Corrective Action Plans

Assistance listing numbers and program names: 84.010 Title I Grants to Local Educational Agencies 84.367 Supporting Effective Instruction State Grants (formerly Improving Teacher Quality State Grants) Agency: Arizona Department of Education (ADE) Name of contact person and title: Dr. Sarka White, ADE Deputy Associate Superintendent Anticipated completion date: December 15, 2024 Agency’s response: Concur The Arizona Department of Education (ADE) has already begun implementing a program to ensure accurate and quality programmatic monitoring for all ESEA programs which specifically requires LEAs to meet 100% of the requirements of all statutorily required items to be monitored regardless of CMO affiliation. This development of programmatic monitoring will design a system of integrity to allow each LEA to have unique monitoring findings and ensure they are treated as all other LEAs regardless of management status. The Arizona Department of Education (ADE) is finalizing all program policies and procedures along with field training and staff training on how this program is implemented. ADE began providing an assurance document to charters in May 2024 which asks the charters to assure that if they do business with a CMO, the CMO does not have fiscal or operational authority for the LEA. The charter is asked to submit to ADE a copy of their organizational chart, along with the assurances document. Grants Management has created a new user role in the Grants Management Enterprise (GME) system, called the LEA Contracted Update role. This role allows a CMO person the access to perform fiscal tasks for which they have been contracted but does not hold the final submit or approve capacity, that must be reserved for authorized employees of the LEA. Grants Management has provided the placeholder for the assurance and organizational chart in the LEA Document Library, along with the communication to eligible entities (charters in this case). Individual program areas within ADE who review and approve funding applications will be responsible for verifying the assurances have been signed and uploaded and only authorized people at the LEA are actioning funding applications in GME prior to the program area giving director approval to the application.

Assistance listing numbers and program names: 84.010 Title I Grants to Local Educational Agencies 84.367 Supporting Effective Instruction State Grants (formerly Improving Teacher Quality State Grants) Agency: Arizona Department of Education (ADE) Name of contact person and title: Nicole Von Prisk, ADE Deputy Associate Superintendent of Grants Management Matt McClary, ADE Compliance Officer Anticipated completion date: April 2025 Agency’s response: Concur • Tech team supervisor will have someone from that team put eyes on the initial generated report to compare results to prior year, looking at total number of LEAs, then greenlighting the initial report for the Tech Director and the Fiscal Director to review. • Once the Fiscal and Tech Directors receive the report, they will be responsible for sampling the data that populated into the report, by looking at overall numbers who Pass, Pass with Exception, or Fail and doing a comparison for analysis to prior year summary results. They will conduct a random sampling, comparing totals to latest AFR totals, to ensure amounts populated correctly. Once random sampling has been completed, it will be sent to Deputy Associate Superintendent for final checks. • Deputy Associate Superintendent will give final approval to move to public display of data, after confirmation of completeness and accuracy of data populated.

Assistance listing numbers and program names: 84.010 Title I Grants to Local Educational Agencies 84.367 Supporting Effective Instruction State Grants (formerly Improving Teacher Quality State Grants) Agency: Arizona Department of Education (ADE) Name of contact person and title: Dr. Sarka White, ADE Deputy Associate Superintendent Chris Brown, Business Officer of Education Programs Anticipated completion date: February 2025 Agency’s response: Concur • The Arizona Department of Education (ADE) has already begun to document and execute practices addressing the recommendations issued by the auditor's office. • ADE has already drafted a comprehensive policies and procedures document outlining eligibility, duties, and responsibilities with individuals who oversee and double-check the work. This document was created and refined by reviewing other states’ procedures, federal technical assistance groups, communications with the Title federal program office at the United States Department of Education, and internal procedures in other units. • The Title I unit has been restructured to have an operations team with multiple staff members overseeing data quality and internal controls for allocations. This updated structure ensures that multiple individuals are involved in the allocation process. Staffing for this should be completed by February 2025. • The updated processes include entity management to determine when charter LEAs open and operate each year. Now, other systems validate this information instead of copying the information from the prior year. As such, this item has already been completed. • Finally, the department will follow up with the United States Department of Education (USED) regarding recalculating the fiscal year 2023 and the six ineligible LEAs for Title II funds to determine feasible processes and resolutions to each audit recommendation.

