Corrective Action Plans

2024-001 Special Education Cluster - Assistance Listing Numbers 84.027, 84.173 Recommendation: We recommend procedures be implemented to document the verification that all vendors are not suspended or debarred from participation in Federal assistance programs or activities. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: For all federal grant expenditures over $25K, the Grants Financial Manger or Executive Director of Finance and Operations is checking the System for Award Management (SAM) Exclusions (https://www.sam.gov/SAM/) and including it in the procurement request. Name(s) of the contact person(s) responsible for corrective action: Kate Fiore and Lincoln Lynch, IV Planned completion date for corrective action plan: Effective as of 07/01/2024

2024-004 Child Nutrition Cluster - Assistance Listing Numbers 10.553, 10.555 and 10.559 Recommendation: We recommend procedures be implemented to document the verification that all vendors are not suspended or debarred from participation in Federal assistance programs or activities. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: For all federal grant expenditures over $25K, the Grants Financial Manger or Executive Director of Finance and Operations is checking the System for Award Management (SAM) Exclusions (https://www.sam.gov/SAM/) and including it in the procurement request. Name(s) of the contact person(s) responsible for corrective action: Kate Fiore and Lincoln Lynch, IV Planned completion date for corrective action plan: Effective as of 07/01/2024

U.S. Department of the Treasury – Assistance Listing No. 21.027 Recommendation: The County should ensure that all established policies and procedures concerning suspension and debarment are consistently applied to every contract, including those that are adopted from state agreements. Action taken in response to finding: The County regularly checks Sam.gov suspension and debarment transactions. We relied on state policies and procedures regarding the contracts in question as they were piggy back contracts. Moving forward, we will ensure thorough documentation of our reviews to maintain diligence in this area. Name of the contact person(s) responsible for corrective action: Susan Durham, Finance Director Planned completion date for corrective action plan: March 2025.

NGA had previously developed and socialized our procurement process and procedure with our staff members. In response to this finding, NGA will continue to train program staff on the documentation requirements regarding procurement decisions required to comply with our established policy. We will continue to review new contract requests carefully to ensure that all the necessary compliance documentation is captured and easily accessible to auditors in the future. Also, in cases where circumstances require that NGA work with a specific entity, we work with program leaders to produce a memo to file highlighting the particular requirements of the work and decision criteria that lead to our selection of individual vendors. The CFO will also work with management to inform supervisors when procedures are not followed. They may follow up with individuals who have not completed the compliance requirements or steps.

Views of Responsible Officials: Additional procedures will be put in place better document in our policies and procedures to satisfy the requirements of 2 CFR 200. SAM background screening will be done on major contractors or vendors that are supported by Federal funds. Competitive bids will be fully documented and justified as why they were the chosen vendor. In the case if noncompetitive procurement based upon the usage at the request of the government agency or of limit of vendors providing that service we will maintain documentation in our files of the 5 specific circumstances of why this fits into a noncompetitive procurement situation.

Views of Responsible Officials: We take this matter seriously and are implementing the following steps to ensure compliance with the suspension and debarment of screening requirements moving forward: 1. Immediate Screening: We are conducting suspension and debarment checks on all current and new grants that were previously overlooked, including those tested in the audit period. Any contractor that is identified as suspended or debarred will be promptly addressed. 2. Routine Reviews: We will schedule regular reviews of all new and ongoing grants to ensure compliance with all eligibility requirements, including suspension and debarment screenings.

2024-002: BHCE – Suspension and Debarment Condition/Context: For one of the contracts selected for testing, we determined that the contractor did not have a suspension and debarment clause in the contract, and Southwest Counseling Services did not keep record of other verification procedures to document the subrecipient was not suspended or debarred. Independently, we verified that the contractor was not suspended or debarred. Recommendation: MHP recommends Southwest Counseling Services implement processes and controls to ensure compliance with the suspension and debarment requirement. Corrective action regarding Suspension and Debarment: The CFO will add the System for Award Management (SAM) Registration Status Search for any contracts using federal funds to the contracting process. The SAM Registration Status Search will allow Contract Managers to verify their sub-recipients are in good standing and not suspended or debarred from receiving Federal Funds. It will be included in the contracting policies of the agency. The CFO will also include to the "Special Provisions" section from the Federal Funds Contract Template in the each individual contract as reviewed and approved by legal counsel. Anticipated completion date: December 31, 2024 Contact person: Melissa Wray-Marchetti, CFO

CORRECTIVE ACTION PLAN Finding 2024-001 Personnel Responsible for Corrective Action: Julie Turck, VP of Finance & Admin Anticipated Completion Date: December 31, 2024 Corrective Action Plan: LFSRM will develop a procurement policy along with procedures to follow, which will include a process of approving vendors that will be used for varying levels of purchases along with a plan to document and store quotes received and the reasoning behind the choice of vendor. Along with this there will be a plan for checking eligibility of vendors on Sam.gov.

