Corrective Action Plans

Finding 2022-001 ? Subrecipient Monitoring Cluster: Research and Development Agency: Department of Commerce and Department of Health and Human Services Award Names: Standards/Guidance for Rapid Qualification of Metal-Based Additive Manufacturing and Development and Testing a Field-based Hazard/Near-Miss Sharing System for Commercial Fishing Vessels Award Numbers: 70NANB21H038 and U01OH012288 Assistance Listing Title: Measurement and Engineering Research and Standards and Occupational Safety and Health Program Assistance Listing Number: 11.609 and 93.262 Award Year: FY 2022 To ensure American Bureau of Shipping (ABS) is in compliance with 2 CFR 200.332(d) and 2 CFR 200.332(f), ABS will obtain and review annual Uniform Guidance reports or annual audited financial statements (if the entity was not subject to a Uniform Guidance audit) of all subrecipients. ABS has revised its Contracted Research and Development Process Instruction for subrecipient monitoring. The process instruction is supplemented by a subrecipient monitoring form and check sheet. The annual subrecipient monitoring form and check sheet outline the necessary steps to document and interpret the review of Uniform Guidance reports or financial reports. The annual review will be completed within two months of the grant date anniversary. The contracts administrator and project manager will provide two-step verification by reviewing, dating, and signing both the subrecipient monitoring form and check sheet to document their understanding of the type of opinion(s) expressed, findings associated with their awards, document their review, and assess whether there is any change in the initial risk assessment and subsequent monitoring need of each subrecipient. The annual reviews commenced in July 2023.

DEPARTMENT OF ELEMENTARY AND SECONDARY EDUCATION 2022-004 Child and Adult Care Food Program ? Assistance Listing No. 10.558 Action taken in response to the finding: The Office for Food and Nutrition Programs (FNP) has moved from a paper based permanent agreement to a web form that exists on the DESE Security Portal. All existing and new Child Nutrition Sponsors will continue to sign off on the document via the web-based portal allowing for a more efficient collection and document retention process. The identified sponsors with missing permanent agreements for the time period selected now have signed permanent agreements via the web-based form. FNP will add the applicable FAIN numbers to the Financial Management portion of FNP?s public website. FNP will review and update these numbers annually as applicable. FNP, in conjunction with DESE?s Federal Accounting Unit, have embarked on a process to provide all Child Nutrition sponsors instructions and collect information related to UEIs. FNP will continue the process and outreach until all UEIs have been collected. Name of the contact person responsible for corrective action: Robert Leshin, Director of Nutrition, Jeffrey Benbenek, Director of Audit & Compliance Planned completion date for corrective action plan: July 1, 2023

Children First Fund: The Chicago Public Schools Foundation State Single Audit Corrective Action Plan For the Fiscal Year Ended 2022 AUDIT FINDINGS Finding Reference Number: 2022-001 Description of Finding: CFF did not communicate the required information to subrecipients noted in the criteria including the communication of what funding represented federal funding and was subject to the related grant requirements. Statement of Concurrence or Nonconcurrence: The organization agrees with the finding and will implement corrective action when applicable. Corrective Action: The Chicago Connected initiative was supported by various external partners, including government and philanthropic funders. As the fiscal sponsor, the Children First Fund executed service agreements with each participating community-based organization (CBO), that noted the amount they were awarded. As deliverables were met, CFF made payments based on when the funds came in since they were not designated to a particular CBO by funder. As a result, CFF did not notify CBOs which payments came from federal vs philanthropic funding. Understanding that this is required when it comes to distributing federal funds to subrecipients, CFF will ensure that it's internal controls are updated to include this moving forward. Name of Contact Person: Yemisi Odedina, Managing Director of Finance & Operations E: yodedina@childrenfirstfund.org P: (312) 883-4977 Projected Completion Date: By the end of the calendar year of 2023, the organization will ensure that it?s internal controls are updated to include the federal uniform guidance standards that applies to federal awards to ensure future awards are managed per those guidelines.

