Corrective Action Plans

Trailhead is establishing a new Contract and Compliance Coordinator role to oversee contract compliance processes and to ensure that Trailhead’s policy on subrecipient monitoring is followed. This role will be responsible for ensuring that compliance requirements are integrated at the outset of each grant. This role will be responsible for internal monitoring and auditing. This role will ensure that all grant kick-off meetings follow a standard procedure and include: 1) A clear understanding of federal requirements for all involved fiscal, program, and compliance staff 2) Delegated assignments to program staff for implementing and documenting: a) Suspension and debarment prior to contracting with subrecipients b) Subrecipient vs contractor determinations c) Evaluation of each subrecipient’s risk of noncompliance i) Establish the appropriate subrecipient monitoring level based on risk. This compliance role will have the authority to ensure the procedures are completed by the assigned staff. Evidence of the completed procedure must be documented and saved in a newly created contracts database. This database will be a centralized storage that will be reviewed during internal compliance checks to ensure all required steps have been completed and documented. These documents and associated grant and contract documents will be part of an official repository.

Finding Number 2023-013 Subject Heading (Financial) or AL no. and program name (Federal) 20.509 - Formula Grants for Rural Areas Planned Corrective Action We concur with the auditor’s recommendation. OMPT—We will develop and implement risk assessments as part of our sub-recipient monitoring process and revise existing procedures related to single audits. Lastly, we will meet with Internal Audit, formerly CWO, to establish a process to ensure audit reviews are documented and received. Internal Audit - Unfortunately the issues that occurred in last year’s audit, also effected the transactions selected in this year’s audit. It should be noted that 6 of the 11 missing files were provided to SA&I, however most of those audits were not performed in a timely manner. After the finding last year many changes were implemented in the Audit Office, including a change in management of the Grants and Contract Auditing area. A Smartsheet application is in now in use that allows OMPT to check on the status of audits at any time. We also have done extensive cross training on these single audit reviews and we are currently performing these audits in a timely manner as they come in. Anticipated Completion Date 7/1/2025 Responsible Contact Person OMPT - Eric Rose/Bobby Parkinson Anne Antonelli, Internal Audit – Holly Lowe

CONDITION: The City of McKeesport inadvertently charged as eligible expenditures two (2) purchases totaling $144,000 on the third quarter financial report required to be filed with the Department of Treasury that had already been claimed as eligible expenditures in the second quarter financial report. CRITERIA: Section 2 CFR 200.1 of the Uniform Guidance defines a disallowed cost as a charge to a Federal Award that is determined to be unallowable under the Award’s terms, which would include duplicate payments. Section 2 CFR 200.339 of the Uniform Guidance gives the federal agency the authority to disallow costs if the recipient fails to comply with the aforementioned Award terms and conditions. MANAGEMENT’S CORRECTIVE ACTION PLAN: Management of the City will reallocate the two vendor payments totaling $144,000 which were inadvertently duplicated in the financial reports required to be submitted to the Department of Treasury. The $144,000 in duplicate payments will be reallocated for eligible road salt purchases made during calendar year 2023.

The Municipality Administration is committed to identify the control of deficiency that allowed for the deficiency to happen. Additionally, the administration is committed to implementing the correct control sturcture to prevent the situation from happening in the future. The Municipality Management will continue the search of supporting documentation of the highlighted transactions. New proposed contrl strucure to be evaluated by Municipality for adequacy. The Municipality ensures the compliance with the Disaster Grants disbursement policies.

The Municipality Administration is committed to identify the control of deficiency that allowed for the deficiency to happen. Additionally, the administration is committed to implementing the correct control structure to prevent the situation from happening in the future. The Municipality Management will continue the search of supporting documentation of the highlighted transactions. New proposed control structure to be evaluated by Municipality for adequacy. The Municipality ensures the compliance with the Coronavirus State and Local Fiscal Recovery Funds Assistance disbursement policies.