Procurement, Suspension, Debarment Description of Finding: The City failed to document that vendors were not suspended or debarred prior to awarding contracts. Statement of Concurrence or Nonconcurrence: Management agrees with this finding. Corrective Action: Management will review existing processes and contracts to ensure procurements are taking place in compliance with local policies and federal guidance. Name of Contact Person: Joshua Pothier, Comptroller Projected Completion Date: June 30, 2025

The District will monitor vendors to ensure they are able to accept federal monies. The District will also review all invoices relating to bids to verify correct charges. This will be completed by Ashley Simmons, Accounts Payable Clerk by 6/30/2025.

The Bethlehem Central School District appreciates the requirements of 2 CFR Section 200.213. The District's recent review of vendors indicated that there weren't any instances of ineligibility for participation in Federal assistance programs. To ensure formalized compliance, the District is updating procurement procedures which will highlight that the Purchasing Agent will check the SAMS Debarment and Suspension website on an annual basis. Results from this annual check will be logged and shared with both the Treasurer and Chief Business and Financial Officer and will be available for access by auditors or the public. Ineligible vendors, as noted on the SAMS website, will be removed from the District's financial management system. Implementation Date - Effective immediately.

As of November 1, 2024, the District will have implemented a process to determine the eligibility of potential vendors to participate in Federal assistance programs or activities prior to disbursing funds.

The District will review the requirements of 2 CFR Section 200.213 and ensure that procurement procedures are being followed and perform a review of the eligibility of potential vendors to ensure they are eligible to participate in Federal assistance programs.

Management is not in agreement with this finding. The Organization has a policy in place to ensure that all contractors engaged with the Organization are being verified in advance of being engaged. This verification includes several security checks included verifying in required databases that they are not suspended or debarred. Senior management was not informed in time to produce the necessary documentation to the auditors. To ensure compliance in the future, management has revised its policy manual to include a formal checklist before signing any contracts for services.

Finding 2023-004 - Significant Deficiency in Internal Control over Compliance, Other Matters Description of Finding The Town of Coventry and Coventry Public School Department do not have policies and procedures in place to ensure that they do not contract with or make subawards to parties that are suspended or debarred. Statement of Concurrence or Nonconcurrence Management concurs with the finding. Corrective Action Management of the Town and School Department will review the district’s suspension and debarment policy and make sure that it is following the criteria as set out in the 2 CFR section 180 of the Uniform Guidance. The policy will then be updated and communicated to all personnel involved in the procurementprocess. Name of Contact Person Robert J. Civetti, CPA, Town Finance Director; Christopher Deverna, CPA, Director of Finance, Coventry Public Schools Projected Completion Date June 30, 2025

Views of Responsible Officials: SAMU will develop a comprehensive corrective action plan that addresses: 1. Creation and implementation of a formal suspension and debarment screening policy 2. Establishment of a documented screening process with clear timelines 3. Training program for staff on federal requirements and internal procedures 4. Regular monitoring and internal audit procedures By implementing these measures, SAMU can strengthen its compliance with federal regulations, mitigate the risk of providing funds to suspended or debarred parties, and protect its federal funding sources.

Finding 2023-002 – Procurement, Suspension, and Debarment (Material Weakness in Internal Controls over Compliance and Material Noncompliance) Planned Corrective Action: The finance department will run the debarment scan at the time that a new vender is entered into the accounting system, the vendor entry and the debarment check documentation will be maintained digitally and will include a time and date entry on the documentation maintained by Accounts Payable and signed off on by Finance Director. The finance department will provide additional training and feedback on procurement policy to program and department staff and implement a two person review process for procurement policy regarding RFP’s submitted threshold for accuracy. Name of Responsible Party: Shawnaa Smith Anticipated Completion Date: 12/31/2025

Personnel changes, including the introduction and the departure of a new Director of Grants, led to a vulnerability in the debarment step of the processes for contracting with consultants under federal grants in isolated circumstances. In this particular instance, a long-term consultant entered into a new contract with the College while an existing contract for related activities was outstanding. The College will formalize a policy requiring that all new contracts under federal grants, even for previously established contractors, be reviewed and processed according to the updated procedures. Patrick Grimes is the individual responsible for oversight of this corrective action plan.

Views of Responsible Officials and Planned Corrective Actions: USTTI management developed and implemented a formal policy on suspension and debarment subsequent to December 31, 2023. The policy includes a threshold for when vendors, suppliers, contractors and employees should be screened and no contract will be signed or payment issued until all screenings have been conducted. All USTTI employees have been notified of this policy.