Assistance listing numbers and program names: 21.027 COVID-19 - Coronavirus State and Local Fiscal Recovery Funds 84.425C COVID-19 Education Stabilization Fund –Governor’s Emergency Education Relief (GEER) Fund Agency: Arizona Governor’s Office of Strategic Planning and Budgeting (Office) Name of contact person and title: Sarah Brown, Director Anticipated completion date: July 31, 2025 Agency’s response: Concur During fiscal year 2024, the Office took significant corrective action to improve subrecipient monitoring by developing and implementing a comprehensive subrecipient monitoring plan. This plan includes the following: • Financial Report-Reimbursement Requests—The Office reviews the grantee's financial reports to ensure costs align with the approved budget, program objectives, and federal cost principles. • Performance Reports—The Office reviews the submission of programmatic reports. The timelines for submission and frequency of the programmatic activity reports are defined in the terms and conditions of each award. The program activity reports document that all program requirements are being satisfactorily fulfilled. Grantee outreach is conducted when performance activity is lagging. Grantee check-ins and/or additional milestones are set to ensure goals are met. The Office may amend or terminate the grant award if sufficient progress is lacking. • Single Audit Reports—The Office confirms any required Single Audits and reviews a copy of the most recent report. • A Single Audit Questionnaire is distributed to grantees annually to confirm if the entity is subject to this federal audit requirement. • The Office also reviews total payments issued to an entity by the Office in the prior year to confirm if disbursements met the audit threshold. • The Office requests grantees submit their Single Audit Reporting Package (SARP) with any findings and the required Corrective Action Plan. In addition, the Office collects SARPs from the federal clearinghouse. • The Office reviews SARPs for any findings and conducts follow-up monitoring of CAPs that impact any grant funding managed by the Office. Management decisions are issued to grantees as required for specific grant findings. • Risk Assessment (RA)—The Office conducts a Risk Assessment (RA) of grantees when applying for grants to inform the grant award decision and possible grantee oversight or restrictions. Additionally, the Office conducts an annual RA of any grantee currently awarded funding. • The RA contains a self-assessment for the grantee to complete and an internal review conducted by the Office. Scores from both are weighted and used to calculate the overall risk score for each grantee as high, medium, and low risk. • The Office utilizes the RA results to prioritize high-risk grantees, which are reviewed through a desk or on-site monitoring. Medium-risk grantees will receive additional support and be referred to our Compliance and Reporting team for further review if additional concerns arise. Office staff now attend ongoing internal and external training to improve their understanding of compliance requirements, identify noncompliance, and actively reduce the risks of waste, fraud, and abuse of federal dollars through our subrecipient monitoring process. The Office has developed and implemented processes for requirements such as single audit review and corrective action follow-up, risk assessment, and subrecipient monitoring to address the specific findings. During the time frame corresponding to this audit finding, the pace and volume of grants management administrative duties required to be executed exceeded staffing capacity, contributing to the findings noted. As of this date, the Office has achieved stability in both manager and staff positions. In addition, the Office has allocated sufficient resources to comply with the award terms and program requirements by establishing a Grants Compliance and Reporting Team dedicated to performing necessary subrecipient monitoring procedures. Furthermore, the Office has implemented all recommendations and would like to specifically highlight efforts to work with subrecipients to resolve the potential disallowed costs of $1,903,858 of program monies that may have been spent in violation of its federal award terms by conducting on-site monitoring visits, desk reviews, and facilitating subrecipient technical assistance. OSPB is committed to continuing these efforts.

