Corrective Action Plans

Reference Number: 2022-023 Prior Year Finding: 2021-018 Federal Agency: U.S. Department of Health and Human Services State Department Name: Department of Health and Social Services State Division Name: Division of Substance Abuse and Mental Health Federal Program: Opioid STR Assistance Listing Number: 93.788 Award Number and Year: H79TI083305 (9/30/2020 ? 9/29/2022) Compliance Requirement: Subrecipient Monitoring Type of Finding: Significant Deficiency in Internal Control Over Compliance, Other Matters Recommendation: The Division should review and enhance internal controls and procedures to ensure that proper subrecipient monitoring is conducted in accordance with Federal regulations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Division has been working to implement corrective action. DSAMH continues to update and enhance policies and procedures to ensure that proper subrecipient monitoring is conducted in accordance with Federal regulations. Name(s) of the contact person(s) responsible for corrective action: Mequoria Bowden, Chief of Administration, Office of the Secretary Administration Planned completion date for corrective action plan: October 31, 2023

CORRECTIVE ACTION PLAN Finding 2022-002: Subrecipient Monitoring Public Allies has developed a Risk Assessment tool that will be implemented with subgrantees ("local sites") for Program Year '23. The tool?s development was driven by noted best practices and guidance shared with AmeriCorps grantees and Public Allies? prior monitoring findings. The tool includes a self-assessment by local sites and the results will drive the level of monitoring and training and assistance each site receives. Public Allies will also be piloting a new Progress Report, that will provide an at-a-glance assessment of site performance based upon metrics determined in collaboration with subgrantees. The programmatic monitoring process will be led by a dedicated monitoring team that is supported by staff that provide direct programmatic training and technical assistance to sites. For fiscal monitoring, Public Allies has shifted from outsourcing all accounting and financial management to bringing all accounting in-house. As described above, this staff now includes a Finance Director, a Staff Accountant and Senior Accountant. This shift was the result of an evaluation of internal operations and financial management systems. The addition of multiple full-time accounting staff has improved our capacity to monitor and manage subgrantees, effectively track and manage process improvements, ensure fiscal-related grants compliance, and efficiently manage our federal grant funding requests and reports. A fiscal Grants Manager was hired to review subgrantee financial reporting, provide technical assistance, and implement financial monitoring of subrecipients. Finally, a desk audit will be implemented in FY23. The number of files to be reviewed for each site will be determined based upon risk factors assessed, including: AmeriCorps Monitoring Common Findings, staff retention data, prevalence of turnover in AmeriCorps members, and length of time since the site underwent an audit. Requested programmatic and fiscal documents will include: ? Ally/Member Leadership Journal Position Descriptions ? Time Logs ? Ally/Member Evaluations ? Exit Documentation ? Ally/Member Payroll Register, and ? Operating Partner Due Diligence ? Annual Financial Statement ? Separation of Duties Survey ? Internal Controls Questionnaire The Public Allies Network will be notified of the Desk-Based Audit by May 26th and the desk audit will conclude by fiscal year end. Findings of the audit, in the form of a Monitoring Report will be shared with subrecipients, including required follow-up necessary to remediate compliance findings. Results of the desk audit will be used to determine future training needs, policy recommendations, and future monitoring Person Responsible: Najah Woods, Apprenticeship Program Grants Manager Implementation Date: August 31, 2023

FINDINGS - FEDERAL AWARD FINDINGS AND QUESTIONED COSTS 2022-003 Allowable Costs Auditor Recommendation: FAM should ensure that charges to federal grants are allowable in accordance with cost principles contained in Uniform Guidance. Additional training should be obtained to gain a further understanding of these requirements. Action Taken: Management agrees with the auditor's recommendation. Because the grant period is still open, we will subtract the 2021 audit cost of $23,768 from the final period report and replace it with an allowed cost. This will enable us to close out the grant with only allowable costs. Corrective Action Completion Date: FAM will replace the unallowed cost with an allowed cost by the end of the grant period of December 31, 2024.

If an award is identified as originating from federal funds the Seaway Valley Prevention Council has put measures in place that trigger a system of trainings for involved personnel that require, they thoroughly review the Uniform Guidance 2 C.F.R. Part 200. Involved personnel are also provided a "Allowable Costs and Activities" desk reference. SVPC has also reviewed our internal control's structure and is implementing changes to comply with the Uniform Guidance. SVPC has also performed a thorough review of agency cost allocation methodologies to identify and correct inconsistencies with expense accounts reviewed and reclassified as necessary. Indirect/admin expense accounts have been grouped accordingly in our chart of accounts streamlining our expense review process.