Significant deficiency in internal controls over compliance and instances of noncompliance related to subrecipient monitoring. Contact Person(s): Beth Mizushima, Chief Operating Officer, mizushimab@crhn.org; and Connie Sowa, Compliance, Governance and Contracts Officer, sowac@crhn.org. Explanation and specific reasons for disagreement with the audit finding or that corrective action is not required (if applicable): Not applicable. Corrective action planned: In FY23 we have established a Compliance, Governance and Contracts Officer staff position (1.0 FTE) that provides compliance support. We have also developed and implemented training around our Ethics and Compliance Manual, which includes 14 new policies and procedures related to ensuring subrecipient compliance standards are met for all grant awards. Since July 1, 2023, we have completed assessments for the risk of noncompliance with all partner agencies before executing contracts. In FY23 we have also amended contracts to be on a reimbursement for allowable expenditures structure rather than fixed amount. We believe that the former leadership team who established the fixed fee award may have misinterpreted the guidance around providing flexibility to reduce burden for financial assistance during COVID response. Furthermore, it is our belief that the former program officer and staff discussed the details of their work and contracts, but we cannot find documentation of receiving prior approval. To address this issue, we have amended contracts in FY23 to include specific contract wording requiring prior approval to implement a fixed fee contract. Additionally, we are in the process of implementing a contract and portal partners management platform. The new contract management system and the improvements in compliance process will ensure that we adhere to the provisions as outlined in 2 CFR200.332. Anticipated completed process September 30, 2023

The South Carolina Department of Social Services respectfully submits the following corrective action plan for the year ended June 30, 2022. The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS?FEDERAL AWARD PROGRAM AUDIT U. S. Department of Agriculture 2022-013 Child and Adult Care Food Program ? Assistance Listing: 10.558 Recommendation: We recommend that the Department follow its established policies and procedures for the program to ensure compliance with federal subrecipient monitoring requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The three-year time frame in which these monitoring reviews were to have occurred included the peak months of the Coronavirus pandemic, when Department staff were working remotely for an extended period and many provider facilities were closed or operating sporadically due to staffing shortages. A significant number of program staff also left the agency during that time. These factors made timely monitoring much more difficult and extended the time required to complete it. The program maintains a worksheet designed to track compliance with this monitoring requirement and reviews, updates and acts upon it monthly. All monitoring reviews are now being conducted within the required time-frame. DSS also has an active project in progress to automate its compliance monitoring processes, and management plans to include a dashboard that displays the detailed status of each provider?s review, from start to completion. It will also report statistics showing the progress toward meeting the required yearly reviews. Management expects to have these system controls in place by December 2023. In the meantime, program staff will maintain the manual monitoring controls now in place to assure compliance. Name(s) of the contact person(s) responsible for corrective action: Mary Abney-Young, Early Care and Education Program Manager Planned completion date for corrective action plan: December 31, 2023

2022-004 - Sub-recipient Agreements: Non-Compliance Auditor Recommendation: Recommend that the City review 2 CFR Part 200 to ensure information required in sub-recipient agreements is properly included. Management's Response: Agree with the finding. Corrective Action Taken: The City will review 2 CFR Part 200 to ensure the assistance listing number of the grant funding being passed through, and the indication that the sub-recipient would be subject to single audit requirements set forth in 2 CFR Part 200, Sub-part F (Uniform Guidance). This Corrective Action will be completed no later than the subsequent quarterly report due date of April 30, 2023.

2022-003 - Sub-recipient Agreements: Significant Deficiency Auditor Recommendation: Recommend that the City review 2 ? CFR Part 200 to ensure information required in sub-recipient agreements is properly included. Management's Response: Agree with the finding. Corrective Action Taken: The City will review 2 CFR Part 200 to ensure the assistance listing number of the grant funding being passed through, and the indication that the sub-recipient would be subject to single audit requirements set forth in 2 CFR Part 200, Sub-part F (Uniform Guidance). This Corrective Action will be completed no later than the subsequent quarterly report due date of April 30, 2023.