VIEWS OF RESPONSIBLE OFFICIALS ADSEF will provide training to personnel on the requirements and regulations related to subrecipient monitoring. Recommendation to management will be implemented, internal controls and compliance measures that allow for the identification, reporting, and monitoring of subrecipient activities Prevention Activities/TANF. IMPLEMENTATION DATE During Fiscal Year 2025-2026. RESPONSIBLE PERSON Administration for Socioeconomic Development of the Family (ADSEF, by its Spanish Acronym)

Chairman of the Board of County Commissioners: Oklahoma County will comply with federal laws and regulations and grant agreements by creating award agreements that are designed and implemented to ensure Subrecipient Monitoring is performed. Anticipated Completion Date: 6/30/2025 Responsible Contact Person: Myles Davidson, BOCC Chairman

2023- 007 - Material Weakness in Internal Control and Material Noncompliance – Sub-recipient Monitoring and Management WPHW understands this finding and recognizes that correction that were planned for FY23 were not able to be fully implemented. One of the significant challenges WPHW had over the past couple of year, in addition to IT system challenges, is staffing. WPHW has hired three individuals to develop our contracting process and had performance issues with all three individuals. In addition to the difficulties with the NetSuite implementation, we have had to re-evaluate our sub-recipient monitoring and management business process. The following process will address this finding: 1) Director of Accounting and the Accounting Manager will review CFR 200.332 and develop a revised business process for the WPHW contract system a. Accounting Team will hire 2 Accounting Specialists who will each have specific sub-recipient monitoring responsibilities 2) Director of Accounting and the Accounting Manager will review all current contract to ensure the following: a. Ensure that every subaward is clearly identified to the subrecipient as a subaward and includes: i. Federal, State or other award identification. ii. Subrecipient name (which must match the name associated with its unique entity identifier); iii. Subrecipient's unique entity identifier; iv. Award Identification Number (FAIN/SAIN); v. Award Date of award to the recipient by the Federal agency; vi. Subaward Period of Performance Start and End Date; vii. Subaward Budget Period Start and End Date; viii. Amount of Federal Funds (if applicable) Obligated by this action by the pass-through entity to the subrecipient; ix. Total Amount of Federal Funds Obligated, if applicable, to the subrecipient by the pass-through entity including the current financial obligation; x. Total Amount of the Federal Award committed to the subrecipient by the pass-through entity; xi. Federal award project description, as required to be responsive to the Federal Funding Accountability and Transparency Act (FFATA); xii. Name of Federal awarding agency, pass-through entity, and contact information for awarding official of the Pass-through entity; xiii. Assistance Listings number and Title; the pass-through entity must identify the dollar amount made available under each Federal award and the Assistance Listings Number at time of disbursement; xiv. Identification of whether the award is R&D; and xv. Indirect cost rate for the Federal, State, or other award (including if the de minimis rate is charged) per § 200.414. b. All requirements imposed by the pass-through entity on the subrecipient are in accordance with Federal, State, Local statutes, regulations and the terms and conditions of the award; c. Determines and ensure completion of required financial and performance reports; d. Has an approved federally recognized indirect cost rate negotiated between the subrecipient and the Federal Government or utilizes the de minimus. e. States that 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 f. Details appropriate terms and conditions concerning closeout of the subaward. g. Subrecipient risk assessment that accesses: i. prior experience with the same or similar subawards; ii. previous audits iii. personnel or substantially changed systems iv. Prior monitoring results 1. Subaward conditions will be placed if issues arise 3) Implement sub-recipient monitoring process. a. Conduct invoice review monthly i. All invoices must include full back up and support for expenses ii. All invoices will be reviewed as they are received to ensure expenses are allowable iii. Any issues that arise will be addressed prior to invoice payment b. Conduct contract monitoring visit annually i. Hold a meeting with the sub-recipient to review the following: 1. Reviewing financial and performance reports 2. Following-up and ensuring that the subrecipient takes timely and appropriate action on all deficiencies detected through audits, on-site reviews, and written confirmation from the subrecipient, highlighting the status of actions planned or taken to address Single Audit findings related to the subaward. 3. Training and technical assistance on program-related matters 4. Determine corrective action for any deficiencies or findings and determine risk 5. Discussion of enforcement action against noncompliant subrecipient This process will be reviewed, and implementation will begin during Q4 FY24. All current FY24 contracts will be reviewed, and monitoring visits scheduled. For FY25, all contracts will be in compliance with requirements.

