Corrective Action Plans

Reference Number: 2022-024 Prior Year Finding: 2021-024 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: Block Grants for Prevention and Treatment of Substance Abuse, COVID-10 - Block Grants for Prevention and Treatment of Substance Abuse Assistance Listing Number: 93.959 Award Number and Year: B08TI083060 (10/1/2019 ? 9/30/2021), B08TI083488 (10/1/2020 ? 9/30/2022) Compliance Requirement: Subrecipient Monitoring Type of Finding: Material Weakness in Internal Control Over Compliance, Material Noncompliance Recommendation: The Division should review and enhance internal controls and procedures to ensure that all required information is included in all subawards and provided to the subrecipients, that proper subrecipient monitoring is conducted, and that evaluation of independent audits is performed. 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

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

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.

Policies, procedures and controls have been reviewed and revised to ensure all sub-awards are monitored consistently and that reports are filed regularly with APS. A new reporting form has been created that will log electronic signatures from both the sub-awardee and APS staff. In addition, APS will request a copy of the single federal audit of each sub-awardee annually. And, APS will monitor award amounts and then make the required filings, to meet all reporting requirements set forth under the Transparency Act. APS begin implementing these procedures in Q2 2023, upon discovery of these deficiencies. APS implemented the corrective action plan on June 5th, 2023. Management's contact responsible for the implementation of the Corrective Action Plan: Name: Jane Hopkins Gould Position: Chief Financial & Operating Officer Telephone number: 301-209-3276

Program: Emergency Rental Assistance Program Assistance Listing No.: 21.023 Federal Agency: U.S. Department of the Treasury Passed-through: Direct Award Award Year: 2021/2022 Compliance Requirement: Subrecipient Monitoring Type of Finding: Material Weakness, Instance of Material Noncompliance Views of Responsible Officials: We concur with the finding. Corrective Action Plan: The Auditor-Controller?s Office issued countywide policies and procedures to address finding 2021-002 from the County?s 2021 Single Audit. The 2021 Single Audit was completed after June 30, 2022, as a result corrective actions did not occur during this review period. The policies and procedures include subrecipient monitoring, risk assessment, and required subrecipient language. Subrecipient monitoring activities were conducted for this contract, including a risk assessment while the policies were in development. This contract has expired and revisions to include subrecipient language would not be beneficial. No additional corrective actions are needed for this finding. Responsible Individual(s): N/A Anticipated Completion Date: N/A

Program: Section 8 Housing Choice Vouchers Assistance Listing No.: 14.871 Federal Agency: U.S. Department of Housing and Urban Development Passed-through: n/a ? direct award Award Year: 2021/2022 Compliance Requirement: Subrecipient Monitoring Type of Finding: Material Weakness, Material Noncompliance Views of Responsible Officials: We concur with the finding. Corrective Action Plan: The Auditor-Controller?s Office issued countywide policies and procedures to address finding 2021-002 from the County?s 2021 Single Audit. The 2021 Single Audit was completed after June 30, 2022, as a result corrective actions did not occur during this review period. The policies and procedures include subrecipient monitoring, risk assessment, and required subrecipient language. This contract is a multi-year agreement. The County is working with the City of Vacaville on revisions to the contract including the required subrecipient language. Responsible Individual(s): Terry Schmidtbauer, Director of Resources Management Anticipated Completion Date: June 30, 2023