New Directions DHS is exploring different possibilities to satisfy the audit finding to include the contracting of a certified public accounting firm to assist in conducting the financial portion of our subrecipient monitoring. Alternatives to Abortion Office of Policy Development (OPD) initiated numerous conversations with the Alternatives to Abortion grantee regarding receiving the requested documentation for monitoring (communication occurred regularly from April 2021 through January 2023). The grantee disagrees that the disclosure of this information is a requirement of the grant agreement and as such has not provided the documentation needed to complete the monitoring. On October 27, 2022, DHS sent a letter to the grantee outlining specific action steps to establish compliance with their grant agreement. The grantee responded on November 28, 2022, disputing the claims of DHS and asserting that they are not out of compliance with their grant agreement. OPD will be scheduling time to visit the grantee to review documents required by the terms of their grant agreement in order to complete the monitoring. Monitoring will occur by June 30, 2023. Anticipated Completion Date: New Directions- 03/01/2024; Alternatives to Abortion- 06/30/2023 Contact Person and Title: New Directions- Joel O?Donnell, Director, Bureau of Program Support, OIM; Alternatives to Abortion- Ana Arcs, Acting Policy Director, OPD

DHS: The Office of Children, Youth, and Families (OCYF) is sending out a Restrictions and Requirements document with each tentative and final allocation letter. This document lists all OCYF?s grants, the federal agency granting the fund and where to find the rules and regulations guiding the usage of the funds. For the State fiscal year 2021-2022, Tentative Allocation Letters were sent out on April 1, 2021, with Federal Award Identification Numbers (FAIN) and funding amounts. Final Allocation Letters were sent out August 12, 2021, with the Amount, FAIN and Name. OCYF has a risk assessment process in place for Title IV-E and TANF awards. During the Quality Assurance reviews, which occur twice a year at a minimum, OCYF reviews a sample of Title IV-E eligible foster care cases, Title IV-E ineligible foster care cases, Title IV-E eligible adoption assistance cases, and TANF eligible cases. Depending on the number of eligibility and claiming errors identified during the review, OCYF schedules more frequent visits as the risk of repeated and continued errors in these County Children and Youth Agencies (CCYAs) is higher. Inaccurate eligibility determinations lead to inaccurate federal claiming, so basing the review schedule on a CCYA?s eligibility review outcome allows OCYF to target those CCYAs where inaccurate claiming is a higher risk. However, to further address this finding, the risk assessment now includes documentation. Anticipated Completion Date: Completed Contact Person and Title: TinaMarie Petrovitz, Director of County Support DOH: The Department plans to develop and implement a robust subrecipient monitoring program which includes establishing a new section within the Budget Office pending enacted budget funds and complement to support the creation of the section. Initiative goals/milestones include: - Assessment: Comprehensive assessment of all current federal grants and subawards and their processes. This assessment will document best practices and identify gaps within the agency?s processes. It will also provide an evaluation of current operational and technological resources that can be leveraged to facilitate compliance. Target start date: February 27, 2023. Target completion date: June 30, 2023. - Educate Department: Budget Office is developing a bulletin that will outline the subrecipient monitoring requirements with links to State and Federal Sources. The bulletin will be shared with all program office staff. The Budget Office will develop the following templates and provide to all program offices: - Determination of vendor status: Subrecipient or Contractor - Risk Assessment Form - Internal Control Self-Assessment for Subrecipient Template - Subrecipient Monitoring Template All materials will be updated with any additional information gained during the assessment. Start date: February 3, 2023. Target Completion Date: June 30, 2023 - Implementation of full compliance initiative: Recommendations provided in the assessment will be used to develop and implement comprehensive policies and procedures led by a new section in the Budget Office. Target start date July 1, 2023. Target fully operational date: June 30, 2024. Anticipated Completion Date: 06/30/2024 Contact Person and Title: Andrea Race, CFO

AMLR program representatives attended Department of Interior, Office of Surface Mining Reclamation and Enforcement online training covering 2 CFR 200 and contractor or subrecipient determinations. DEP ceased issuing AMLR grants under Management Directive 305.20, Grant Administration. DEP management has determined the recipients with existing agreements are subrecipients and DEP will follow this determination consistently with future agreements and accounting. DEP has developed written policies and procedures for subrecipient monitoring and has notified grantees to implement the policies and procedures immediately to ensure timely subrecipient compliance with federal regulations. Anticipated Completion Date: Completed Contact Person and Title: Patrick Webb, Acting Dir., Bureau of AMLR; Tim Golding, Executive Assistant, Office of Admin. and Management

