Corrective Action Plans

The Division of Aging Services (DoAS) will comply with the pass-through entity and subrecipient monitoring requirements under the federal Uniform Guidance as per CFR § 200.332(a). The DoAS will provide all required information to the subrecipient at the time of award issuance. This subaward notice will be posted as a miscellaneous attachment to contracts in the Division's System for Administering Grants Electronically (SAGE), or via mail, fax or email to those subawards not administered in SAGE. DoAS plans to complete and update this information on SAGE within 60 days. COMPLETION DATE/ CONTACT PERSON May 31, 2024 Hetal Bhatt (609) 438-4586 Hetal.Bhatt2@dhs.nj.gov Dennis McGowan (609) 438-4739 Dennis.McGowan@dhs.nj.gov

Finding Number 2023-213: The Department erroneously determined that two recipients of Temporary Assistance for Needy Families (TANF) funding were contractors instead of subrecipients resulting in noncompliance with the subrecipient monitoring requirements. Federal Programs: 93.558 – Temporary Assistance for Needy Families Related to Prior Finding: N/A Agency’s view: The Department agrees with this finding. Corrective Action: The Department has revised our training of personnel involved in subrecipient and contractor determinations. These contract managers and monitors completed grant training on March 12th-13th, 2024 which included sections about subrecipient and contractor determinations, risk assessment and documentation. All newly hired employees will be trained beginning April 2024 with an on-line module. For the impacted vendor, an updated Risk Assessment was completed and submitted to LSO. Additionally, the Department has started the work to effectively change the designation of the vendor and ensure all required information is provided to this subrecipient. This process will be completed by April 30th, 2024. The Department will develop internal control procedures to ensure all required information is provided to the subrecipients at the time of the subawards. These updated internal control procedures will be completed by June 30th, 2024. Anticipated Corrective Action Date: June 30, 2024 Responsible for Corrective Action: Cameron Gilliland, Division Administrator Cameron.Gilliland@dhw.idaho.gov 208-334-0641 Kelly Combs, Bureau Chief, Compliance Kelly.Combs@dhw.idaho.gov 208-334-5814

The Department Concurs with paragraph A – Since this same finding was reported in March of 2023 for FY22, items a, c, and d are now included on all federal subaward contracts and policies have been updated to reflect this. The Department will ensure b is also included going forward. The Department concurs with paragraph B - The finding was a result of personnel turnover and medical issues. The Department has hired and trained additional program staff and updated policies to ensure programmatic monitoring and subsequent reports are done in a timely manner. The Department partially concurs with paragraph C. Fiscal monitoring was done for all 3 subrecipients during the federal program year. However, 1 subrecipient monitoring fell outside the state fiscal year so was not covered during the audit period. The Department has changed the wording on its risk assessment procedures to ensure no misinterpretation of the timeframe each subrecipient will be monitored in accordance with its risk assessment. The Department has also changed the requirements of the frequency of fiscal monitoring in each of the risk assessment categories. The Department Concurs with paragraph D – The Department is reviewing policies and procedures and will update them to ensure compliance with 2 CFR section 200.332(a), 2 CFR section 200.332(b) and 2 CFR section 200.521. The Department also created a tracking mechanism to ensure we receive, review, and issue management decisions (if required) in a timely manner. The Department concurs with Paragraph E - The Department is reviewing policies and procedures for both reporting and subrecipient monitoring to ensure data is tested and verified. The Department has already gained increased access to data in current software and is in the process of selecting a vendor for new software that will provide more testing and enhanced internal controls.