Rural Health Care Services Outreach, Rural health Network Development and Small Health Care Provider Quality Improvement ? AL No. 93.912 Recommendation: Our auditors recommended that the Organization create effective internal controls and procedures over subrecipient monitoring and tracking that allow for compliance with all applicable Federal laws, regulations, and compliance requirements of various federal grants. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Management?s response: The ROAMS grant did not clarify with the Network partners that receive $20,000 yearly stipends whether they were subrecipients or contractors, but instead assumed everyone was a contractor. We agree to this as a finding. We have since followed up with the stipend partners and all but one has declared their stipends as contracts. ROAMS agrees with the classification of three as contractors and one as a subrecipient which is described below: ? Union County General Hospital (UCGH): Both ROAMS and UCGH see this relationship as a contractor. The stipend pays for a Tele-OB room in their facility and the budget even lists rent as part of the reason for the stipend. The stipend per the MoU also supports their participation in the monthly Governing Council meetings, data collection, IT support for the program implementation and decision making. ? Questa Health Center/Presbyterian Medical Services (Questa): Both ROAMS and Questa see this relationship as a contractor. The stipend pays for an OB room in their facility and is even listed as rent in the stipend budget. The stipend per the MoU also supports their participation in the monthly Governing Council and decision making. ? UNM Envision (UNM): UNM declared a portion of their stipend over the three-year period they received as subrecipient. They declared $39,635 as subrecipient and they received a total of $68,000 from ROAMS. ROAMS always saw the relationship as a contractor and not a subrecipient and we do not understand why they have declared a portion of their stipend as subrecipient. UNM was not an essential grant partner, joined in year two to assist with data review, participated in the Governing Council, and ROAMS has a data evaluation agreement with UNM that we understood as a contract. This different understanding of the relationships highlights the audit finding that the type of relationship should be agreed upon upfront. ? Miners Colfax Medical Center (MCMC): sees themselves as a subrecipient and we agree. They are a state hospital and the other Labor and Delivery hospital in the ROAMS grant, and like Holy Cross Medical Center have a very high data reporting burden and serve as the home for the patients. The Memorandum of Agreement signed by all Network partners outlines their obligations in section IV Provision of Services and VI Records and Information (a. b. and c.). As we have investigated the monitoring of subrecipients verses a contractor, we have found that the same follow up is necessary, as long as the subrecipient receives less than $750,000 in federal funds in a year, which is the case for MCMC. Rural Health Care Services Outreach, Rural health Network Development and Small Health Care Provider Quality Improvement ? AL No. 93.912 (Continued) Our procedures for paying the stipend for both the contractors and one subrecipient (MCMC), have been attendance at the monthly Governing Council meetings, and deliverables from data collection, to IT support and meetings, workflow meetings, and clinical meetings. Reminders of deliverables that are pending are in the monthly Governing Council notes as is the attendance. ROAMS and the network partners were very clear in written documents and practice that the quarterly stipend payment was linked to participation and deliverables. We can provide you with monthly Governing Council notes to show this. A draft policy is in the works that will have the network partners formally declare their relationship as contractor or subrecipient and outline the monitoring of subrecipients. From our research we do not see the subrecipient monitoring being significantly different from a contractor unless the $750,000 threshold is met. The ROAMS grant did not clarify with the Network partners that receive $20,000 yearly stipends whether they were subrecipients or contractors, but instead assumed everyone was a contractor. We agree to this as a finding. We have followed up with the stipend partners and all but one has declared their stipends as contracts. ROAMS agrees with the classification of three as contractors. The ROAMS Director will request from the entities the audits for the CFO review to review for deficiencies on an annual basis. Name(s) of the contact person(s) responsible for corrective action: Connie Prewitt, Interim CFO Planned completion date for corrective action plan: Will implement in fiscal year 2023

Cluster: Research and Development Federal Agency: All awards with subrecipients on the SEFA Award Names: All awards with subrecipients on the SEFA Award Numbers: All awards with subrecipients on the SEFA Assistance Listing Title: All awards with subrecipients on the SEFA Assistance Listing Number: All awards with subrecipients on the SEFA Award Year: 2021 - 2022 Pass-through entity: All pass-through entities noted on the SEFA Management agrees with the finding related to the Subrecipient Risk Assessments. To address these deficiencies Research Operations will update its subrecipient monitoring policy to explicitly state the ongoing monitoring activities that must be conducted and the frequency of required monitoring. Additionally, training will be provided to the staff who perform the risk assessment to ensure they are documenting the details of the review including the date and results of the subrecipient audit report review. Furthermore, updates will be made to the risk assessment procedure to ensure subrecipient annual audits are reviewed and the results of the review and follow-up are sufficiently documented. To ensure compliance, internal monitoring will be performed. Leadership Responsible: Barbara A. Vance, PhD, CRA, Vice President, Research Operations Anticipated Completion Date: 12/31/2023; Monitoring of compliance will continue throughout FY24