PDE: Audits retrieved from the Federal Audit Clearinghouse are now reviewed after entry into PDE?s SharePoint website, to ensure PDE remains compliant with federal guidelines to respond to any and all findings pertaining to federal dollars it passes to subrecipients. Likewise, PDE Audit Section continues to improve upon its processes for timely determinations of those single audits with findings by multiple means, including periodic SharePoint enhancements designed to aid in timely review of single audit packages, working closely with PDE program areas to assist in timely responses and quickly addressing SharePoint access issues as they arise. Anticipated Completion Date: 06/30/2023 Contact Person and Title: Clayton P. Carroll, II, Audit Coordinator; Jessica Sites, Director, Bur. of Budget and Fiscal Mgmt DEP: BAFM now provides agencies with single audit reporting packages that have findings each week that have been accepted by the Federal Audit Clearinghouse (FAC). This allows for us to start our management decision process in a timelier manner and meet the six-month deadline for issuing our decision. This information first appeared in our notifications starting April 30, 2021. In addition, the DEP program that had been previously identifying agreements as contracts rather than subrecipient agreements has corrected this issue and all subrecipients have been notified in writing of this correction and provided the information for submitting their single audits (if necessary). The letters were sent to subrecipients on approximately May 31, 2022. DEP Fiscal Management staff will continue to monitor the BAFM SharePoint site and FAC for additional filings to attempt to avoid this issue in the future. DEP is also hiring additional staff for the oversight and monitoring of the subrecipient single audits to ensure compliance with all requirements. These positions are currently in the filing process, and we are hopeful that they will be filled, and staff trained by September 30, 2023. Anticipated Completion Date: 09/30/2023 Contact Person and Title: Jennifer L. Brandt, Senior Fiscal Management Specialist, Federal Grants and Audits DOH: NORTH Inc.?s Single Audit report for the period ending 9/30/2020 was officially submitted and showing on the FAC on 2/9/2023. Bureau of WIC staff reached out to the Director and CFO of NORTH Inc. by phone and email. Emails were sent with instructions on how to submit the report as well as the importance of submitting the report timely per their grant agreement. Each follow-up phone call included discussion on the importance of submitting their single audit as soon as possible. Moving forward the Bureau of WIC will implement the following procedure: 1 .Three months after the end of the audit period (Federal Fiscal Year), Project Officers will send an email that outlines the process for submitting a single audit reporting package to the FAC to their respective WIC local agencies. This email will provide a date that the single audit is due to be submitted to the FAC in order to stay in compliance with their current WIC grant agreement. 2. Six months after the end of the audit period (three months from the due date of the single audit reporting package) an official letter from the Bureau Director will go out to the WIC local agencies that are due to submit a single audit. The letters will include instructions on how to submit the single audit in FAC and the Audit Requirements link referenced in their grant agreement. 3. If the WIC local agency notifies the Bureau of WIC that their auditor will not be able to submit their agency?s single audit by the due date, then the Project Officer will work with the local agency to get a projected date of completion and a timeline on when the local agency?s auditor is able to finalize the audit and submit it to the FAC. The Bureau of WIC will then notify DOH?s Audit Coordinator and OB-BAFM of this information, so they are able to track it. 4. If the WIC local agency does not submit the report by the due date and fails to notify their project officer; a notice to cure letter will be sent to the agency. Concerning NORTH Inc.?s Single Audit report for the period ending September 30, 2021: 1. The Bureau of WIC will contact NORTH Inc. and request a meeting with their auditor. 2. Following the meeting with NORTH Inc.?s auditor, the Bureau Director will send an official letter to NORTH Inc. The letter will include the instructions on how to submit the single audit in the FAC and the Audit Requirements link referenced in their grant agreement. They will also be made aware of the actions that could result from them not submitting this audit by the agreed upon date. 3. If the single audit is not received by the agreed upon date, then the Bureau of WIC will send a notice to cure letter. Anticipated Completion Date: 03/24/2023 Contact Person and Title: Sally Zubairu-Cofield, Director, Bureau of WIC DHS: Regarding the timeliness of finding resolution and procedures related to the SEFA reviews, the Audit Resolution Section (ARS) hired an additional staff member in August 2021 and hired two additional staff members in February 2022, and an additional staff member in January 2023. Finally, the ARS worked with Office of the Budget, Bureau of Accounting and Financial Management to develop a risk-based approach for single audit reviews, which will greatly streamline the process of single audit reviews to gain substantial efficiencies. Regarding late audit report submissions, we will continue to follow the requirements of 2 CFR ?200.339 and Commonwealth Management Directive 325.8. We will continue to work with counties and their independent auditors to obtain any late Single Audit reports. Anticipated Completion Date: 06/30/2023 Contact Person and Title: David Bryan, Manager, ARS; Alexander Matolyak, Director, Division of Audit & Review

