Also, we recommend any updating to the policy for 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. Corrective Action: The Department understands this issue. Administrative Services Bureau does complete subrecipient monitoring via desktop review and uses a monitoring checklist housed in the subgrant files. The Department has onboarded a Grants Unit Manager to include oversight of the subrecipient monitoring process. The process is currently being reviewed, modified, and implemented. Now that COVID restrictions have been lifted significantly, the Sub Grant Analysts will include physical monitoring visits as well as desk monitoring reviews as part of their job duties in FY23. Due Date of Completion: June 30, 2023 Responsible Person(s): Chief Financial Officer, Grants Unit Manager

SUBRECIPIENT MONITORING Division of Emergency Management (DEM) Assistance Listing Number 97.036, COVID-19 97.036 A new grant monitor has been hired for the recovery grants managed by DEM. The monitor has reviewed and updated the agency policies related to subrecipient monitoring and is conducting training with other program staff to ensure understanding. The Public Assistance (PA) Program in DEM has completed the Risk Assessment for 2022 using the risk assessment tool and identified the highest risk project worksheets. DEM is reviewing the municipal audits conducted by the State Auditor?s office for PA sub-recipients. DEM has developed a Monitoring Plan for the coming year and completed a calendar of upcoming monitoring visits. DEM is using the FEMA approved monitoring protocol and the subrecipient monitoring standards outlined in 2 CFR 200.303, and it is our belief that we are complying with all applicable regulations and requirements.

CORRECTIVE ACTION PLAN Finding 2022-002: Subrecipient Monitoring Public Allies has developed a Risk Assessment tool that will be implemented with subgrantees ("local sites") for Program Year '23. The tool?s development was driven by noted best practices and guidance shared with AmeriCorps grantees and Public Allies? prior monitoring findings. The tool includes a self-assessment by local sites and the results will drive the level of monitoring and training and assistance each site receives. Public Allies will also be piloting a new Progress Report, that will provide an at-a-glance assessment of site performance based upon metrics determined in collaboration with subgrantees. The programmatic monitoring process will be led by a dedicated monitoring team that is supported by staff that provide direct programmatic training and technical assistance to sites. For fiscal monitoring, Public Allies has shifted from outsourcing all accounting and financial management to bringing all accounting in-house. As described above, this staff now includes a Finance Director, a Staff Accountant and Senior Accountant. This shift was the result of an evaluation of internal operations and financial management systems. The addition of multiple full-time accounting staff has improved our capacity to monitor and manage subgrantees, effectively track and manage process improvements, ensure fiscal-related grants compliance, and efficiently manage our federal grant funding requests and reports. A fiscal Grants Manager was hired to review subgrantee financial reporting, provide technical assistance, and implement financial monitoring of subrecipients. Finally, a desk audit will be implemented in FY23. The number of files to be reviewed for each site will be determined based upon risk factors assessed, including: AmeriCorps Monitoring Common Findings, staff retention data, prevalence of turnover in AmeriCorps members, and length of time since the site underwent an audit. Requested programmatic and fiscal documents will include: ? Ally/Member Leadership Journal Position Descriptions ? Time Logs ? Ally/Member Evaluations ? Exit Documentation ? Ally/Member Payroll Register, and ? Operating Partner Due Diligence ? Annual Financial Statement ? Separation of Duties Survey ? Internal Controls Questionnaire The Public Allies Network will be notified of the Desk-Based Audit by May 26th and the desk audit will conclude by fiscal year end. Findings of the audit, in the form of a Monitoring Report will be shared with subrecipients, including required follow-up necessary to remediate compliance findings. Results of the desk audit will be used to determine future training needs, policy recommendations, and future monitoring Person Responsible: Najah Woods, Apprenticeship Program Grants Manager Implementation Date: August 31, 2023