MANAGEMENT VIEWS AND CORRECTIVE ACTION PLAN REPORT ON FEDERAL AWARDS IN ACCORDANCE WITH THE OMB UNIFORM GUIDANCE SEPTEMBER 30, 2022 Finding 2022-001 Subrecipient Monitoring To ensure Auburn University is in compliance with 2 CFR 200.332(b), 2 CFR200.332 (d), 2CFR 200.332 (e), and 2CFR (f). Auburn University will implement the following corrective action plan: The Office of Sponsored Programs will verify that every subrecipient is audited as required by the Uniform Guidance when it is expected that the subrecipient's Federal awards expended during the respective fiscal year equaled or exceeded the threshold set forth in 2 CFR 200.501. The Office of Sponsored Programs has begun addressing this issue by enhancing the existing Subagreement Checklist utilized at the beginning of the subaward set-up. The new checklist provides a place for documenting the judgment around whether a new risk assessment should be performed, the results of the audit review, and the results of any necessary risk assessments. It also provides an opportunity for the administrator to detail the reasons for the risk assessment results. These documents will be monitored by the lead subaward administrator before the subaward is fully executed. Once reviewed, the lead subaward administrator will date and sign the checklist as verification that all applicable monitoring has been performed and gone through a two-step review process. The results will then be added to a master list that will be utilized when pulling the audit reports on a yearly basis for review. The checklist will be accompanied by a guide to completing the form and the regulatory backup for each applicable step. The Office of Sponsored Programs will evaluate each subrecipient's risk of noncompliance with Federal statutes, regulations, and the terms and conditions of the subaward for purposes of determining the appropriate subrecipient monitoring described in paragraphs (d) and (e) of this section of the guidance. These procedures include (among other items) obtaining a certification letter or current audit from the subrecipient and performing an annual risk assessment on all subrecipients. Auburn University has also engaged in the implementation of an electronic research administration (eRA) solution that will include a subaward module. We expect the eRA system to be fully operational during the first quarter of fiscal year 2025. Additionally, the Office of Sponsored Programs is currently reviewing the required staffing levels to ensure the timely implementation and operation of the above-referenced procedures. Contact: Tony Ventimiglia Asst. VP for Research Administration, Office of the Senior VP for Research & Economic Development Amy Douglas Assoc. VP Financial Services/Controller Anticipated Completion Date: July 31, 2023

SUBRECIPIENT MONITORING Recommendation: We recognize the agency has established a policy over sub-grant recipient files effective June 29, 2017. We recommend the policy begin to be enforced in fiscal year 2023. Also, we recommend any updating to the policy for implementation of effective internal controls and procedures over subrecipient monitoring and tracking that allow for compliance with all applicable federal laws, regulations, and compliance requirements of various federal grants. Corrective Action: The Department understands this issue. Administrative Services Bureau does complete subrecipient monitoring via desktop review and uses a monitoring checklist housed in the subgrant files. The Department has onboarded a Grants Unit Manager to include oversight of the subrecipient monitoring process. The process is currently being reviewed, modified, and implemented. Now that COVID restrictions have been lifted significantly, the Sub Grant Analysts will include physical monitoring visits as well as desk monitoring reviews as part of their job duties in FY23. Due Date of Completion: June 30, 2023 Responsible Person(s): Chief Financial Officer, Grants Unit Manager