Finding 2022-004 ? Subrecipient Monitoring - Name of the Contact Person Responsible for the Corrective Action Plan: Deborah Sherman, Division Director ? Finance ? Grants Division. - Corrective Action Plan: The Grants Division will work closely with the sub-recipients to communicate the grant requirements and review their supporting documentation to ensure the required documentation is listed/provided. - Anticipated Completion Date: December 31, 2023.

2022-003 Subrecipient Monitoring The Organization has created a subrecipient monitoring schedule that follows the grant cycle of each of its federal grants and has also created a template document to collect the information required by 2 CFR Part 200, Subpart D, Section 200.332. Staff time has been allocated to collecting the required information from each subrecipient during 2023, which will continue annually to complete this requirement from this point forward.

Finding Number 2022-001 Contact Person Patricia Hayden 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 a risk assessment for each subrecipient under a federal award. Anticipated completion date The Organization will update their policy no later than October 31, 2023.

Finding: 2022-006 Department of Health Response/Corrective Action Plan: The Public Health Division of the Department of Health and Human Services (formerly Department of Health) agrees with the recommendation. Procedures will be developed in cooperation with the integrated Department of Health and Human Services audit division to designate responsibility and processes for subrecipient monitoring activities during the award period. Contact Person: Karol Riedman, Assistant CFO and Amanda Westlake, Audit Manager Anticipated Completion Date: June 30, 2023

Department of Health Finding: 2022-005 Department of Health Response/Corrective Action Plan: The Public Health Division of the Department of Health and Human Services (formerly Department of Health) agrees with the recommendation. Procedures and additional internal controls have been added to ensure all required award information is communicated to subrecipients, to the extent this information is available. Contact Person Karol Riedman, Assistant CFO Anticipated Completion Date Completed

Finding: 2022-007 Department of Health Response/Corrective Action Plan: The Public Health Division of the Department of Health and Human Services (formerly the Department of Health) agrees with this recommendation. Procedures will be implemented to ensure all subrecipients obtain audits or a certification that an audit is not required in accordance with 2 CFR 200 Subpart F. Contact Person: Karol Riedman, Assistant CFO Anticipated Completion Date: June 30, 2023

Finding No. 2022-001 (Repeat of 2021-004) Identifying Federal Award Information of Pass-Through Funds to Subrecipients Assistance Listing Program Title and Number: Special Programs for the Aging - Title III, Part B -Grants for Supportive Services and Senior Centers 93.044 Special Programs for the Aging - Title III, Part C - Nutrition Services 93.045 COVID-19 ? American Rescue Plan Act for Special Programs for the Aging - Title III, Part C -Nutrition Services 93.045 COVID-19 - Consolidated Appropriations Act for Special Programs for the Aging - Title III, Part C -Nutrition Services 93.045 Nutrition Services Incentive Program 93.053 Special Programs for the Aging - Title III, Part D - Disease Prevention and Health Promotion Services 93.043 National Family Caregiver Support - Title III, Part E 93.052 Social Services Block Grant 93.667 Coronavirus Relief Fund 21.019 Federal Agency: U.S. Department of Health and Human Services Pass-through Entity: State of Connecticut Department of Aging and Disability Services Description of Finding: The audited financial statements of subrecipients reviewed during the audit did not appropriately identify federal subawards passed through by the Agency. Statement of Concurrence: WCAAA concurs with the audit finding. Corrective Action: In the past, the Agency provided confirmations to subrecipients as requested. Going forward, the source of funding along with the breakout by federal assistance listing number will be clearly communicated to all subrecipients. The Agency will also ensure that reported expenditures by each subrecipient reconciles to the Agency?s advances to that subrecipient during the review of the subrecipient audit reports. WCAAA took corrective action but due to the timing of the subrecipients fiscal year they did not provide updated information to their auditor. This has been addressed with the subrecipient?s leadership and will be corrected in their next audit. Name of Contact Person: Spring Raymond, Interim Executive Director, 203-757-5449, sraymond@wcaaa.org Projected Completion Date: September 30, 2023