Assistance listing numbers and program names: 21.023 COVID-19 - Emergency Rental Assistance Program 21.027 COVID-19 - Coronavirus State and Local Fiscal Recovery Funds Agency: Arizona Department of Economic Security (DES) Name of contact person and title: Molly Bright, DES CCSD Assistant Director Anticipated completion date: June 30, 2026 Agency’s Response: Concur The Department of Economic Security will address the audit recommendations as follows: 1. Ensure benefit payments are for allowable costs paid to or on behalf of eligible program applicants. The Department will review and confirm that benefits payments paid to or on the behalf of eligible program applicants are allowable expenditures of the federal funding being disbursed. 2. Follow existing policies and procedures to obtain required documentation to support requirements related to where the applicant lives and their income to ensure program applicants are eligible to receive benefit payments. The Department will abide by the existing adjudication policies and procedures that require the submission of substantiating documentation supporting the claims made by applicants regarding where they live and their household income to confirm that applicants are eligible to receive benefit payments under the program and to verify the amount of benefits they shall receive. 3. Allocate sufficient staffing resources to perform a thorough evaluation of program benefits applications and provide training on eligibility requirements and allowable benefit payments. The Department will attempt to obtain or allocate additional resources to staffing to support the program benefits application evaluation process and will provide additional training to staff on eligibility requirements and allowable benefit payment regulations. 4. Update the checklist Division personnel use to perform a post-review of eligibility determinations to include detailed guidance for verifying the determinations aligned with the Division’s written policies and procedures and supported by adequate documentation. The Department will update the checklist being used by staff to perform post-review of eligibility determinations to include detailed guidance on verifying the applicant benefits determinations in alignment with the divisional policies and procedures and evidenced by adequate substantiating documentation.

Assistance listing number and program name: 14.267 Continuum of Care Program Agency: Arizona Department of Housing (DOH) Name of contact person and title: Keon Montgomery, DOH Assistant Deputy Director of Programs Anticipated completion date: January 30, 2025 Agency’s Response: Concur The Department is in the process of developing written policies and procedures to address matching, level of effort, and earmarking. The policies and procedures will address communication with subrecipients and maintaining records and documentation of the amounts used to fulfill matching requirements.

Assistance listing number and program name: 14.267 Continuum of Care Program Agency: Arizona Department of Housing (DOH) Name of contact person and title: Keon Montgomery, DOH Assistant Deputy Director of Programs Anticipated completion date: January 30, 2025 Agency’s Response: Concur The Department resumed monitoring duties and developed a monitoring schedule to ensure subrecipients maintain program compliance. The Department also established a risk assessment tool that assess risk associated with each subrecipient. Records of subrecipient monitoring will be kept for a period of time to demonstrate monitoring activities were performed.

Assistance listing number and program name: 14.267 Continuum of Care Program Agency: Arizona Department of Housing (DOH) Name of contact person and title: Keon Montgomery, DOH Assistant Deputy Director of Programs Anticipated completion date: January 30, 2025 Agency’s Response: Concur The Department is no longer reimbursing the subrecipient for unsupported or ineligible costs and is pursuing repayment of funds from the subrecipient. Written policies for reviewing and approving subrecipient reimbursements, as well as, risk assessment were reviewed, updated and amended to ensure ongoing compliance. Staff has been trained and new policies were implemented in FY 2024 subsequent to the period reviewed in this audit. Contract Specialists in the Special Needs Division have received additional training through HUD TA support on CoC standards to ensure all request for reimbursement from subrecipients are eligible, reasonable and appropriately documented, including any allocations and purchasing requirements.

Assistance listing numbers and program names: 14.231 Emergency Solutions Grant Program 14.231 COVID-19 - Emergency Solutions Grant Program 93.558 Temporary Assistance for Needy Families 93.558 COVID-19-Temporary Assistance for Needy Families Agency: Arizona Department of Economic Security (DES) Name of contact person and title: Molly Bright, DES CCSD Assistant Director Anticipated completion date: June 30, 2025 Agency’s Response: Concur The Department will stop the reimbursement of costs to all nonprofit and contracted subrecipients for items that are disallowed and/or restricted by the regulations of the federal Emergency Solutions Grant (ESG) program and Temporary Assistance for Needy Families (TANF) grant, including payments to personnel that violate the conflict-of-interest disclosure requirements. The Department will revise its expenditure review procedures to ensure compliance with these regulations prior to disbursing any ESG and/or TANF funding to any subrecipient for any purpose. These revisions will include review and approval by applicable management personnel prior to disbursement of federal funding. The Department is also in the process of establishing a divisional Monitoring and Compliance Policy and Procedure Manual which will establish procedures specific to subrecipient monitoring. The Department will continue to assess the risk of noncompliance violations for each subrecipient and establish a plan of action to address noncompliance. The plan of action will include an array of training and educational processes to ensure applicable personnel are knowledgeable of programmatic compliance requirements and Department contracts. The Department will also monitor subrecipients per its updated policies and procedures and will ensure proper oversight of federal expenditures as required by federal regulations. The Department has amended its contracts with the applicable subrecipients to more clearly outline the regulatory requirements and expectations for expenditures under the ESG and TANF grants. The Department will also continue to resolve the unallowable costs reimbursed to subrecipients as deemed appropriate by the applicable federal agencies.