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

2022-001 Coronavirus Relief Fund ? Assistance Listing No. 21.019 Recommendation: We recommend LAHSA implements controls to ensure that the subrecipient monitoring plan is revisited at the time contracts are entered into in order to ensure proper coverage. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: LAHSA acknowledges that there is an opportunity to enhance its current subrecipient monitoring procedures. LAHSA conducts risk-based monitoring reviews of our subrecipients. Our FY 21- 22 Annual Monitoring Plan describes how LAHSA oversees the monitoring selection of our subrecipients, depending on the complexity of their activity, subrecipients? monitoring could be more frequent. It should be noted that LAHSA?s monitoring plan is inclusive of multiple LAHSA funding streams and programs. Additionally, the annual monitoring plan endeavors to alleviate any duplication of efforts. Subrecipients are selected for review based on Monitoring Priorities established each Fiscal Year. Moreover, since the onset of COVID-19, Monitoring and Compliance (M&C) now Grants Management and Compliance (GMC) shifted our monitoring efforts to help stand up Project Room Key, our compliance responsibilities were bifurcated between our grants management side of the house, whose core focus/activities were remote, and the compliance side of the house which implements more intensive monitoring which include onsite visits. During FY 21-22, monitoring was reduced to cover high risk and urgent priorities. All agencies selected for monitoring will have analysis conducted to review agencies risk assessment results, spending trends, and performance data on an on-going basis throughout the FY. This analysis will help identify if the risk assessment was accurate and if the activities of the agency need additional review. Moving forward, LAHSA acknowledges the opportunity to enhance monitoring and will conduct 100% monitoring of subrecipients that receive federal funds. We will bring the monitoring plan to a future Audit and Risk committee meeting. Name(s) of the contact person(s) responsible for corrective action: Jeffrey Samson, Deputy Chief Financial & Administrative Officer, jsamson@lahsa.org; Amy Williams, Director ? Grants Management & Compliance, awilliams@lahsa.org Planned completion date for corrective action plan: To be implemented effective in FY 22-23.

State Agency: Department of Health Single Audit Contact: Melissa Fiore Title: Audit Services Director Telephone: 518-473-0525 E-mail Address: Melissa.Fiore@health.ny.gov Federal Program(s) (ALN # [s]): Child & Adult Care Food Program (10.558) Audit Report Reference: 2022-003 Anticipated Completion Date: 12/31/2023 Corrective Action Planned: The Department?s Audit Clearinghouse will continue to work with NYS Office of Information Technology Services to develop a system to better track grantees that require a single audit report, when a single audit report is available for review, and, if a management decision letter is needed. This will provide better assurance of timely review of all submitted single audit reports and communication to Child & Adult Care Food Program staff of findings in need of management decision letters.

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.

Recommendation: We recommend the Authority design controls to ensure subrecipients are responding to and addressing questions and findings within its monitoring reports. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Views of responsible officials and planned corrective actions: MF A uses the Tracker database to track monitoring deadlines electronically. The Tracker automatically sends reminders to all staff in the department every two weeks to follow up with pending and outstanding monitoring issues. However, some staff were not using the Tracker as intended. The Director will enforce and monitor the use of the Tracker and ensure staff follow up on the monitorings by the required deadlines. Name of the person responsible for corrective action: Chief Housing Officer Planned completion date for corrective action plan: November 30, 2022

Recommendation: We recommend the Authority design controls to ensure subrecipients are responding to and addressing questions and findings within its monitoring reports. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Views of responsible officials and planned corrective actions: MF A uses the Tracker database to track monitoring deadlines electronically. The Tracker automatically sends reminders to all staff in the department every two weeks to follow up with pending and outstanding monitoring issues. However, some staff were not using the Tracker as intended. The Director will enforce and monitor the use of the Tracker and ensure staff follow up on the monitorings by the required deadlines. Name of the person responsible for corrective action: Chief Housing Officer Planned completion date for corrective action plan: November 30, 2022

Planned Corrective Action: Management agrees with the finding. Policies and procedures are being updated to address the material weakness identified. A monitoring calendar has been developed to use to monitor and track when the necessary monitoring is scheduled and performed for all subrecipients. We have worked with the Division of Aging Services to ensure that the most up to date guidelines and forms are used during the monitoring process. Training will also be provided to staff to ensure that they are aware of the monitoring requirements and the forms to be used by the staff during the process. We have also implemented procedures to perform risk assessments of subrecipients prior to awarding the contract to the provider. Documentation of the risk assessments and monitoring will be reviewed quarterly by the Executive Director and properly stored and maintained. Name of Contact Person: Laura M. Mathis, Executive Director Anticipated Completion Date: December 31, 2022