2022-066 Oregon Department of Education Improve subrecipient monitoring procedures Federal Awarding Agency: U.S. Department of Education Assistance Listing Number and Name: 84.425C, 84.425D, 84.425U & 84.425W Education Stabilization Fund (COVID-19) Federal Award Numbers and Years: S425C200048; 2020 (COVID-19), S425D200049; 2020 (COVID-19), S425C210048; 2021 (COVID-19), S425D210049; 2021 (COVID-19), S425U210049; 2021 (COVID-19), S425W210038; 2021 (COVID-19) Compliance Requirement: Subrecipient Monitoring Type of Finding: Significant Deficiency; Noncompliance Prior Year Finding: N/A Questioned Costs: N/A Criteria: 2 CFR 200.332 Federal regulations require the department to evaluate each subrecipients risk of noncompliance with Federal statues, regulations, and the terms and conditions of the subaward for purposes of determining the appropriate monitoring to perform. In addition, the department should monitor the activities of the subrecipients receiving funds to ensure the subaward is used for authorized purposes, is in compliance with Federal statutes, regulations, and the terms and condition of the subaward; and the subaward performance goals are achieved. Depending on the department risk assessment, which was not performed, the department could perform various monitoring tools to ensure accountability and compliance. As of June 30, 2022, the department was still in the process of drafting and implementing a plan to monitor the funds. The department had not completed a risk assessment process of the local educational agencies (LEA) for these funds and stated it planned to begin some desk or on-site monitoring in Spring 2023. $522 million in funds have been passed through to subrecipients as of June 30, 2022. The department required LEA?s to submit applications to receive funds and sign agreements that outlined all federal requirements. In addition, the department also required the LEA?s to complete a reimbursement request form that contains general ledger detail but no additional support is provided. According to the department, it follows-up with a LEA if funds appear to be ineligible or other questions are raised. Finally, although LEAs programs may have had a single audit the department could not provide a list of which LEAs had audits and whether there were findings or not. In fiscal year 2021, the department was also working to finalize its risk assessment and monitoring plans. However, the department experienced staff turnover which delayed its plans. Insufficient subrecipient monitoring increases the risk of not timely identifying subrecipients that are not administering federal awards in compliance with federal requirements. We recommend department management complete its risk assessment, consider the results of LEAs single audits and perform desk or on-site monitoring as necessary. MANAGEMENT RESPONSE: We agree with this recommendation. ODE acknowledges that it did not implement pandemic funding related desk audit and site monitoring procedures in FY 21. FY 21 saw the COVID-19 Delta and Omicron variants continue to infect school staff and students so on-site visits were not feasible. The pandemic also forced districts to dedicate administrator time and attention to student health and safety and adjusting to the ever-changing health environment, guidance and requirements. In anticipation of such challenges during the pandemic, ODE set up the ESSER reimbursements to districts allows for much more detailed reporting when requesting reimbursement to allow ODE to track how districts were spending their funds. While not traditional monitoring, it was an effective, efficient, and creative way to ensure ODE spending oversight in unprecedented times. As discussed with Secretary of State auditors, ODE finalized and implemented a risk assessment tool in the spring of 2023 and has completed an initial set of ten monitoring desk reviews with districts. Anticipated Completion Date: June 30, 2024 Contact: Cynthia Stinson, Senior Manager of Federal Investments & Pandemic, Renewal Effort, OTLA