The City will devise subrecipient monitoring procedures.

Upon learning of the requirement for the Federal Funding Accountability and Transparency Act (FFATA) reporting, the Highway Safety (HS) office completed the reporting in January 2024. The highway safety office completed FFATA reporting for grants from 2019-2023 which resulted in nine sub-awards being reported. Going forward HS will complete the FFATA reporting after the subaward agreement is signed. During the year, HS will review agreements for additional obligations and update the FFATA reporting as necessary. Also, at the end of the year HS will conduct a final review to ensure all FFATA reporting was completed. Additionally, the Internal Review (IR) program has met with all of the grant administrators on January 29, 2024 to let them know about the FFATA requirements for each of their funding types. IR discussed the FFATA reporting requirement for sub-awards over $30,000. Each grant administrator will determine the best way to report their sub-awards in the Federal Subaward Reporting System (FSRS). Contact: Karson James, Highway Safety Grants Coordinator, Highway Safety and Mariá LaBorde, Internal Review Manager, Internal Review Anticipated Completion Date: January 29, 2024

PDA: PDA will be hiring a complement position to develop and maintain an audit tracking report to ensure that all single audits are properly logged and processed. In addition, this position will review the financial information in each audit report to determine if all pass-through funding is properly included and subject to audit. This position will coordinate with the bureaus within PDA to ensure all required follow-up is completed in a timely manner. Anticipated Completion Date: 06/30/2024 Contact Name: Tracee Gotwalt, Audit Coordinator PDOA: The PDOA is looking to improve management decision communications in addition to more thorough evaluations as a new Comprehensive Monitoring Process pilot is starting in April 2024 to address the noncompliance of subrecipient monitoring. This has resulted in management designing control activities to achieve timely submissions in the future by initiating the following: 1. An audit tracking log has been established to track report submissions, document when they were received, initiated, findings requiring follow-up, and subsequent steps to finalize the audit. 2. A separate tracking mechanism is in place to ensure the monitoring of subrecipient activities for compliance with federal statutes, regulations, and the terms and conditions of the Agreement for the 52 Area Agency on Aging subrecipients. 3. PDOA is looking to fill a vacant position with a focus of tracking subrecipient expenditures in the aggregate and tracks Single Audit submissions on a Commonwealth wide basis since the Aging Cluster is material and has material sub-granted expenditures. 4. Since receiving the finding, PDOA has reached out to the resource account where Subrecipient Single Audit reports are received by the Federal Audit Clearinghouse (FAC) to verify all outstanding audit items for PDOA, as action is required within six months of receipt. 5. It is PDOAs impression that having increased oversight of the Schedule of Expenditures of Federal Awards (SEFA) will allow for timely dissemination of Management Decision Letters (MDL) in the six-month timeframe for making a management decision for federal award findings. 6. Additionally, PDOA will confirm a closure letter was sent to the Philadelphia Corporation for Aging documenting PDOA’s management decision regarding federal award findings, as included in their FYE 06/30/2021 Single Audit report. 7. Follow-Up procedures resulting from this finding will be reviewed and adjusted as needed to deliver optimal outcomes. Preliminary procedures will be directed to the agency’s audit review committee for resolution of completeness. 8. In the event the audit review committee determines additional steps beyond the monitoring efforts outlined above are insufficient, additional efforts will be communicated to the AAA network. Anticipated Completion Date: 06/30/2024 Contact Name: Jennifer Cave, Fiscal Management Specialist, PDOA Audit Liaison DOH: DOH’s subrecipient single audit tracking report now includes a mechanism to monitor management decision deadlines related to each entity’s FAC submission date. The process for tracking subrecipient audit reports with findings has been updated to include and highlight subrecipients’ audit reports where DOH is the lead agency for finding resolution or the report contains findings that relate to the Department. Anticipated Completion Date: 03/31/2024 Contact Name: Steven Marsden, Chief, Audit Resolution Section PDE: PDE has implemented weekly, monthly and quarterly checks to ensure that all single audits are properly logged and processed. The clerk typist will conduct a weekly review and provide confirmation to the audit coordinator by signature. Bi-weekly, the clerk typist will follow up on any single audits that remain open. Anticipated Completion Date: Completed Contact Names: Clayton Carroll, Audit Coordinator, Bureau of Budget & Fiscal Management; Jessica Sites, Director, Bureau of Budget & Fiscal Management