Corrective Action Planned (Condition A): The DAS analyzed the six items erroneously reported as subawards and noted the errors were isolated to two specific agencies, the Department of Health and Human Services and the Department of Environmental Services. In response to the prior year finding 2022-002, the DAS had strengthened internal controls related to the review and validation of amounts reported by individual state agencies as pass through expenditures. This included an additional control specifically verifying SLFRF pass through expenditures reported by each agency. The DAS will offer additional training relative to identification and reporting of subaward expenditures in its annual statewide Single Audit training and re-evaluate the precision of execution of controls over the validation of pass through reporting in assembling the SEFA for fiscal year 2024. Corrective Action Planned (Conditions B through E): The State largely concurs with the findings and recommendations and has implemented procedures to address the identified conditions already or will do so. With regards to condition B, The State will work with the individual agencies to ensure that individual agencies entering into such agreements clearly indicate the terms required by Uniform Guidance, including permitted indirect cost rates and whether the award is for R&D. The State has already begun this corrective action plan with the agencies. With regards to condition C, for a. and b. for payments by agencies, there are standard procedures for review and authorization of invoices and payments and those payments are documented. For c. The State has already implemented an agency wide framework for subrecipient monitoring. The State will provide re-training for those agencies that had not properly documented monitoring as outlined by the subrecipient risk assessments and ensure monitoring reports are documented. With regards to condition D, The State has already implemented an agency wide framework to help ensure policies and procedures are in place concerning Uniform Guidance Reports. We will work those agencies that had not documented the date received and the review of the Uniform Guidance Reports to ensure written documentation occurs. Where findings have been reported in the Uniform Guidance Report, ensure timely Management Letters are documented and provided with the summary review of Uniform Guidance Report.

1. Person responsible: Division Chief, Auditor-Controller Accounting Division 2. Corrective action plan: The County agrees with the finding and recommendation. In September 2022, the County issued the Notice of Federal Subaward Information template, which contains the 14 reporting elements required by 2 CFR §200.332(a) that must be provided to subrecipients at the time of the subaward. The County will issue written correspondence reminding departments to complete the Notice of Federal Subaward Information template and provide a completed copy to the subrecipient at the time of the subaward. The County will also remind departments to provide all the required elements from 2 CFR §200.332(a) via letter or amended agreement to existing subrecipients that were not initially provided all the requirements. In the same correspondence, the County will remind departments to monitor their Coronavirus State and Local Fiscal Recovery Fund (CSLFRF) subrecipients, maintain sufficient records of the monitoring, and utilize the Subrecipient Monitoring Guide issued in June 2023. 3. Anticipated implementation date: June 28, 2024

Contact Person: Kristen Nagle, Assistant VP Finance/Controller Corrective Action: The University Finance department has updated their policies and procedures to ensure that the SEFA is being prepared in accordance with required guidelines. We will work closely with our grants department to ensure all required elements are properly identified and disclosed. Anticipated Completion Date: July 1, 2024

Type of Finding: Significant Deficiency in Internal Control over Compliance relating to inadequate documentation and controls in place to ensure costs are reasonable and intended for the program charged. Views of Responsible Officials: Management accepts the finding. Effective internal control over the allocation of indirect costs exceeding the de minimis cost rate of 10%, which can be attributed to a lack of communication and review of the total expenditures being charged to the federal program. Program managers were accidentally invoicing before reconciling adjustments made. More thorough training of staff, along with careful supervisory review of total expenditures being charged to the federal program, and invoicing would likely have prevented this error. Corrective Action: An annual training of all grant accountants is being developed and will cover indirect and allowable costs. In addition, a process for secondary review of all invoices is being developed.

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.

Condition: The College did not have a control system in place to monitor performance measures as outlined in the subrecipient and grant agreements. The College was also not completing any site visits of the subrecipients or requiring annual financial reporting be submitted. Planned Corrective Action: Below are three items implemented to address the subrecipient monitoring requirement: 1. To address the finding of noncompliant subrecipient agreements, Grand Rapids Community College has implemented a new Grants Administration Guide. This guide can be found on the Grand Rapids Community College website. 2. To address the finding of lack of progress monitoring, subrecipient partners have been given monthly metric reports which include planned vs actual outcomes as a means of outlining their progress. The reports also include historical data for each category. This information is broken down by month and to be reviewed with subrecipients on a bi-weekly basis. This bi-weekly monitoring will provide oversight and help manage performance. Each grant partner will submit quarterly outreach plans that will be balanced against planned vs actual outcomes. These outreach plans will consist of detailed information highlighting the purpose of the event, target audiences, and updates from previous events. 3. To address the finding of lack of subrecipient monitoring, Grand Rapids Community College has scheduled formal site visits with subrecipients. Within the meetings they will discuss the following topics: Narrative Visit Overview, Financial Status Discussions, Metrics Verification, Narrative Overview, Participant Records and Revenue and Evaluation. Contact person responsible for corrective action: C. Dennis Triggs II- Program. Manager – One Workforce Grant. Anticipated Completion Date: 7/31/2023