2022-029 Oregon Housing and Community Services Ensure accessible documentation to evidence compliance with program requirements Federal Awarding Agency: U.S. Department of the Treasury Assistance Listing Number and Name: 21.023 Emergency Rental Assistance Program (COVID-19) Federal Award Numbers and Years: ERA 1, 2021 (COVID-19) Compliance Requirement: Activities Allowed or Unallowed; Allowable Costs/Cost Principles; Eligibility Type of Finding: Material Weakness Prior Year Finding: N/A Questioned Costs: N/A Criteria: 2 CFR 200.302(a); 2 CFR 200.332(a)(5) Department management is responsible for communicating to subrecipients that they are required to permit the department and auditors access to their records as necessary to ensure the department is compliant with program requirements. To ensure compliance with program requirements, subrecipient records must also be sufficiently detailed. The department passed through $140 million phase one program funds to community action agencies (subrecipients) to provide program delivery. The department performed limited fiscal monitoring during the audit period which included procedures to address compliance with activities allowed and allowable cost requirements for administrative costs. The department did not perform any program monitoring during the audit period which primarily addresses compliance with eligibility requirements. To determine whether the department complied with program requirements for the fiscal year, auditors attempted to reconcile detailed subrecipient ledgers with the intent of selecting and testing sample items at each individual subrecipient organization. We noted issues with two individual subrecipients, resulting in an inability to perform testing procedures over a total of $21,438,521 in program expenditures. For the first subrecipient we were able to reconcile their detailed ledgers to the department?s financial records, however their detailed ledger included pass-through payments to a third organization for program delivery. As a result of the combination of direct and pass-through payments, we were unable to obtain sufficiently detailed data that also reconciled to the department?s financial records to select individual transactions for testing. This subrecipient represents $19,877,962 of the unaudited expenditures. For the second subrecipient we were able to reconcile their detailed ledgers to the department?s financial records and select administrative and program transactions for testing. However, the subrecipient was unresponsive to documentation requests to substantiate expenditures. This subrecipient accounted for $1,560,559 of the unaudited expenditures. We recommend department management obtain and reconcile sufficiently detailed subrecipient ledgers and support to substantiate expenditures to allow for fiscal and program monitoring to ensure subrecipients are administering program funds in accordance with program requirements. MANAGEMENT RESPONSE: We agree with this recommendation. To effectively deliver much needed funds to maintain the housing stability of tens of thousands of Oregonians on the brink of experiencing homelessness during the pandemic, agency staff raced to stand up a first-of-its-kind ?single entry point? program for Oregonians to apply for assistance regardless of zip code. In our efforts to focus on speed we acknowledge that there was insufficient planning and capacity to stand up a large-scale emergency program including sufficient assurances our subrecipients could generate evidence of compliance with program requirements including transaction level details to assist with reconciliation. Oregon?s experience is in line with national findings. According to the January 2021 research brief conducted by the National Low Income Housing Coalition around key program challenges with administering emergency rental assistance programs. Survey respondents listed the two most common limitations to be staff capacity and the completeness of applications. Many agencies leaned on whatever local capacity was available to develop programs, review, and process applications, make payments and conduct outreach. Corrective action plan: OHCS had significant compliance monitoring staff turnover in FY22 leading to incomplete subrecipient monitoring reviews. OHCS completing these reviews would?ve ensured subrecipients had adequate time to produce necessary documentation to evaluate compliance, or if not, subrecipients would?ve been required to take corrective actions. For fiscal compliance, OHCS hired a contractor to perform fiscal monitoring of federal funded Grantees. OHCS also hired fiscal staff to pre-FY22 levels, fully trained them, conducted coordinated working sessions, and reached out to the CAA network for discussions on improving processes. OHCS continues to work with the contractor for much needed assistance in monitoring of back log while internal staff move forward to allow for all monitoring to be back on schedule and coordinating both fiscal and program compliance during future fiscal years. Program compliance employees have been hired and compliance efforts are underway. All providers will have internal compliance visits at regular intervals to ensure they have necessary documents and eligibility is being determined in compliance with program requirements. Additionally regular and ongoing check ins and trainings are being offered by program staff. Finally, program compliance teams are working with the Finance compliance team as well as a contracted expert to develop systems and processes in alignment with the Finance compliance team. As a result of program compliance efforts, a risk evaluation is being developed and incorporated into future contracting decisions. Efforts in hiring and systemic investments in infrastructure, processes, and procedures in addition to partner communications have taken place to ensure agency readiness in the event another emergency occurs. As part of our commitment to continual learning, our OHCS research team is collaborating closely with university and national partners to analyze our ERA program data and findings to see what themes emerge for improvement both nationally and in Oregon. Anticipated Completion Date: December 31, 2023 Contact: Jill Smith, Director of Housing Stabilization Division and Dean Criscola, Controller