FINDING 2023-002 Finding Subject: COVID-19 – Education Stabilization Fund – Subrecipient Monitoring Summary of Finding: The School Corporation received and passed through to subrecipients $495,386 of ESF funds. The School Corporation is to clearly identify the award and applicable requirements to the subrecipients, evaluate the risk of noncompliance related to the subrecipients to determine appropriate monitoring of the subaward, and monitor the activities of the subrecipients to ensure that the subaward is used for authorized purposes, complies with the terms and conditions of the subaward, and achieves performance goals. Contact Person Responsible for Corrective Action: Dr. Judi Hendrix, Director of WVEC and Michelle Cronk, CFO of West Lafayette Schools Contact Phone Number and Email Address: Dr. Judi Hendrix Michelle Cronk 765-894-0333 765-746-1602 judi.hendrix@esc5.k12.in.us cronkm@wl.k12.in.us Views of Responsible Officials: We concur with the finding regarding the informing and monitoring of subrecipients for federal grants. Description of Corrective Action Plan: We concur with the findings from the State Audit regarding the 3E grants funds; 2023-002. Our Corrective Action Plan would consist of the following:  Before ESF funds are dispersed to school districts (subrecipients), the WVEC Grant Director will ask districts for proper documentation such as receipts, college entrance letters, staff documented timesheets to support their request for funding.  The WVEC Grant Director will monitor the activities of the subrecipients to ensure that the financial subaward is used for authorized purposes, complies with the terms and conditions of the subaward, and achieves performance goals of the grant.  Once the school district’s information and documentation is received and approved, grant funding will be dispersed. Both the Service Center Executive Director and WVEC Grant Manager will approve and sign off on any payment made to a subrecipient.  On a biannual basis (periods ending June 30 and December 31), West Lafayette School Corporation will request the monitoring documentation from WVEC to ensure that proper monitoring is taking place. The WVEC Grant Director will create a sub-grantee reporting procedure:  Monthly spreadsheet with district allowable expense and sign off by Grant Manager, WVEC Executive Director and WVEC Treasurer approval.  This will take place every pay period to monitor the disbursement of any federal funds and to ensure that they are used for allowable expenditures under the grant.  This monitoring will begin in the month of March 2024 and continue until the end of the grant or Final Report, December 31, 2024. This procedure will also be used for other federal grants received.  On a biannual basis (periods ending June 30 and December 31), West Lafayette School Corporation will request the monitoring documentation from WVEC to ensure that proper monitoring is taking place. Anticipated Completion Date: Monthly monitoring will begin promptly (March 2024) and end with the final report of 3E grant activities on December 31, 2024.

2023-001: Special Education Cluster – Procurement Context/Condition - Of the four procurement transactions subjected to testing, there were two professional service contracts that the District did not have documentation supporting the sole source procurement method. Corrective Action Plan – Laramie County School District No. 1 (LCSD1) appreciates the thorough review conducted by the auditing team, identifying the lack of documentation for two sole source contracts for special education trainers hired in response to the Wyoming Department of Education’s monitoring review. In response, LCSD1 has undertaken a comprehensive corrective action plan to rectify the identified issues and prevent future occurrences. Immediate steps include a detailed review of the existing contract, identification of missing documentation, engagement with legal counsel to ensure compliance, and the development of clear procedures for documenting sole source justifications. To address potential gaps in staff understanding, LCSD1 has implemented additional training programs and reviews by procurement staff. LCSD1 will also evaluate federal, state and district procurement policies and initiate additional internal monitoring requirements for special education contracts. LCSD1 does not dispute the finding and will continue to improve processes and procedures with a focus on periodic reviews to enhance procurement practices. Contact Person – Jed Cicarelli, Chief Financial Officer Anticipated Completion Date – Immediately