2023-002 Coronavirus State and Local Fiscal Recovery Funds – Assistance Listing No. 21.027 Recommendation: We recommend that the Organization review and follow the indirect cost rate guidance set out at 2 CFR section 200.414 within Uniform Guidance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management is in the process of updating it’s calculation of indirect costs to be in compliance with the indirect cost rate guidance set out at 2 CFR section 200.414 within Uniform Guidance. Name of the contact person responsible for corrective action: Shannon Marimón Planned completion date for corrective action plan: February 29, 2024

2023-002 - Noncompliance and Significant Deficiency in Internal Controls over Compliance for Subrecipient Monitoring Corrective Action Plan: Wellbeing Initiative has reviewed subrecipient monitoring criteria and updated the Internal Controls Policy and Procedure Manual to include the following policy. The appropriate measures have been taken to ensure these requirements are met in the coming years. Item 10.8.b.i-xv. Subrecipient monitoring requirements for pass-through entities, include the requirement that pass-through entities ensure that every subaward is clearly identified to the subrecipient as a subaward and includes the following information at the time of the subaward and if any of these data elements change, include the changes in subsequent subaward modification. When some of this information is not available, the pass-through entity must provide the best information available to describe the Federal award and subaward. Required information includes but is not limited to: i. Subrecipient name (which must match the name associated with its unique entity identifier); ii. Subrecipient's unique entity identifier; iii. Federal Award Identification Number (FAIN); iv. Subaward Period of Performance Start and End Date; v. Subaward Budget Period Start and End Date; vi. Total Amount of Federal Funds Obligated to the subrecipient by the pass-through entity including the current financial obligation; vii. Total Amount of the Federal Award committed to the subrecipient by the pass-through entity; viii. Federal award project description, as required to be responsive to the Federal Funding Accountability and Transparency Act (FFATA); ix. Name of Federal awarding agency, pass-through entity, and contact information for awarding official of the Pass-through entity; x. 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; xi. Indirect cost rate for the Federal award (including if the de minimis rate is charged) per § 200.414. xii. All requirements imposed by the pass-through entity on the subrecipient so that the Federal award is used in accordance with Federal statutes, regulations and the terms and conditions of the Federal award; xiii. Any additional requirements that the pass-through entity imposes on the subrecipient in order for the pass-through entity to meet its own responsibility to the Federal awarding agency including identification of any required financial and performance reports; xiv. 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 xv. Appropriate terms and conditions concerning closeout of the subaward Anticipated Completion Date: Completed 11/16/2023 Responsible: Chief Executive Team: Danielle Smith and Sadie Thompson

The City will review the process for identifying federal awards to minimize the likelihood of errors in preparing the schedule of expenditures of federal awards to minimize the likelihood of errors in preparing the schedule of expenditures of federal awards. This will include inquiries of the Engineer’s Office.

Upon conducting the FY21 audit, TAS’ Director of Finance was informed that the inclusion of the Biological Expertise line item on federal budgets (approx. 7.5% additional uplift) was not allowable as it was currently being calculated. TAS is allowed a 10% de minimus rate on noted FY22 Federal awards some of which also included a Biological Expertise line item that is budgeted as an hourly rate. TAS had been calculating uplift amounts owed by simply adding the Biological Expertise (7.5%) to the de minimus rate (10%) for a total uplift of 17.5%. This was done at the direction and approval of our federal partners. However, due to Biological Expertise being entered in the federal and approved budgets as an hourly line item and not a percentage TAS was considered out of compliance by using this method of calculation. Moving forward TAS will be billing the de minimus rate (10%) as a percentage, unless otherwise noted in the agreement.