2022-026 Oregon Housing and Community Services Department Implement program monitoring over client assistance payments to ensure compliance Federal Awarding Agency: U.S. Department of the Treasury Assistance Listing Number and Name: 21.023 Emergency Rental Assistance Program (COVID-19) Federal Award Numbers and Years: ERA 1, 2021; ERA 2, 2021 (COVID-19) Compliance Requirement: Activities Allowed or Unallowed; Eligibility Type of Finding: Material Weakness; Material Noncompliance Prior Year Finding: N/A Questioned Costs: $21,624 (known); $11,067,350 (likely) (COVID-19) Criteria: 2 CFR 200.332(d); 2 CFR 200.501(g) Department management is responsible for monitoring the activities of subrecipients to ensure subawards are used for authorized purposes and are compliant with federal requirements. Additionally, department management is responsible for ensuring compliance when a contractor is responsible for program compliance or the contractor?s records must be reviewed to determine program compliance. The department provided $140 million and $46 million of phase one program funds to community action agencies (subrecipients) and a third-party vendor (contractor) to provide program delivery, respectively; and $132 million phase two program funds to only the contractor. Program delivery included determining client eligibility and making payments for direct client assistance for rent, utilities, internet, and other housing related costs. During implementation of the program, the department provided program manuals to the subrecipients and contractor. Due to the department?s limited staff, they focused on updating policies and procedures to address systemic issues identified; however, if a particularly challenging application required the department?s review, they were available to provide direct assistance. The department did not implement any predefined, systemic program monitoring of the subrecipients or contractor to ensure direct client assistance payments were paid to only eligible clients for only allowable and supported amounts. Therefore, auditors performed additional procedures at the subrecipient and contractor level to determine whether direct client assistance payments were paid to eligible clients for allowable activities. We tested a total of 62 randomly selected direct client assistance payments at 16 subrecipients totaling $183,515, and found the following: One subrecipient did not respond to audit requests for documentation, resulting in an inability to test one transaction in the amount of $360. One subrecipient did not obtain documentation to support that there was a lease agreement in place, resulting in questioned costs of $5,775. When extrapolated to the total population, these errors result in over $2.3 million in likely questioned costs. We tested 61 randomly selected contractor direct client assistance payments totaling $374,274, and found the following: One payment where an incorrect landlord was paid in the amount of $2,700. Attempts to recover the funds have been unsuccessful as of the date of the finding. Two payments where the rental amount was doubled, resulting in overpayments totaling $5,910. Seven payments where amounts already paid were not accurately reflected in the calculation of assistance provided, resulting in overpayments totaling $4,191. Three payments where amounts did not agree to supporting documentation, resulting in overpayments of $2,181. Three payments where there was insufficient documentation for amounts paid, resulting in overpayments of $432. One payment where costs were paid for the same household on alternate applications, resulting in an overpayment of $73. When extrapolated to the total population, these errors result in over $8.7 million in likely questioned costs. We recommend department management implement predefined, systemic program monitoring to ensure the subrecipients and contractor are administering program funds in accordance with program requirements. MANAGEMENT RESPONSE: We agree with this recommendation. OHCS agrees and had we not been operating during a global health pandemic and had we had adequate time and staffing, we would have addressed this issue more carefully as we have in previous years. However, given that this was a new program that lacked sufficient time and resources to design, launch and operate to meet the pressing needs of Oregonians facing eviction and homelessness, the work required unprecedented action that sometimes fell short of our usual standards for client assistance payment compliance. OHCS will use these lessons moving forward should we operate future emergency programs to move towards best practices. Corrective action plan: Lack of staff significantly limited our ability to perform the necessary monitoring. An additional contractor was brought on to monitor the work of our vendor in February of 2022. The contractor continued to provide program compliance support to OHCS through the end of January 2023. This contractor was also engaged in other projects and activities as needed during their contract term. The largest workload was investigating payments or cases that were identified as potentially non-compliant. All these cases were researched extensively, and findings were identified, and corrective action and collection activities were started if needed. Out of concern for the lack of administrative dollars associated with ERA staff knew an internal compliance effort would also be required. Since the summer of 2022 OHCS staff have been conducting internal random samples of applications and payments in addition to the work of our hired contractor. Additionally, this spring the program compliance team has engaged in a formalized review process focused on specific agencies administering ERA funds. Anticipated Completion Date: December 31, 2023 Contact: Jill Smith, Director of Housing Stabilization Division