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.

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

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

ALN Number 17.258, 17.259, 17.278 ? Workforce Innovation and Opportunity Act 2022-023 ? Strengthen Controls to Ensure Compliance with Subrecipient Monitoring Requirements. Cat ? M, Finding Type, A, C1 (MW, MNC) MDES Response: The Mississippi Department of Employment Security concurs in principle with the three conditions noted in the finding. During and prior to this audit, MDES enacted new procedures to address the concerns noted in this finding. MDES renewed its commitment to ensuring that subrecipients are qualified to receive funds. MDES contracted with Booth Management Consultants and more recently Trace Advisory Group to ensure compliance with all DOL monitoring requirements, including on-site monitoring and through other modes. Also, we started implementing a risk-based assessment tool to ensure the performance of a thorough qualification assessment on all grantees. Corrective Action Plan: A. The Offices of Grant Management and Business Management will develop a plan to document our assessment of the subrecipients? awareness of audit requirements at 2 CFR 200.332(f). MDES will start implementing the plan detailed below on or before October 31, 2023. This plan involves the following: 1) Perform a pre-award risk assessment to determine risk for awarding grant and the level of monitoring required during program; 2) Issue a standardized audit requirement letter or agreed upon procedures to all subgrantees to remind them of grant requirements; 3) Receipt of required federal single audit from subgrantees expending more than $750,000 in federal funds from all sources OR receipt of a statement that the entity did not meet this threshold; 4) Document the review and assessment of the audits received for findings or questioned costs using tools, such as the templates found in the DOL Core Monitoring Guide; and 5) Document all required agency action necessary to mitigate the risks identified in the audits. B. COVID-19 caused extensive travel and in-person meeting restrictions nationwide. MDES did not restrict travel or virtual meetings. As contact guidelines fluctuated, the on-site monitoring team had discretion regarding the method to conduct this process. Also during this time, DOL staff observed similar contact restrictions, which limited federal monitoring of MDES. Such challenges and restrictions no longer exist. MDES will perform on-site and remote monitoring, as required. Where possible, MDES intends to conduct future monitoring on-site. MDES management will also hold regular meetings with the subrecipients to monitor progress and to ensure questions related to grant expenditures receive timely responses. C. Although the agency did not perform a risk-based assessment in the year reviewed by the auditors (PY21), MDES did incorporate the Risk Assessment Tool, Tool S from the U. S. Department of Labor?s Core Monitoring Guide, into its review of subgrantees for PY 2022. MDES will continue to ensure the performance of a thorough risk-based assessment on all grantees.

Contact person(s) responsible: Executive Director Vanessa Timmons; Associate Director Keri Moran Kuhn; Accounting Manager Linda Koonce. Corrective action planned: OCADSV added an Administrative Cost Center to its General Ledger effective 10-01-22, the beginning of FY23, and began costing administrative payroll costs to that cost center. Additionally, the organization re-trained administrative staff on direct cost-allowable activities vs. administrative activities relative to timekeeping and timesheet preparation and the necessity of daily work descriptions supporting the hourly allocation. The Payroll policy that requires supervisors to review and sign off on timesheets and hourly allocations to cost centers was also reviewed. Audit Costs for FY22 will be allocated in accordance with 2 CFR 200.405 requirements. Beginning with FY23, all accounting and other admin payroll-related costs will be costed to the administration cost center with the exception of time spent in activities related to a specific grant or other cost centers. FY22 Grants expenditures were reviewed post year-end, and a line-by-line review was conducted to bring the direct and indirect expense cumulative total into compliance with audit findings. Any outstanding reports were adjusted to reflect the adjusted Life of Grant to the current date reporting. Executive, Financial, and Grant Management staff will, during FY24, complete the Online Grants Financial Management Training available at onlinegfmt.training.ojp.gov to improve knowledge and compliance with 2 CFR 200 guidance and requirements. The said training will be incorporated into onboarding processes for any newly hired employees who have direct responsibilities related to Grant management and/or reporting. Said training requirements will be added to hire letters and work plans. Anticipated completion date: Effective 6/21/2023 and ongoing