Corrective Action Plans

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.

Finding 2022-005 Contact Person Responsible for Corrective Action: Debbie Morton-Crum, County Auditor Contact Phone Number: 765-482-2940 View of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The County Commissioners are responsible for the American Rescue Plan project list along with that responsibility is to have a sub-recipient agreement in place with those outside entities that received American Rescue Plan grant monies from the County. An Internal Control is now in place that requires a sub-recipient agreement in place before a warrant can be paid to those outside entities. We will put procedures in place to ensure that money disbursed to sub-recipient is monitored. Anticipated Completion Date: October 1, 2023

June 14, 2023 Roslund, Prestage & Company, P.C. 525 West Warwick Drive Suite Alma, MI 48801 Finding: 2022-001 Federal Program: ALN 93.959 Block Grants for Prevention and Treatment of Substance Abuse (Prevention, COVID-19 Prevention II, and COVID-19 ARPA Prevention) Condition: During testing of contracts with subrecipients it was noted that these contracts did not include portions of required disclosures. Corrective Action Plan: The NMRE will include the information in contracts with subrecipients that are required in 2 CFR 200.332. Responsible Party: Chris VanWagoner, Provider Network Manager Date of anticipated implementation: FY23 going forward Thank you Regards, Deanna Yockey, CFO Northern Michigan Regional Entity 1999 Walden Drive Gaylord, MI 49770 231-383-6438

Assistance Listings number: 17.258 WIOA Adult Program; Assistance Listings number: 17.259 WIOA Youth Activities; and Assistance Listings number: 17.258 WIOA Dislocated Worker Formula Grants Contact Person(s): Jeremy Flowers, WIOA Executive Director and Lisa Grannis, WIOA Board Clerk and Compliance Specialist Anticipated completion date: June 30, 2023 Concur. The nonprofit organization was created in part to serve as the administrative arm of the Local Board and to provide a location for a resource center where WIOA services would be provided. The County did not distinguish fiscal responsibilities between parties and therefore assumed that certain expenditures of the Local Board and nonprofit would be allowable and could be paid directly by the County. The County considered the expenditures of the nonprofit to be program related, even though they were not directly incurred by the County. The County will improve its accounts payable policies and procedures for processing invoices using established process within the Finance Department, including ensuring all invoices are addressed to the County prior to payment. In addition, the County will establish clear contractual agreements that establish fiscal responsibilities that follow the program?s requirements. Finally, the County will coordinate with the pass-through grantor for the repayment of the unallowable costs identified in the finding.

Finding 2022-001 Condition Out of the three executed subrecipient agreements selected for testing, none of them included the subaward information required by the Uniform Guidance. Corrective Action Plan Corrective Action Planned: Lake County acknowledges that subaward information required by the Uniform Guidance was not provided to subrecipients in a separate notice. The County had previously incorporated the information in various clauses of the contracts/agreements with each subrecipient. The County has since developed a single notification form with the required subaward information which it includes with the initial contract and upon any modifications or change orders. Name(s) of Contact Person(s) Responsible for Corrective Action: Melissa Gallagher, Deputy Finance Director Anticipated Completion Date: August 31, 2023

Finding Number: 2022-001 Condition: It was noted through testing that there were multiple agencies where a monitoring visit had not taken place within the last two years per the Food Bank's subrecipient monitoring policy. Planned Corrective Action: The Director, Compliance Manager, and three (3) Area Leaders of the Agency Team maintain a schedule of due site monitors. During COVID there were extensive site closings and reduced hours thus impeding the ability to maintain the schedule. In order to maintain a safe work environment, it was necessary to reduce visits during peak periods of the pandemic. This was a unique and short-term issue. Each team member has a goal of conducting weekly monitors in order to complete the overdue monitor site visits by June 30, 2023. Monitors will be prioritized of oldest to newest until caught up with the schedule. Area Leaders will continue conducting site monitors with agencies prior to their upcoming due dates. Contact person responsible for corrective action: Persons responsible for enacting this corrective action plan include Director of Agency Relations Jacqui Hebein, contact jhebein@northernilfoodbank.org, or Compliance and Member Insights Manager Mackenzie Peshek, contact mpeshek@northernilfoodbank.org, (630) 443-6910 ext. 278. Anticipated Completion Date: 06/30/2023

