Corrective Action Plans

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.

Temporary Assistance for Needy Families (TANF) ? Assistance Listing No. 93.558 Recommendation: We recommend the County determine whether an entity receiving payment under TANF is a subrecipient or a contractor prior to entering into an agreement with the entity and to include all guidance under 2 CFR 200.331 when making this determination. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Prior to the finding we have been working to properly classify entities that receive TANF fund as subrecipients versus contractors. We will continue to implement a process to analyze the entities that are receiving payments through TANF and make sure that we properly determine them as a subrecipient or a contractor. Once the determination is made, we will work with Legal and enter into the correct agreement with the entity. We will also perform the required monitoring for the TANF subrecipients. Name of the contact persons responsible for corrective action: Eddie Valdez ? Deputy Director, Candace Cadena ? Executive Strategist, Nick Beston ? Accounting Manager. Planned completion date for corrective action plan: July 1, 2024

DPH agrees with the finding and recommendations. DPH will notify its subrecipients about their subawards and include any changes in subsequent subaward modifications. DHSP will strengthen its review processes to complete and include the Notice of Federal Subaward Information form as part of the contract copy at the time of the contract execution.

Corrective Action Plan: The Agency has recognized a need to provide training and technical assistance to State Agencies and Departments. The Agency has created Uniform Guidance trainings that began in February 2023 and continue in March. These trainings include reference materials such as desk references, job aids, etc. As a follow-up to the training, we will be developing and delivering a subrecipient monitoring framework which includes tools to facilitate subrecipient risk assessments, subrecipient monitoring plans based on the initial risk assessment, testing of transaction records, desk reviews of low-risk subrecipients, and corrective action plans. Finally, we will be working to provide oversight and monitoring for agency adherence to subrecipient monitoring procedures, informed by program-level compliance risk assessment. Scheduled Completion Date of Corrective Action Plan: Completed: February 16, 2023: Uniform Guidance Training (Part 1) Expected: March, 2023: Uniform Guidance Training (Part 2) Expected: July, 2023: Subrecipient Monitoring Framework Provided to Agencies & Departments Expected: December, 2023: Sampling completed by Agency Expected: February, 2024: Post-Sampling Follow-up with Agencies and Departments Contacts for Corrective Action Plan: Doug Farnham Deputy Secretary, Agency of Administration Douglas.Farnham@vermont.gov (802) 585-8119 Holly S. Anderson Chief Financial Officer, Agency of Administration ? Financial Services Division Holly.S.Anderson@vermont.gov (802) 505-1177

The Supervisor and Director of the CDBG program are now meeting weekly with the staff person assigned for review the Single Audits to understand the workload and assist in ensuring the backlog and the current audits are all reviewed in a timely manner. Additionally, going forward, the Agency is working to fund an agency-wide compliance officer to ensure impartial oversight of the agencies programs with regard to federal requirements (including single audit review), as well as avoiding taking the time of the CDBG program staff away from their duties. Scheduled Completion Date for Corrective Action Plan: Completed: Reviewed audits selected for testing September 30, 2023: Supervisor and Director have assisted in reviewing to ensure backlog brought current August 30, 2023: new position for Agency-wide compliance officer funded and position-filled Point of Contact: Ann Karlene Kroll, Federal Programs Director annkarlene.kroll@vermont.gov; (802) 828-5225.

Recommendation: Providers that receive findings as a result of their on-site monitoring should submit a corrective action plan to the County. Action Taken: The County Child and Youth Services department will require a corrective action plan for all subrecipients with findings as a result of their on-site monitoring in 2023, and thereafter, that will include the entity?s plan to correct the errors noted, individual responsible and timeline for corrections to be implemented. Responsible Individual for Corrective Action: Angelique Hiers, County of Delaware Department of Human Services Director Completion Date: March 1, 2023

Recommendation: We recommend the Authority design controls to ensure subrecipients are responding to and addressing questions and findings within its monitoring reports. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Views of responsible officials and planned corrective actions: MF A uses the Tracker database to track monitoring deadlines electronically. The Tracker automatically sends reminders to all staff in the department every two weeks to follow up with pending and outstanding monitoring issues. However, some staff were not using the Tracker as intended. The Director will enforce and monitor the use of the Tracker and ensure staff follow up on the monitorings by the required deadlines. Name of the person responsible for corrective action: Chief Housing Officer Planned completion date for corrective action plan: November 30, 2022