Federal Agency: U.S. Department of Treasury Federal Program: Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number: 21.027 Award Number: SLFRP1026 Compliance Requirement: Suspension and Debarment Type of Finding: Significant Deficiency in Internal Control Over Compliance Prior Year Finding: No Criteria: Compliance: 2 CFR 200.213 Suspension and Debarment restricts awards, subawards, and contracts with certain parties that are debarred, suspended, or otherwise excluded from or ineligible for participation in Federal assistance programs or activities 2 CFR 180.300 states that an entity may determine suspension and debarment status by: (a) Checking SAM (System for Award Management) Exclusions; or (b) Collecting a certification from that person; or (c) Adding a clause or condition to the covered transaction with that person (7) Distribution of work to individuals and firms or economic considerations. Control: Per 2 CFR Section 200.303(a), a non‐Federal entity must: Establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non‐Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should comply with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States or the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). Condition: Spotsylvania County Public Schools could not provide supporting documentation that suspension and debarment status was determined prior to award. Questioned Costs: None Context: The suspension and debarment status for one out of two vendors was not retained related to the Coronavirus and Local Fiscal Recovery Funds Program Cause: Spotsylvania County Public Schools did not adhere to established internal controls over suspension and debarment transactions. Effect: In the absence of required documentation, it is not possible to verify that particular vendors were not suspended or debarred at the time that the applicable agreement or contract was finalized. Recommendation: Spotsylvania County Public Schools should ensure that employees are following the requirements they have outlined in their procurement policy. Views of Responsible Officials and Planned Corrective Action: Our procurement office will complete a check list to ensure compliance. Current procedures already require for suspension and debarment verification prior to entering into contracts/agreements with vendors. In this case, the procedure was followed appropriately, but documentation was not retained. Failure to retain a screenshot of the debarment search is easily corrected and staff will ensure such screenshots are saved when the search is completed. Action taken in response to finding: Spotsylvania County Public Schools will ensure the procurement checklist is followed and all supporting documentation is retained on file. Name of contact person (s) responsible for the corrective action plan: Phil Trayer and Jamie Pitts

Brightside Up, Inc will review the procurement policy and document considerations for any vendors that meet the thresholds and verify the vendors' compliance through sam.gov. Contact person Keely Weise, CFO, 518-426-7181, kweise@brightsideup.org. The anticipated date for resolving the audit finding is December 31, 2024. Brightside Up, Inc will research through sam.gov, every vendor that is paid with Federal funds.

Recommendation: We recommend procedures be implemented to document the verification that all vendors are not suspended or debarred from participation in Federal assistance programs or activities. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: For all federal grant expenditures over $25K, the Grants Financial Manger or Executive Director of Finance and Operations is checking the System for Award Management (SAM) Exclusions (https://www.sam.gov/SAM/) and including it in the procurement request. Name(s) of the contact person(s) responsible for corrective action: Kate Fiore and Lincoln Lynch, IV Planned completion date for corrective action plan: Effective as of 07/01/2024

Finding 2023-003: Federal Procurement Requirements for Suspension and Debarment a. Responsible Official’s Response: Management will modify its internal control practices to ensure procurement activities are consistent with the current federal requirements and specifically with the regard to ensuring contractual parties are not disbarred. This is to ensure compliance with HUD entering into contracts with vendors who are disbarred or suspended from participation in federal programs. Maintain documentation in each vendor file to verify selected vendors are not disbarred or suspended. b. Planned Implementation Date of Corrective Action: Management will implement this change immediately to ensure proper documentation is in place for selected vendors. c. Person Responsible for Corrective Action: Executive Director

Finding: Akron Children’s screening for suspension and debarment through the third-party vendor results does not include controls to ensure file completeness or accuracy. Corrective Action Plan: Akron Children’s implemented a periodic independent review of a sample of vendors sent to the third-party vendor to ensure that the processes employed by third-party vendor are accurate. Completion Date: December 31, 2023 Corrective Action Plan: Akron Children’s developed a retention process for all vendor searches and file submissions to evidence compliance with the Federal regulations, including independent review of the accuracy of file submissions. Completion Date: October 31, 2024 Corrective Action Plan: Further, a contract management system was installed in 2023 that holds the validation of new vendors as acceptable for federal procurements. Completion Date: December 31, 2023 Resposible Party: Chief Legal Counsel

Planned Corrective Action: Choose New Jersey (“CNJ”) understands the findings outlined in the audit report. CNJ has updated its procurement procedures for the federal grant to align with 2 CFR section 200.213 and 2 CFR section 180.300. To ensure that vendors supporting efforts on the federal grant are not suspended or debarred from doing business with the federal government, CNJ has added a task in our Procurement Summary (procurement checklist) that specifically requires the project manager and CAO to verify the vendor’s eligibility in the System for Award Management ("SAM") maintained by the General Services Administration ("GSA") (available at SAM.gov). In addition to the verification that the vendor is NOT prohibited (debarred or suspended) from providing services to or contracting with the United States government, CNJ will retain a copy of the verification for the procurement file. This action will be completed during the vendor evaluation stage of the procurement and before contract is awarded to the vendor. It should be noted that the vendors selected for testing for 2023 were found to be in good standing. Corrective Action incorporation has already begun and will be fully implemented by 10/15/2024. Name of Contact Person: Jen Lenhardt, CAO, Choose New Jersey, Inc. One Gateway Center 11-43 Raymond Plaza West – Suite 1420 Newark, NJ 07102 609.293.1423 jlenhardt@choosenj.com