2022-025 Oregon Housing and Community Services Perform fiscal monitoring for subrecipients administrative expenditures to ensure compliance Federal Awarding Agency: U.S. Department of the Treasury Assistance Listing Number and Name: 21.023 Emergency Rental Assistance Program (COVID-19) Federal Award Numbers and Years: ERA 1, 2021 (COVID-19) Compliance Requirement: Activities Allowed or Unallowed; Allowable Costs/Cost Principles Type of Finding: Material Weakness; Material Noncompliance Prior Year Finding: N/A Questioned Costs: $121,463 (known) (COVID-19) Criteria: 2 CFR 200.332(a)(5) and (d) Department management is responsible for monitoring the activities of subrecipients to ensure subawards are used for authorized purposes and in compliance with federal requirements. Additionally, department management is responsible for communicating to subrecipients that they are required to permit the department and auditors access to their records as necessary to ensure the department is in compliance with program requirements. The department passed through program funds to community action agencies (subrecipients) to provide program delivery, including administrative costs. The department performed fiscal monitoring for only five of their 18 subrecipients during the audit period due to staff turnover. Fiscal monitoring includes procedures to address compliance with activities allowed and allowable cost requirements for administrative costs. Due to the limited fiscal monitoring performed, auditors performed additional procedures at the subrecipient level to determine whether the department was compliant with program requirements. We tested a total of 82 transactions, 70 randomly selected and 12 judgmentally selected from the 13 subrecipients that did not receive subrecipient monitoring during the fiscal year. We noted the following: One subrecipient did not respond to audit requests for documentation, resulting in an inability to test four transactions totaling $4,114. One subrecipient did not provide sufficiently detailed documentation to determine whether 7 transactions were for accurate amounts totaling $117,349. Of those seven transactions, we were unable to determine whether two transactions were for allowable activities or appropriately categorized as administrative expenditures. Without adequate monitoring of subrecipients, the department?s ability to ensure compliance with program requirements is diminished. We recommend department management perform fiscal monitoring to ensure subrecipients are expending administrative funds in accordance with program requirements. MANAGEMENT RESPONSE: We agree with this recommendation. Corrective action plan: OHCS had significant compliance monitoring staff turnover in FY22 which led to a lack of monitoring. OHCS has subsequently hired a contractor to perform fiscal monitoring of all ESG funded grantees. OHCS also hired staff to pre-FY22 levels, fully trained all staff and began developing internal working relationships with program staff to assure operational efficiencies. This includes an annual workshop with all grantees, internal training, and standardizations of monitoring processes. Anticipated Completion Date: June 30, 2023 Contact: Dean Criscola, Controller

2022-063 Oregon Department of Transportation Consistency needed when providing required federal award information to subrecipients Federal Awarding Agency: U.S. Department of Transportation Assistance Listing Number and Name: 20.205 Highway Planning and Construction Federal Award Numbers and Years: Various Compliance Requirements: Subrecipient Monitoring Type of Finding: Significant Deficiency, Noncompliance Prior Year Finding: N/A Questioned Costs: N/A Criteria: 2 CFR 200.332(a)(1) Federal regulations require pass-through entities to ensure every subaward is clearly identified to the subrecipient as a subaward and includes certain required information. We examined 17 subrecipient awards to ensure the information required under 2 CFR 200.332(a)(1) was communicated at the time of the subaward. Each award examined was missing one or more of the required elements: 15 samples did not include the subrecipient?s Unique Entity Identifier or DUNS number; 7 samples did not provide the Federal Award Identification Number (FAIN); 5 samples did not provide the Federal Award date; and 1 sample did not provide the correct assistance listing number. The required award information is necessary for the subrecipient to accurately report the subaward information in its accounting records and on the schedule of expenditure of federal awards. Procedures to communicate award information are not consistently followed across the department and as a result do not ensure that all the required award information is communicated. Specifically, some required information is included in the Federal Project Agreement from the Federal Management Information System (FMIS), but not all managers were aware it needed to be provided. In many cases an exhibit was included with the agreement that could have provided all the required information, but the exhibit was not completed. We recommend the department adopt procedures for preparing subaward agreements that ensure all required information is provided to subrecipients at the time of the subaward. MANAGEMENT RESPONSE: We agree with this recommendation. The Department will implement the following: 1. Communicate to all Program Managers of federal funds the requirements of sending the FMIS document to the sub-recipient. The FMIS document includes the FAIN, Award Date and starting 6/1/23 will also include the UEI. 2. Procurement will ensure the exhibit included with the agreement is completed and returned by the subrecipient. 3. Identify a staff person to enter data into the FFATA Subaward Reporting System (FSRS). Anticipated Completion Date: December 31, 2023 Contact: Katie Parlette, Federal Aid Funding Manager or Melissa Canfield, Procurement Manager