Finding 2022-005 – Indirect Cost Allocations In response to the finding, GEM will improve program costs allocation documentation by instituting the following controls and procedures. GEM will allocate indirect costs and charges to the NSF program based on incurred costs and monthly allocations approved by the program administrator. These indirect costs will be separately reported in the accounting records. Anticipated date of completion: Monthly journal entry is set up with calculations for determining the dollar amount. The date of completion was October 2022 and have been updated since then. Responsible party: Jamie D. Hicks, Senior Accounting Manager

Management agrees with the finding and is implementing the accompanying corrective action plan. Views of Responsible Officials: Jacy Hyde, Executive Director Joel Rusco, Chief Financial and Administrative Officer Jessica Martinez, Deputy Director Contact Person: Jessica Martinez, Deputy Director Joel Rusco, Chief Financial and Administrative Officer Corrective Action Plan: In response to FY21 Corrective Action Plan, CFSC implemented an updated Reporting Policy in June 2024 to strengthen internal controls prior to review and submission of invoices and drawdown/payment requests to funders. To ensure further compliance with 2 CFR 200.414(c), 2 CFR 200.403(d), and 2 CFR 200.302(b)(3), CFSC will implement the following corrective actions: 1.Verification of Indirect Cost Rate Before Submission: a.CFSC will require that all invoices, including indirect costs, be reviewed by the CFAO to confirm that the rate used is in accordance with an approved provisional or final NICRA agreement. b.Any invoice for federal funding lacking an approved indirect cost rate will be flagged and returned for correction before submission. 2.Pre-Submission Approval Process for Invoicing Indirect Costs: a.All invoice requests containing indirect costs must be reviewed and approved by the CFAO prior to submission. b.The Finance Department will verify and document that the rate applied is consistent across all federal awards and matches the NICRA. 3.Indirect Cost Rate Agreement Tracking & Documentation: a.CFSC Finance will establish an Indirect Cost Rate Agreement tracker to ensure that: i.All provisional and final indirect cost rate agreements are maintained on file. ii.Indirect cost rates used on invoices are consistently aligned with approved agreements. 4.Quarterly Internal Audits of Indirect Cost Rate Compliance: CFSC Finance Department will conduct quarterly reviews of a sample of drawdown/payment request invoices to confirm: a.The correct indirect cost rate was applied b.The rate was consistently applied across all federal awards Anticipated Completion Date: These corrective actions will be fully implemented by the end of Quarter 2 of FY25

Consortium’s Fiscal Agent will ensure that supporting documentation will be maintained for all expenditures to ensure that each expenditure charged to the program is for an allowable activity/cost. In addition, Fiscal Agent will complete corrective action for 2022-005 & 2022-006

The Township Fiscal Officer will prepare the SEFA or contract with a CPA firm to have the SEFA prepared going forward.

Finding 2022-005 – Indirect Cost Allocations In response to the finding, GEM will improve program costs allocation documentation by instituting the following controls and procedures. GEM will allocate indirect costs and charges to the NSF program based on incurred costs and monthly allocations approved by the program administrator. These indirect costs will be separately reported in the accounting records. Anticipated date of completion: Monthly journal entry is set up with calculations for determining the dollar amount. The date of completion was October 2022 and have been updated since then. Responsible party: Jamie D. Hicks, Senior Accounting Manager

Internal communication processes for direct pay projects were used in conjunction with ODOT reports to capture these offsetting revenues and expenditures as well as the additions to capital assets in 2023.

The School District will review the Uniform Guidance requirements and ensure all expenditures are accurately reported on the School District’s federal schedule.