Recommendation: We recommend the Authority design controls to ensure subrecipients are responding to and addressing questions and findings within its monitoring reports. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Views of responsible officials and planned corrective actions: MF A uses the Tracker database to track monitoring deadlines electronically. The Tracker automatically sends reminders to all staff in the department every two weeks to follow up with pending and outstanding monitoring issues. However, some staff were not using the Tracker as intended. The Director will enforce and monitor the use of the Tracker and ensure staff follow up on the monitorings by the required deadlines. Name of the person responsible for corrective action: Chief Housing Officer Planned completion date for corrective action plan: November 30, 2022

2022-010 Improve Controls over Subrecipient Monitoring Federal Agency: U.S. Department of Education State Entity: Department of Education (GaDOE) Corrective Action Plans: We have transitioned the subrecipient audit monitoring process to the Financial Review team within GaDOE which currently performs local educational agency (LEA) audit monitoring. The controls already in place for the Financial Review team?s LEA audit monitoring will be duplicated for nonprofit audit monitoring to ensure all required procedures are complete and timely. Additionally, we will review the Division of Federal Programs Handbook, the 21st Century Community Learning Centers (CCLC) Subgrantee Manual, and the 21st CCLC Internal Operations manual to ensure compliance to the Uniform Grants Guidance for subrecipient monitoring. Where needed, language will be added to each manual to clarify and emphasize that subrecipient monitoring includes application review, budget review, drawdown approval, completion report review in addition to virtual or onsite monitoring of specific program indicators. The 21st CCLC documents will be updated to ensure a clear subrecipient monitoring process is established for the final year of a cohort. This process will clarify that subrecipient monitoring during the last funded year will include application review, budget review, drawdown approval, and completion report review. Additionally, LEAs identified as ?high-risk? will have an onsite or virtual monitoring on specific 21st CCLC indicators. Estimated Completion Date: June 30, 2023 Contact Person: Metsehet Ketsela, Assistant Director Telephone: 678-472-7898; E-mail: metsehet.ketsela@doe.k12.ga.us

Department of Health and Human Services 2022-003 Immunization Research, Demonstration, Public Information and Education, Training and Clinical Skills Improvement Projects - Assistance Listing No. 93.185 Recommendation: We recommend the Foundation attend training, review federal requirements, and fully understand the requirements over indirect costs Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: CFGF will engage with external firm to assist with fully understanding requirements related to indirect costs and federal requirements. CFGF will also work with external firm to assist in the identification and selection of additional training opportunities for staff who work on federal programs. Name(s) of the contact person(s) responsible for corrective action: Brett Hunkins Planned completion date for corrective action plan: December 31, 2023 If the Department of Health and Human Services has questions regarding this plan, please call Brett Hunkins at 810-767-8270.

The County agrees with the finding and recommendation. On September 12, 2022, the County issued the ?Notice of Federal Subaward Information Template and Subrecipient Monitoring? memo, which provided departments with a template to communicate the 14 subrecipient reporting requirements from 2 CFR ?200.332(a) to their subrecipients at the time of the subaward. The memo also reminded departments to provide all the required elements from 2 CFR ?200.332(a) to existing CRF subrecipients that were not initially provided all the requirements. In addition, the memo reminded departments that subrecipient agreements must include detailed expectations for periodic reporting and timing of reporting submission. On January 12, 2023, the County issued the ?CARES and ARP Act Funds Subrecipient Monitoring? memo, which reminded departments that subrecipient agreements must include data encryption requirements. The memo also reminded departments that existing subrecipient agreements without data encryption requirements will need to be amended by departments. In May 2023, during the Single Audit Kick-off annual meeting, the County will include the issued ?Notice of Federal Subaward Information Template? on the presentation slides and remind departments that the template should be used to communicate the 14 subrecipient reporting requirements. The County will also reiterate that departments need to maintain documentation that the template was provided to subrecipients at the time of the subaward and existing subrecipients that were not initially provided all the subaward requirements.