2022-024 Oregon Housing and Community Services Subrecipients need to be monitored to ensure compliance with procurement standards Federal Awarding Agency: U.S. Department of Housing and Urban Development Assistance Listing Number and Name: 14.231 Emergency Solutions Grants Program (COVID-19) Federal Award Numbers and Years: E-20-DW-41-0001, 2020 (COVID-19) Compliance Requirement: Procurement, and Suspension and Debarment Type of Finding: Significant Deficiency; Noncompliance Prior Year Finding: N/A Questioned Costs: N/A Criteria: 2 CFR 200.317 - .327; 2 CFR 200.332(d) Federal regulations state that non-federal entities, including subrecipients, are required to have and use procurement procedures consistent with state and local laws and regulations and that conform to the federal procurement standards identified in 2 CFR 200.317 - .327. Pass-through entities, like the department, are required to monitor subrecipients for compliance with federal regulations and the terms and conditions of the award. Inquiries and testing determined the department?s fiscal monitoring procedures, which normally include review of compliance with procurement standards, were not fully performed during the fiscal year and only 6 of 45 subrecipients were reviewed. As a result, subrecipients could be out of compliance with procurement requirements. We recommend the department ensure subrecipients are monitored for compliance with procurement requirements. MANAGEMENT RESPONSE: We agree with this recommendation. OHCS had significant staff turnover in FY22, and that coupled with the substantively increased number of subrecipients, lead to a lack of monitoring. OHCS has subsequently hired staff and established vendor relationships to perform fiscal monitoring as a backup for when staff vacancies exist. Additionally, OHCS is on track to complete fiscal and program monitoring for all subrecipients of ESG funds in FY23. Anticipated Completion Date: June 30, 2023 Contact: Dean Criscola, Controller

2022-001 Coronavirus Relief Fund ? Assistance Listing No. 21.019 Recommendation: We recommend LAHSA implements controls to ensure that the subrecipient monitoring plan is revisited at the time contracts are entered into in order to ensure proper coverage. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: LAHSA acknowledges that there is an opportunity to enhance its current subrecipient monitoring procedures. LAHSA conducts risk-based monitoring reviews of our subrecipients. Our FY 21- 22 Annual Monitoring Plan describes how LAHSA oversees the monitoring selection of our subrecipients, depending on the complexity of their activity, subrecipients? monitoring could be more frequent. It should be noted that LAHSA?s monitoring plan is inclusive of multiple LAHSA funding streams and programs. Additionally, the annual monitoring plan endeavors to alleviate any duplication of efforts. Subrecipients are selected for review based on Monitoring Priorities established each Fiscal Year. Moreover, since the onset of COVID-19, Monitoring and Compliance (M&C) now Grants Management and Compliance (GMC) shifted our monitoring efforts to help stand up Project Room Key, our compliance responsibilities were bifurcated between our grants management side of the house, whose core focus/activities were remote, and the compliance side of the house which implements more intensive monitoring which include onsite visits. During FY 21-22, monitoring was reduced to cover high risk and urgent priorities. All agencies selected for monitoring will have analysis conducted to review agencies risk assessment results, spending trends, and performance data on an on-going basis throughout the FY. This analysis will help identify if the risk assessment was accurate and if the activities of the agency need additional review. Moving forward, LAHSA acknowledges the opportunity to enhance monitoring and will conduct 100% monitoring of subrecipients that receive federal funds. We will bring the monitoring plan to a future Audit and Risk committee meeting. Name(s) of the contact person(s) responsible for corrective action: Jeffrey Samson, Deputy Chief Financial & Administrative Officer, jsamson@lahsa.org; Amy Williams, Director ? Grants Management & Compliance, awilliams@lahsa.org Planned completion date for corrective action plan: To be implemented effective in FY 22-23.

FY 2022 CMHPSM Single Audit Findings Response Finding 2022-001: Considered a significant deficiency in internal control over compliance/immaterial non-compliance Program: ALN 93.959 Block Grants for Prevention and Treatment of Substance Abuse (Treatment and Access Management) Condition: During testing of contracts with subrecipients it was noted that these contracts did not include portions of required disclosures. Corrective Action: CMHPSM will revise all contracts that disburse Block Grant Funds so that they include that the recipient is a subrecipient and include the grant number. Matt Berg and CJ Witherow are responsible for implementing this change. The change to be complete by August 31, 2023.