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.

Condition and Context: ACT noted that it did not request and review audited financial statements for all subrecipients. Recommendation: ACT evaluates the policies and procedures to ensure appropriate monitoring is performed over all subrecipients and reviews audited financial statements for those subrecipients that are required to have an audit performed. Views of Responsible Officials and Planned Corrective Action: ACT accepts the auditors’ recommendation. We will review and update the monitoring policies and procedures to include requesting and reviewing the audited financial statements for those subrecipients that are required to have an audit performed.

EXECUTIVE OFFICE OF LABOR AND WORKFORCE DEVELOPMENT 2023-012 WIOA Cluster, Employment Service Cluster – Assistance Listing No. 17.258, 17.259, 17.278, 17.207, 17.801 Action taken in response to the finding: The corrective action plan (CAP) for this finding was implemented and completed in Fiscal Year 2023 with the addition of the FAIN numbers to the subawards and the completion of FY23 CommCorp monitoring. MDCS continues to include FAIN as part of the revised documented process and monitoring is current and timely performed. MDCS therefore considers this item to be completed and closed. Name of the contact person responsible for corrective action: Michael Williams, Director of Field management and Oversight Planned completion date for corrective action plan: December 31, 2022

Yamhill County Finance staff will prepare a recorded presentation about our responsibilities for subrecipient monitoring. The recording will be presented to all employees who manage fede ral grants and presented during a MS Teams meeting where a Q&A session will be held afterwards to solidify learning and appropriately applying the federal requirements. County staff will ensure these grant award recipients are registered with the County via the County's grant administrat ion program and monitoring activities will commence immediately, and in the same manner that the County has been monitoring other similar awards that did not involve a third-party administrator. Further, the County as a practice will now require that all future grant recipients, regard less of whether administered by a third-party or the County directly, be required to register their organization via the County's grant administration programming for ongoing monitoring and reporting.

Cluster name: TRIO Cluster Assistance Listing number and name: 84.042 TRIO – Student Support Services 84.047 TRIO – Upward Bound Award numbers and years: P047A171009, September 1, 2017 through August 31, 2022 P047A170820, September 1, 2017 through August 31, 2023 P042A200873, P042A201342, and P042A200859, September 1, 2020 through August 31, 2025 P047A221154 and P047A221160, September 1, 2022 through August 31, 2027 Federal Agency: U.S. Department of Education Compliance Requirements: Eligibility Questioned costs: $5,612 Name of contact persons: Kristina Winterstein, Associate Controller, District Business Services Anticipated completion date: June 30, 2024 The District is aware of the importance of maintaining effective internal control over federal awards and ensuring compliance with applicable federal regulations. The District will work with the TRIO project directors at each college to review and revise existing procedures to require an independent and knowledgeable employee review and approve student eligibility determinations prior to awarding program services to them. The District will enhance communication and training efforts to ensure that the TRIO project directors and all staff administering the TRIO programs understand all eligibility requirements and related district-wide policies and procedures. As of March 21, 2024, the questioned costs for the program have been resolved.