Finding 2022-010 U.S Department of Agriculture Special Supplemental Nutrition Program for Women, Infants, and Childre – 10.557 Award number 202222W100643 Management’s Response: Management agrees it is imperative to foster collaboration for successful award management. Finance leads the annual effort working with an outside consultant to calculate the indirect rate using information supplied by Unified Government of Wyandotte County & Kansas City KS. The annual indirect rate will be calculated annually for use by all departments in the spring and available by July 1 each fiscal year. This will be used consistently across all departments unless the State of Kansas rate is permitted by the grant. Finance will work to find the best way to make the information easily accessible to grant program managers embedded in departments. After the audit, management received an authorization letter from the Kansas Department of Health and Environment (KDHE) that supported the indirect rate we used for Jul2022-Dec2022, however because the letter was dated in 2024, we are still subject to this finding. Views of Responsible Officials and Corrective Action: Management will work internally to complete the annual calculation of the indirect rate and develop a solution, a shared document solution to provide indirect rate information to departments in a consistent and timely manner. Management will ensure this is addressed by December 31, 2024. Responsible Official: Dr. Shelley Kneuvean Chief Financial Officer Unified Government of Wyandotte County & Kansas City KS

2022-006 Program: WIOA Cluster Federal Financial Assistance Listing Number: 17.258, 17.259, 17.277, 17.278 Federal Grantor: U.S. Department of Labor Pass-Through: California Department of Employment Development Award No. and Year: AA011008 and 2019 Compliance Requirements: Subrecipient Monitoring Type of Finding: Material Weakness Management’s or Department’s Response: Imperial County Workforce Development Office (ICWDO) agrees with the finding. Views of Responsible Officials and Corrective Action Plan: The questions from finding 2021-008 relate to a formalization of the fiscal processes and protocols. ICWDO operates under WIOA guidelines and follows Imperial County’s fiscal policies. Internal policy will be formally updated to reflect compliance with WIOA regulations, as well as Imperial County policies. These policies will include formal controls and procedures to evaluate each subrecipient’s risk of noncompliance. Once the formal procedure is drafted, it will go through the ICWDO Policy Committee for comment and direction, and then finally reviewed and approved for implementation by the full Workforce Development Board. Additionally, for any future Memorandums of Understanding (MOUs) between this Imperial County department and any outside agency, there will be an additional step to include review by Imperial County Counsel to reflect that recital around the funding source will specify the following required information: • Federal Award Identification Number • Federal award date of award to recipient by the Federal agency • Name of Federal awarding agency • CFDA Number • Specific identification of whether the award is research and development ICWDO will develop internal policies for formalizing all subrecipient monitoring process. ICWDO operates under WIOA guidelines for monitoring; therefore a formal internal policy for future contracts will be developed and implemented using the usual review and approval procedures followed by the department. ICWDO will develop a formal internal documentation system, with appropriate checks and signatures, for the evaluation and assessment of each subrecipient’s risk of noncompliance. ICWDO will utilize this formal process to properly document the risk assessment of all subrecipients. ICWDO anticipates to implement the corrective action by December 31, 2023. Name of Responsible Person: Priscilla A Lopez, ICWDB Director Implementation Date: December 31, 2023

Responsible: Denice Hairston, Chief Quality, Compliance and Accountability Officer Corrective Actions: Update subrecipient award agreements to ensure the final approved scope of work or project description is specified. Completion Date: March 29, 2023 Explanation: Policies and procedures were updated in 2023 in response to an OJJDP/OCFO recommendation to ensure subaward files contain the requisite components for the award agreement. In addition to these updates, which include a master file checklist, National CASA/GAL has updated the subrecipient Terms & Conditions agreement to include CFR requirements as recommended.

All future federal expenditures will be reconciled to the disbursement ledger.

The Organization has taken steps to ensure that the calculation of indirect costs is executed properly and reviewed for compliance in accordance with the contract agreement. Management brought the error in the contracted indirect rate to the funders attention initially, but unfortunately a misstep back to the original contract terms was made before close-out. The development and application of indirect rates will be conducted by the Sr. Director of Finance with oversight by the Chief Financial & Operating Officer and is in place as of the date of this corrective action plan.