The Institute has engaged an auditor to complete the December 31, 2022, 2023, 2024, and 2025 Single Audits concurrently, and will submit each reporting package and data collection form to the Federal Audit Clearinghouse as each audit is completed. Thereafter, the Institute will complete the audit and submit the reporting package within nine months after year end. Anticipated completion date: December 31, 2026. Responsible contact person: Kathy Walker, Executive Director.

We concur with the finding. The Republic has executed a signed subrecipient subaward agreement to formalize the relationship and ensure compliance with applicable requirements. Applicable laws and regulations include the COMPACT Fiscal Procedures for Palau, which take precedence as special terms and conditions where both these procedures and 2 CFR 200 address the same matter. The Ministry of Finance has implemented internal control policies and procedures to identify and document subrecipient relationships at the time of award, monitor subrecipient activities through periodic reporting, and verify compliance with federal and local requirements prior to processing drawdown requests. We further confirm that the program audit requirement for this subrecipient has been met through the separate single audit.

ALN 21.023 – Lack of Internal Controls and Noncompliance with Subrecipient Monitoring – Emergency Rental Assistance Program (Repeat Finding 2021-013) Cleveland County takes the auditor's findings seriously and has already implemented several improvements in documentation, monitoring, and reporting practices. Cleveland County is working toward improvements for Fiscal Year 2025 and has reconciled billing to align with the contract scope of work. However, we recognize the need for documented internal controls and are committed to addressing all recommendations to ensure compliance and transparency in future programs. The County appreciates the constructive feedback and will continue to refine its processes to better serve its citizens.

Description of Finding: Lack of documentation on sole source contracts and verification of vendors Statement of Concurrence or Nonconcurrence: The California Asian Pacific Chamber of Commerce (CalAsian) agrees with the finding. Corrective Action: CalAsian understands the serious nature of this finding and the compliance required with 2 CFR sections 200.318 through 200.327, as well as Part 1326 for vendor exclusions. The Interim Controller and Director of Finance will be revising procedures to document requirements for all procurement activities, regardless of type. We also understand these findings are repetitive from the 2021 audit; however, due to catch-up of the prior year audits, we were unable to address these issues prior to completion of the 2022 audit. This delay was caused by a change in auditors as our previous auditor did not have the capacity to retain us as clients due to staff shortages related to COVID. Resolution of this issue began in 2024 as staff were trained and provided the updated procedure to ensure all procurement activities adhere to the company policies. Continuing education will be provided in 2025 to ensure continued compliance with these policies. In 2025, a formal procurement system in the new ERP structure will be implemented and utilized for vendor quotes, requisitions and POs to ensure compliance. Periodic reviews of the procurement activities will be performed to ensure compliance with these procedures to mitigate the risk of continued deficiencies. Name of Contact Person: Ryan Fong, Director of Finance, 916-446-7883, rfong@calasiancc.org Pat Fong Kushida, President & CEO, 916-446-7883, patfongkushida@calasiancc.org Projected Completion Date: December 2024

The Municipality Administration is committed to identify the control of deficiency that allowed for the deficiency to happen. Additionally, the administration is committed to implementing the correct control structure to prevent the situation from happening in the future. The Municipality Management will continue the search of supporting documentation of the highlighted transactions. New proposed control structure to be evaluated by Municipality for adequacy.