Finding 2022-001 Federal Agency Name: U.S. Department of the Treasury Program Name: COVID-19 Coronavirus State and Local Fiscal Recovery Funds (CSLFRF) Assistance Listing Number: 21.027 Finding Summary: The County provided a subaward of SLFRF funds to a subrecipient. The County did not include the required data elements in the subaward document, did not perform an assessment of the risk of subrecipient noncompliance with federal guidelines and grant terms, and did not review to determine that the subrecipient was not suspended or debarred. The County did not have a subrecipient monitoring policy in place that required compliance with these guidelines. Responsible Individuals: Elijah Anderson, County Auditor Corrective Action Plan: Taylor County will adopt a subrecipient grant policy before any other subrecipient awards are approved. The policy will include all required elements noted at 2 CFR 200.331-333. Policy provisions will provide for the review of contracts so that all required clauses are included, an assessment of risk for potential subrecipients, and monitoring guidelines to ensure compliance with federal requirements. The review of suspension or debarment performed by the County will be documented in the future so that verification of this step can be reviewed. Anticipated Completion Date: Ongoing

State Agency: Department of Health Single Audit Contact: Melissa Fiore Title: Audit Services Director Telephone: 518-473-0525 E-mail Address: Melissa.Fiore@health.ny.gov Federal Program(s) (ALN # [s]): Child & Adult Care Food Program (10.558) Audit Report Reference: 2022-003 Anticipated Completion Date: 12/31/2023 Corrective Action Planned: The Department?s Audit Clearinghouse will continue to work with NYS Office of Information Technology Services to develop a system to better track grantees that require a single audit report, when a single audit report is available for review, and, if a management decision letter is needed. This will provide better assurance of timely review of all submitted single audit reports and communication to Child & Adult Care Food Program staff of findings in need of management decision letters.

Management agrees with this finding and is in the process of developing internal controls to ensure timely and appropriate actions are made on the deficiency noted.

Contact Person: Erin Adams, Executive Director Corrective Action Plan: The Organization will update their subrecipient monitoring policy to include the requirements outlined in CFR 200.332, which will also include a requirement to formally document all relevant award information for each subrecipient under a federal award. Anticipated Completion Date: The Organization will update their policy no later than December 31, 2023.

Prepared by: Greg Burrell Date Prepared: 12/21/2022 Person Respomible for Corrective Action Plan: Warren County Fiscal Court Anticipated Completion Date: 3/31/2023 Official's Response: The Treasurer and County Judge have been in communication with Live the Dream Development about proper sub recipient reporting and they are providing quarterly reports. The project had not started and there was some confusion on whether they had to report that they hadn't started. They had communicated this verbally to the county but a written report was not received by June 30, 2022.

FINDING 2022-003 Individuals Responsible for Corrective Action Plan: Kristine Steinmann, Director, Georgia Alliance of Boys & Girls Clubs Corrective Action: Management will update subrecipient monitoring procedures to ensure compliance with subrecipient monitoring requirements and will continue to follow these enhanced policies to properly detect and prevent unallowable charges to the grant. Management will implement monitoring processes to ensure subrecipients submit sufficient documentation prior to disbursing funds. Anticipated Completion Date: October 1, 2023

Finding 2022-001 ? M. Subrecipient Monitoring Information on the federal program: Grantor: Department of Health and Human Services Program Name: Research and Development Cluster Assistance Listing No. / FAIN: 93.847 / R24DK106743 Views of responsible officials and planned corrective actions: During 2022, management has implemented a policy which addresses the 2 CFR section 200.332(b) requirements, including evaluating the results of previous audits obtained by its subrecipients including whether or not the subrecipient receives a single audit in accordance and the extent to which the same or similar subaward has been audited as a major program. Name of responsible official: Name ? Betty-Jane Sloan Title ? Clinical Research Manager Phone: 646-317-0701 Email: bjsloan@nyp.org Projected completion date: June 10, 2022