Finding 2022-001 ? Subrecipient Monitoring Cluster: Research and Development Agency: Department of Commerce and Department of Health and Human Services Award Names: Standards/Guidance for Rapid Qualification of Metal-Based Additive Manufacturing and Development and Testing a Field-based Hazard/Near-Miss Sharing System for Commercial Fishing Vessels Award Numbers: 70NANB21H038 and U01OH012288 Assistance Listing Title: Measurement and Engineering Research and Standards and Occupational Safety and Health Program Assistance Listing Number: 11.609 and 93.262 Award Year: FY 2022 To ensure American Bureau of Shipping (ABS) is in compliance with 2 CFR 200.332(d) and 2 CFR 200.332(f), ABS will obtain and review annual Uniform Guidance reports or annual audited financial statements (if the entity was not subject to a Uniform Guidance audit) of all subrecipients. ABS has revised its Contracted Research and Development Process Instruction for subrecipient monitoring. The process instruction is supplemented by a subrecipient monitoring form and check sheet. The annual subrecipient monitoring form and check sheet outline the necessary steps to document and interpret the review of Uniform Guidance reports or financial reports. The annual review will be completed within two months of the grant date anniversary. The contracts administrator and project manager will provide two-step verification by reviewing, dating, and signing both the subrecipient monitoring form and check sheet to document their understanding of the type of opinion(s) expressed, findings associated with their awards, document their review, and assess whether there is any change in the initial risk assessment and subsequent monitoring need of each subrecipient. The annual reviews commenced in July 2023.

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

PDE: Audits retrieved from the Federal Audit Clearinghouse are now reviewed after entry into PDE?s SharePoint website, to ensure PDE remains compliant with federal guidelines to respond to any and all findings pertaining to federal dollars it passes to subrecipients. Likewise, PDE Audit Section continues to improve upon its processes for timely determinations of those single audits with findings by multiple means, including periodic SharePoint enhancements designed to aid in timely review of single audit packages, working closely with PDE program areas to assist in timely responses and quickly addressing SharePoint access issues as they arise. Anticipated Completion Date: 06/30/2023 Contact Person and Title: Clayton P. Carroll, II, Audit Coordinator; Jessica Sites, Director, Bur. of Budget and Fiscal Mgmt DEP: BAFM now provides agencies with single audit reporting packages that have findings each week that have been accepted by the Federal Audit Clearinghouse (FAC). This allows for us to start our management decision process in a timelier manner and meet the six-month deadline for issuing our decision. This information first appeared in our notifications starting April 30, 2021. In addition, the DEP program that had been previously identifying agreements as contracts rather than subrecipient agreements has corrected this issue and all subrecipients have been notified in writing of this correction and provided the information for submitting their single audits (if necessary). The letters were sent to subrecipients on approximately May 31, 2022. DEP Fiscal Management staff will continue to monitor the BAFM SharePoint site and FAC for additional filings to attempt to avoid this issue in the future. DEP is also hiring additional staff for the oversight and monitoring of the subrecipient single audits to ensure compliance with all requirements. These positions are currently in the filing process, and we are hopeful that they will be filled, and staff trained by September 30, 2023. Anticipated Completion Date: 09/30/2023 Contact Person and Title: Jennifer L. Brandt, Senior Fiscal Management Specialist, Federal Grants and Audits DOH: NORTH Inc.?s Single Audit report for the period ending 9/30/2020 was officially submitted and showing on the FAC on 2/9/2023. Bureau of WIC staff reached out to the Director and CFO of NORTH Inc. by phone and email. Emails were sent with instructions on how to submit the report as well as the importance of submitting the report timely per their grant agreement. Each follow-up phone call included discussion on the importance of submitting their single audit as soon as possible. Moving forward the Bureau of WIC will implement the following procedure: 1 .Three months after the end of the audit period (Federal Fiscal Year), Project Officers will send an email that outlines the process for submitting a single audit reporting package to the FAC to their respective WIC local agencies. This email will provide a date that the single audit is due to be submitted to the FAC in order to stay in compliance with their current WIC grant agreement. 2. Six months after the end of the audit period (three months from the due date of the single audit reporting package) an official letter from the Bureau Director will go out to the WIC local agencies that are due to submit a single audit. The letters will include instructions on how to submit the single audit in FAC and the Audit Requirements link referenced in their grant agreement. 3. If the WIC local agency notifies the Bureau of WIC that their auditor will not be able to submit their agency?s single audit by the due date, then the Project Officer will work with the local agency to get a projected date of completion and a timeline on when the local agency?s auditor is able to finalize the audit and submit it to the FAC. The Bureau of WIC will then notify DOH?s Audit Coordinator and OB-BAFM of this information, so they are able to track it. 4. If the WIC local agency does not submit the report by the due date and fails to notify their project officer; a notice to cure letter will be sent to the agency. Concerning NORTH Inc.?s Single Audit report for the period ending September 30, 2021: 1. The Bureau of WIC will contact NORTH Inc. and request a meeting with their auditor. 2. Following the meeting with NORTH Inc.?s auditor, the Bureau Director will send an official letter to NORTH Inc. The letter will include the instructions on how to submit the single audit in the FAC and the Audit Requirements link referenced in their grant agreement. They will also be made aware of the actions that could result from them not submitting this audit by the agreed upon date. 3. If the single audit is not received by the agreed upon date, then the Bureau of WIC will send a notice to cure letter. Anticipated Completion Date: 03/24/2023 Contact Person and Title: Sally Zubairu-Cofield, Director, Bureau of WIC DHS: Regarding the timeliness of finding resolution and procedures related to the SEFA reviews, the Audit Resolution Section (ARS) hired an additional staff member in August 2021 and hired two additional staff members in February 2022, and an additional staff member in January 2023. Finally, the ARS worked with Office of the Budget, Bureau of Accounting and Financial Management to develop a risk-based approach for single audit reviews, which will greatly streamline the process of single audit reviews to gain substantial efficiencies. Regarding late audit report submissions, we will continue to follow the requirements of 2 CFR ?200.339 and Commonwealth Management Directive 325.8. We will continue to work with counties and their independent auditors to obtain any late Single Audit reports. Anticipated Completion Date: 06/30/2023 Contact Person and Title: David Bryan, Manager, ARS; Alexander Matolyak, Director, Division of Audit & Review