The accounting staff will continue searching for supporting documentation related to the disbursements amounting $17,565. The Coronavirus State & Local Fiscal Recovery Funds (CSLFR) Department of Treasury Final Rule of January 2022., offers a standard allowance for revenue loss of $10 million, allowing recipients to select between a standard amount of revenue loss or complete a full revenue loss calculation. Recipients that select the standard allowance may use that amount, in many cases their full award, for government services. The Municipality’s management selected the standard allowance, since the amount awarded of CSLFR funds were less than $10 million ad determined that the use of these funds was for governmental services, which are services traditionally provided by recipient governments. The Municipality determined that the payroll expenditures of several departments of the Municipality’s General Fund will be charged to the CSLFR fund as government services. The transfer of $1,468,197 of CSLFR to other Municipality’s bank accounts was to cover the payrolls related to governmental services accounted in the Municipality’s General Fund during the fiscal year 2021-2022. Due to an involuntary omission, these transfers were not recorded as expenditures in the CSLFR fund in the accounting system of the Municipality. To correct this accounting error the Municipality’s management gave instructions to the accounting staff to start reclassifying in the accounting system as soon as possible, these transfers to payroll expenditures accounts in the CSLFR fund. Municipality’s management believes that this finding should be related to an issue of reporting because the Municipality complied with the requirements of activities allowed or unallowed and allowable costs, since the Municipality disbursed CSLFR funds related to governmental services in accordance with the Department of Treasury Final Rule of January 2022. No actions are required related to this finding.

Evidence of AAFAF Funds closeout report was provided, there is no issue.

21.023 - Lack of Internal Controls and Noncompliance with Subrecipient Monitoring Requirement – Emergency Rental Assistance Program (Repeat Finding – 2021-002) Oklahoma County will comply with federal laws and regulations and grant agreements by creating award agreements that are designed and implemented to ensure Subrecipient Monitoring is performed. Anticipated Completion Date: 6/21/2023 Responsible Contact Person: Brian Maughan, BOCC Chairman

21.019 - Lack of Internal Controls and Noncompliance with Subrecipient Monitoring Requirement – Coronavirus Relief Fund (Repeat Finding - 2021-001) Oklahoma County will comply with federal laws and regulations and grant agreements by creating award agreements that are designed and implemented to ensure Subrecipient Monitoring is performed. Anticipated Completion Date: 6/30/2024 Responsible Contact Person: Brian Maughan, BOCC Chairman

Corrective action was taken on contracts 2023 and beyond.  The 2023 contracts already awarded were amended to include them and the new contracts that are being formalized in 2024 are including FEMA's mandatory clauses.

Wabanaki Public Health and Wellness received our FY21 audit in April 2023, which did not allow for the changes to be made in time for FY22. The corrective action plan from FY21 continues to be our course of action and will be fully implementing the following to ensure compliance in FY23. Wabanaki Public Health & Wellness followed sections of the subrecipient monitoring for requirements of documentation and follow through, however there were areas in which the audit team brough forth to light that needed some enhancing for procedures. WPHW will follow through with full review of the OMB standards for the subrecipient monitoring and build a check list to determine that each required section/item is followed throughout the period of award. The WPHW team, which includes, the Director of Finance, Financial Quality and Compliance Manager, and the Contract Specialist will be working together to build the required list and procedure and reviewing the checklist for when the award is first presented to allow both parties, (sub awardee and WPHW) to understand the requirements for the award. Throughout the award period WPHW will maintain required documentation following the CFR 200.332 guidelines. The Financial Quality and Compliance Manager will review processes through the periodic review of all awards to verify that monitoring has been completed at the deemed timeframe and all parties involved are maintaining the set forth requirements of the award. Person(s) Responsible: Beth McLean Timing for Implementation: Summer 2023

2022-001: Procurement and Suspension and Debarment Corrective Action: Northwest College will perform a review of its current procurement policy, including purchasing thresholds, record retention of supporting documentation regarding method of procurement utilized, and maintaining supporting documentation regarding suspension and debarment for all contracts or purchases expected to equal or exceed $25,000 of Federal funds. Northwest College will revise its procurement policy as determined necessary and in accordance with Northwest College?s policies. Anticipated Completion Date: June 30, 2023 Contact Persons: Brad Bowen, Finance Director