City of Warren, Michigan June 30, 2022 Corrective Action Plan Finding Number: 2022-001 Condition: The City did not perform a risk assessment of the subrecipient during the year, and did not maintain documentation of subrecipient monitoring, as evidence to support subrecipient monitoring performed. Planned Corrective Action: The City agrees with the finding and will put procedures in place to ensure appropriate documentation is retained related to subrecipient monitoring and comply with the relevant internal policies. Contact person responsible for corrective action: Controller Anticipated Completion Date: 06/30/2023

Department: Health and Human Services Title: Internal control over TANF subrecipient audit procedures needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department will revise the standard operating procedures to include a search for out of state subrecipients. Completion Date: April 30, 2023 Agency Contact: Herb Downs, Director, Division of Audit, DHHS, 207-287-2778

Department: Health and Human Services Title: Internal control over TANF subrecipient risk evaluation procedures needs improvement Questioned Costs: None Status: Management?s opinion is that corrective action is not required Corrective Action: The Department disagrees with the finding. The Department has subrecipient monitoring procedures for all of its subrecipients whether they were competitively bid or not. The first assessment of risk, as noted in the finding, is when a subaward is competitively bid. Secondly, another risk assessment built into the Maine Uniform Accounting and Auditing Practices for Community Agencies (MAAP) in which requires higher risk subrecipients to undergo a higher level of testing. Additionally, there are audit and review requirements at a much lower threshold than that of the Uniform Guidance (UG). Finally, the Social Service Unit of the Division of Audit performs a risk assessment and tests transactions for those subrecipients that have been determined to be higher risk. The Department's subrecipient monitoring procedures ensures that we comply with the UG 200.332(d) Pass-through entity (PTE) monitoring of the subrecipient must include: 1) Review of financial and performance reports. 2) Following-up and ensuring that subrecipients take timely and appropriate action on all deficiencies. 3) Issues management decisions. 4) PTE is responsible for resolving audit findings specifically related to the subaward. Based on the Department's MAAP rules we ensure we comply with UG 200.332(e) Depending on the PTE's assessment of risk, the following tools may be useful: 1) Training and technical assistance. 2) On-site reviews. 3) Arranging for agreed upon procedures. The Department covers #3 by ensuring that all of our subrecipients have a requirement to submit to the Department a/an Audit, Review or Schedule of Expenditures of Department Awards (SEDA). Completion Date: N/A Agency Contact: Jim Lopatosky, Director, Division of Contract Management, DHHS, 207-287-5075

Department: Health and Human Services Title: Internal control over ICA program subrecipient monitoring procedures needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: The Department will update subrecipient monitoring policies and procedures for all OPHE subawards based on this finding and recommendations. The Department will develop a subaward tracking tool for each agreement. The Department will transfer all subaward monitoring records to a centralized location within OPHE that can be accessed by the entire team, including approval records and copies of reports submitted by each subaward recipient. The Department will conduct subaward risk assessments for SFY23 contracts. The Department will complete subaward monitoring processes for SFY23 contracts following the updated monitoring policies and procedures and ensure all documentation (including approvals) is saved in the centralized location. Completion Date: March 30, 2023, April 15, 2023, April 30, 2023 and June 30, 2023 respectively Agency Contact: Ian Yaffe, Director, Office of Population Health Equity, DHHS, 207- 592-1481

Department: Education Title: Internal control over ESF subrecipient monitoring procedures needs improvement Questioned Costs: None Status: Corrective action in progress Corrective Action: During the review of ESF applications, the Office of Federal Emergency Relief Programs (OFERP) team will confirm that equipment purchases are denoted in the equipment budget category of the application. Equipment inventories and real property lists will be collected during the subrecipient monitoring process from school administrative units (SAUs) and reviewed for compliance by the OFERP team. Completion Date: December 31, 2023 Agency Contact: Shelly Chasse-Johndro, Director of OFERP, DOE, 207-458-3180