FAIN (Federal Award Identification Number) and Federal Award Date: The following action has been implemented to include the FAIN & Award date on all awards for ALN 20.509: All awards executed for Public Transit will include a “Grant Insert Sheet”. The Grant Insert Sheet will be identified on the Part 1 Grant award detail document. Box “36” titled FAIN, will include text that reads “See attachment B”. The Grant Insert Sheet is a document that is completed by the Public Transit Unit and is provided to the Grants Unit for award execution. This sheet includes detailed information related to the award. To address the deficiency, The Grant Insert sheet has been updated to include FAIN Numbers and the Federal Award Date. To ensure the Agency of Transportation meets this compliance requirement, the Grants Unit will verify this information is included prior to award execution. Anticipated completion date: This action went into effect as of January 12, 2024. Person Responsible for Corrective Action: Ross MacDonald, Public Transit Program Manager ross.macdonald@vermont.gov Tricia Scribner, Grants Unit Manager tricia.scribner@vermont.gov Management Review Schedules In the past, The Public Transit Program has used the State Fiscal year for the timing/scheduling of the 3-year Management Reviews. For example, if the completion of the last Management Review occurred in FY 2020, then we would ensure a new Management Review began at any time during FY2023. We understand this could lead to more than exactly 3 years between these reviews. Due to this finding, we will now establish a starting month/date for each provider, with 3-year intervals between the start of each Management Review. We have attached the updated schedule and will adhere to this from this day forward. Anticipated completion date: As of December 27, 2023, the updated Management Review Schedule is in effect. Person Responsible for Corrective Action: Ross MacDonald, Public Transit Program Manager ross.macdonald@vermont.gov

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.

Finding No.: 2022-031 AL Program: 21.027 - Coronavirus State and Local Fiscal Recovery Funds Area: Subrecipient Monitoring Questioned Costs: $61,003,095 Contact Person(s): Tracy B. Norita, Secretary of Finance Corrective Action Plan: Condition 1-3: The Department of Finance agrees with this finding. The Department has recently adopted and approved (August 2025) a Subrecipient Monitoring Policy and Procedures which specifically focused on the implementation of 2 CFR 200.331. The Department will expand on this policy and procedure to include the development and implementation of a comprehensive subrecipient monitoring policies that clearly outline the process for identifying subawards, assessing the risk of noncompliance, and conducting monitoring activities based on those risks. These policies will be aligned with federal requirements and best practices to ensure consistency and accountability. Furthermore, due to internal scheduling constraints and the compressed timeline required to complete the FY22 audit, the requested documents were not submitted by the specified deadline, resulting in this finding. However, the Department maintains all relevant supporting documentation and is prepared to provide it upon request from the Grantor. Proposed Completion Date: Ongoing

Public Health’s Center for Preparedness and Response (CPR) agrees that it did not establish a formal risk assessment process over its subrecipients of ELC COVID-19 awards. CPR will establish and document formal procedures for conducting risk assessments of ELC subrecipients. Public Health will also develop and implement specific subrecipient monitoring procedures. CPR also agrees that it did not obtain single audit reports from ELC subrecipients. CPR will develop and implement procedures outlining the process for obtaining single audit reports from subrecipients, which will include a monitoring mechanism to track compliance with the single audit mandate. Estimated Implementation Date: December 2024 Contact: Melissa Relles, Assistant Deputy Director Division of Operations Center for Preparedness and Response California Department of Public Health

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

Assistance Listings number and name 84.425F COVID-19 Education Stabilization Fund?Higher Education Emergency Relief Fund (HEERF) Institutional Portion Award number and years P425F201546-20B, May 6, 2020 through June 30, 2023 Federal agency U.S. Department of Education Compliance requirement(s) Allowable costs/cost principles Questioned costs $4,249,864 Name(s) of contact person: Ross Poppenberger Anticipated completion date: Q1 (January - March) 2023 The District misinterpreted its Federal Indirect Cost Rate (IDC) as it applies to HEERF funding. Although the District applied their prenegotiated IDC rate to the HEERF Grant, the District did not apply the rate to the correct program expenditures when calculating the IDC. The District updated its internal grants IDC calculation policies and procedures to ensure that indirect costs are properly calculated and reviewed for accuracy and written confirmation is obtained from the grantor for a new grant?s IDC calculation. Further, the District is working with the U.S. Department of Education to reappropriate the unallowable funds to allowable direct costs.