Finding: 2022-028 Department of Public Instruction Response/Corrective Action Plan: The Department of Public Instruction agrees with the recommendation. The Department of Public Instruction has multiple individuals who watch for changes to federal regulations. The budget period requirement was missed by DPI and we appreciate the State Auditor?s Office for identifying this. Immediately upon having this been pointed out to us we added the information to our grant award notifications. Contact Person Jamie Mertz, Fiscal Management Director Anticipated Completion Date Change to grant award notifications was implemented in October 2022

Finding: 2022-027 Department of Public Instruction Response/Corrective Action Plan: The Department of Public Instruction agrees with the Recommendation. The risk assessment process has been completed for Comprehensive Literacy State Development awards for the 2023-2024 school year. The department is contracting with the Vander Weele Group to assist the department in designing a comprehensive federal programs monitoring system, which will take into account the sub-recipient risk. Contact Person Ann Ellefson, Academic Support Director Anticipated Completion Date 2022-2023 risk assessments for Comprehensive Literacy will be finalized by March 31, 2023.

Finding: 2022-031 Department of Public Instruction Response/Corrective Action Plan: The Department of Public Instruction agrees with the recommendation. The risk assessment process has been completed for Supporting Effective Instruction awards for the 2023-2024 school year. The department is contracting with the Vander Weele Group to assist the department in designing a comprehensive federal programs monitoring system, which will take into account the sub-recipient risk. Contact Person Ann Ellefson, Academic Support Director Anticipated Completion Date 2022-2023 risk assessments for Supporting Effective Instruction will be finalized by March 31, 2023.

Finding: 2022-024 Department of Public Instruction Response/Corrective Action Plan: The Department of Public Instruction agrees with the recommendation. When this issue was pointed out to us in the prior audit in February of 2021, we immediately made the change to our grant awards. Contact Person Jamie Mertz, Fiscal Management Director Anticipated Completion Date Implemented in February 2021

Finding: 2022-023 Department of Public Instruction Response/Corrective Action Plan: The Department of Public Instruction agrees with the recommendation. When this issue was pointed out to us in the prior audit in February of 2021, we immediately made the change to our grant awards. Contact Person Jamie Mertz, Fiscal Management Director Anticipated Completion Date Implemented in February 2021

2022-002 ? CORONAVIRUS STATE AND LOCAL FISCAL RECOVERY FUNDS ? NONCOMPLIANCE WITH SUBRECIPIENT GRANT AGREEMENT REQUIREMENTS ? ALN 21.027 ? OTHER NONCOMPLIANCE Condition: Burleigh County did not communicate and document all of the elements as outlined in 2 CFR 200.332(a) for the subrecipients of the Coronavirus State and Local Fiscal Recovery Funds program. During testing, we noted the following elements were not included: ? subrecipient's unique entity identifier ? federal award identification number ? federal award date (see definition of Federal award date ? 200.1) of award to the recipient by the Federal agency ? subaward period of performance start and end date ? name of Federal awarding agency, pass-through entity, and contact information for awarding official of the Pass-through entity ? Assistance Listings number and Title ? identification of whether the award is Research and Development ? indirect cost rate for the Federal award (including if the de minimis rate is charged) per ?200.414 ? a requirement that the subrecipient permit the pass-through entity and auditors to have access to the subrecipient's records and financial statements as necessary for the pass-through entity to meet the requirements of this part, and appropriate terms and conditions concerning closeout of the subaward Corrective Action Plan: We agree with the recommendation. Burleigh County has implemented new policies and procedures in 2023 regarding subrecipient monitoring. Anticipated Completion Date: FY 2023

Michael Fields Agricultural Institute will work with O'Leary & Anick to establish policies and procedures to monitor subrecipient's activities in compliance with the Uniform Guidance requirements. The organization will review such policies and procedures annually or more frequently if necessary to reflect any changes. Contact Person: Shannah Schmitt, MFAI, and Kevin O'Leary, O'Leary & Anick. Anticipated date of completion: December 2023.