Finding: 2022-033 Department of Public Instruction Response/Corrective Action Plan: The Department of Public Instruction agrees with the finding. For the FY 2021 audits we increased the emphasis on reviewing subrecipient?s single audits. We had a 100% response rate on our audit survey and reviewed submitted reports in a timely manner. We still have some subrecipients who have not completed their FY 2021 audits do to various reasons. We check in with these entities on a quarterly basis to get updates on the status of their audits. We are on track for similar results for the FY 2022 audits. Contact Person Jamie Mertz, Director of Fiscal Services Anticipated Completion Date Already implemented

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

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 2022-061 Disaster Grants - Public Assistance (Presidentially Declared Disasters), ALN 97.036 - Subrecipient Audits Management Views MSP agrees with the finding. Planned Corrective Action MSP will improve monitoring by reconciling expenditures by program to ensure that all subrecipients are included on the single audit tracking sheet for review. In addition, MSP will transition to each division having the responsibility for the completion of their own single audit reviews beginning October 1, 2023. Anticipated Completion Date MSP will reconcile expenditures by program by October 1, 2023, and each division will have their single audit reviews completed by September 30, 2024. Responsible Individual(s) Matt Opsommer, MSP

Finding 2022-040 Formula Grants for Rural Areas and Tribal Transit Program, ALN 20.509 - Subrecipient Audits Management Views MDOT agrees with the finding. Planned Corrective Action MDOT will update and implement its procedures to include management decision letter timelines that are consistent with the Uniform Guidance related to subrecipient report review. Anticipated Completion Date September 30, 2023 Responsible Individual(s) Adam Feldpausch, MDOT Dave Wearsch, MDOT