Finding # 2022-007 Title of Finding Subrecipient Monitoring Contact Person Brook Hinzman Anticipated Completion Date June 2023 Corrective Action planned to be taken: Will comply and monitor subrecipient spending going forward.

CFDA No. and Name: 10.691 Good Neighbor Authority Responsible Persons: Siri Mullaney, Finance Director Anticipated completion date: June 30, 2023 Corrective Action: Concur. In fiscal year 2023, the Flood Control District was moved from the Public Works Department and formed into a stand-alone department, allowing for the hire of new staff dedicated to the management of federal awards. This increase in oversight will provide the capacity to accurately account for federal awards and comply with requirements such as adherence to the award start and end dates and the receipt of pre-approval by the federal agency for pre-award costs. The County will continue to provide technical assistance and resources to departments managing federal awards.

Finding 2022-001 Federal Agency: Various Program Name: Research and Development Cluster Assistance Listing Number: Various Federal Award Year: Programs active between July 1, 2021 ? June 30, 2022 Compliance requirement: Subrecipient Monitoring Finding Type: Significant Deficiency The Office of Research and Sponsored Programs lost both its primary and secondary resources responsible for subrecipient monitoring in July 2020 and June 2021. The University could not replace them immediately due to a hiring freeze during the Covid pandemic. A full time Subaward Coordinator was hired in December 2021. The Subaward Coordinator has operationalized all tasks associated with Subrecipient Monitoring as identified in the Uniform Guidance as well as in accordance with Lehigh policies, procedures and internal controls. The review of current active subawards has been completed, including all single audits for fiscal year 2022, with no findings for any of Lehigh?s subawards. The Subaward Coordinator continues to monitor for the posting of these remaining reports on a weekly basis in order to complete the review of subrecipient single audit reports on a timely basis. We are confident with the full-time focus of the Subaward Coordinator and the enhancements to our subrecipient monitoring processes and controls that this finding is fully remediated. Name of contact person: Cynthia Kane, Assistant Vice Provost, Office of Research and Sponsored Programs. Completion date: May 31, 2022

FINDING 2022-004 Contact Person Responsible for Corrective Action: Chad Shireman Contact Phone Number: 812-738-8241 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The county will be retaining and periodically reviewing the grant application and award to stay current on applicable requirements of the subrecipient in order to ensure compliance. Lines of communication with the subrecipient will be established and maintained to better monitor activities, ensuring that the subaward is used for authorized purposes, complies with the terms and conditions of the subaward and achieves performance goals. Policies and procedures will be adopted and implemented to allow the county to evaluate the subrecipient?s risk of noncompliance. The county will request supporting documentation from the subrecipient when reimbursement requests are made, and this process will be documented in order to provide evidence that it is taking place. Anticipated Completion Date: The anticipated completion date will be December 31, 2023. This will allow the county and the subrecipient to work together to create the necessary policies and procedures. Once created, the remainder of the year will be used to implement them, allowing the county to evaluate all activities for the entire 2023 audit period that will be under review by SBOA in 2024.

Finding: The Health Care Authority did not have adequate internal controls over and did not comply with federal requirements to ensure subrecipients of the Block Grants for Community Mental Health Services program and the Block Grants for Prevention and Treatment of Substance Abuse program received required single audits, and that it appropriately followed up on findings and issued management decisions. Questioned Costs: Assistance Listing # 93.958 93.958 COVID-19 93.959 93.959 COVID-19 Amount $0 Status: Corrective action in progress Corrective Action: The Authority concurs with the finding. The Authority will: ? Follow established procedures related to the agency-wide monitoring of subrecipients? single audits. ? Issue management decision letters for findings subrecipients received related to programs that are funded by the Authority?s pass-through federal funding. ? Evaluate corrective actions to ensure subrecipients adequately address audit recommendations. Completion Date: Estimated July 2023 Agency Contact: William Sogge, CPA External Audit Liaison PO Box 45502 Olympia, WA 98504-5502 (360) 725-5110 william.sogge@hca.wa.gov