2022-012 ? Subrecipient Monitoring (Significant Deficiency) Governor?s Office care of State Department of Budget and Finance AL Number: 21.027 Program Title: Coronavirus State and Local Fiscal Recovery Fund Direct Award from: U.S. Department of Treasury Condition 2 CFR Section 200.332(b) requires a pass-through entity to evaluate each subrecipient?s risk of noncompliance for purposes of determining the appropriate subrecipient monitoring related to the subaward. The auditing firm selected a sample of 7 subawards active in FY 2022. The auditing firm noted that program management did not evaluate the subrecipient?s risk of noncompliance at the time of the subaward for one of the subawards tested. Current Status of Corrective Action Plan Concur. B&F will ensure that program personnel are familiar with federal program requirements, including compliance with 2 CFR Section 200.332(b) which requires an evaluation of each subrecipient?s risk of noncompliance with federal statutes, regulations, and the terms and conditions of the subaward. Person Responsible Mark K. Anderson, Office of Federal Awards Management, Administrator Anticipated Date of Completion July 1, 2023

2022-010 ? Subrecipient Monitoring (Significant Deficiency) Governor?s Office care of State Department of Budget and Finance AL Number: 21.026 Program Title: Homeowner Assistance Fund Direct Award from: U.S. Department of Treasury Condition 2 CFR Section 200.332(b) requires a pass-through entity to evaluate each subrecipient?s risk of noncompliance for purposes of determining the appropriate subrecipient monitoring for the subaward. The auditing firm selected a sample of two subawards that were executed in FY 2022. The auditing firm noted that program management did not evaluate the subrecipient?s risk of noncompliance prior to the execution of the subawards. Current Status of Corrective Action Plan Concur. B&F will ensure that program personnel are familiar with Federal program requirements, including compliance with 2 CFR Section 200.332(b) which requires an evaluation of each subrecipient?s risk of noncompliance with Federal statutes, regulations, and the terms and conditions of the subaward. Person Responsible Mark K. Anderson, Office of Federal Awards Management, Administrator Anticipated Date of Completion July 1, 2023

Finding No. 2022-007 ? Subrecipient Monitoring (Significant Deficiency) Governor?s Office care of State Department of Budget and Finance AL Number: 21.023 Program Title: Emergency Rental Assistance Program Direct Award from: U.S. Department of Treasury Condition 2 CFR Section 200.332(b) requires a pass-through entity to evaluate each subrecipient?s risk of noncompliance for purposes of determining the appropriate subrecipient monitoring related to the subaward. The auditing firm selected three subawards and noted untimely evaluation of the subrecipients? risk of noncompliance for two subawards. The auditing firm noted that one assessment was performed 2 days after a subaward was made, and for the second subaward, an assessment was performed 172 days after the subaward was made. Current Status of Corrective Action Plan Concur. B&F will ensure that program personnel are familiar with federal program requirements, including compliance with 2 CFR Section 200.331(b) which requires an evaluation of each subrecipient?s risk of noncompliance with federal statutes, regulations, and the terms and conditions of the subaward. Person Responsible Mark K. Anderson, Office of Federal Awards Management, Administrator Anticipated Date of Completion July 1, 2023

Recommendation: We recommend that the County review its procedures for communicating information to subrecipients and implement the procedures necessary to ensure information is included in the subrecipient award documents at time of funding and that appropriate monitoring is performed for each subrecipient. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will ensure that all subrecipients of American Rescue Plan (APRA) funds are monitored by using appropriate subrecipient monitoring procedures to ensure compliance with the grant awarded throughout the contract period. Name(s) of the contact person(s) responsible for corrective action: Sherri Crow, Interim Director of Budget and Finance Planned completion date for corrective action plan: January 1, 2024

Finding #2022-009: regarding subrecipient monitoring were not performed on the Health Equity Grant, Award# 11442, CFDA # 93.391 as required by CCH Policy and Federal Regulations. Cause: The cause of this finding resulted from subrecipients being identified as vendors in the Grant application. The Program Lead informed Finance late which did not allow sufficient time to mobilize CCH staff and/or external consultant to perform subrecipient monitoring. Correction Action: The CCH Director of Grant Accounting will engage an outside consultant to conduct subrecipient monitoring for the grant and collaboratively work to modify the established policy. Anticipated completion of the corrective action will be December 31, 2023.