Corrective Action Plans

The National Conference of State Historic Preservation Officers respectfully submit the following corrective action plan for the year ended December 31, 2024 Name and address of independent public accounting firm: CBIZ 1899 L Street, NW, Suite 850 Washington, DC 20036 Audit Period: January 01, 2024 to December 31, 2024 The findings from the Schedule of Finding for the year ending December 31,2024, are discussed below. The findings are numbered consistently with the number assigned in the schedule. Finding No. 2024-001 Revenue Recognition – Significant Deficiency in Internal Control over Financial Reporting: The finding was that NCSHPO provided a trial balance and SEFA that omitted indirect cost rates on accrued direct expenditures through December 31, 2024. Contacts for Corrective Action: Sharon Smith, Business Manager – email: smith@ncshpo.org – phone: 202-624-5465 Erik Hein, Executive Director – email: hein@ncshpo.org – phone: 202-624-5465 The NCSHPO only recognized the direct costs as revenue for the period ending 12/31/24 not considering that the indirect cost rate should be accrued as revenue also thus causing the SEFA to not balance with the Trial Balance at the end of the year. NCSHPO agreed with CBIZ that the indirect costs should be recognized. The NCSHPO will begin a new internal control procedure to recognize the indirect costs as revenue to include on the SEFA schedule monthly beginning July 1, 2025. The SEFA and the Trial Balance will be reconciled for each job report. When Accounts Receivable (1120-000-0000), Revenue (4700-104-XXXX) and Administration fee/Indirect costs (4420-000-0000) are reconciled, then the SEFA, the Trial balance and the journal entry transaction(s) to recognize revenue will be given to the Executive Director to review and approve to be entered into the General Ledger. Implementation date: 07-01-2025 Finding No. 2024-002 Procurement – Significant Deficiency in Internal Control Over Compliance RE: Federal Award Identification Numbers P17AC00528 and P22AM01146 The finding was that NCSHPO failed to perform the required search of vendors per Title 2 U.S. Code of Federal Regulations (CFR) Part 200 Section 200.213. NCSHPO agreed with CBIZ that we did not do a search for suspension and debarment in SAM for any of the vendors and that it was not included in our Procurement Policy. Contacts for Corrective Action: Sharon Smith, Business Manager – email: smith@ncshpo.org – phone: 202-624-5465 Erik Hein, Executive Director – email: hein@ncshpo.org – phone: 202-624-5465 The NCSHPO updated the Procurement Policy to include a section for Suspension and Debarment. NCSHPO then used SAM to obtain the proper documentation to include in each respective vendor’s file. The NCSHPO will implement the new procedure to do a search in SAM.gov for every vendor it selects to do business with under the Cooperative Agreement and continue to do the search annually. Below is the new policy that is included in NCSHPO’s Procurement Section: Suspension and Debarment: NCSHPO verifies that the vendor or subrecipient with whom NCSHPO intends to do business is not excluded or disqualified in accordance with 2 C.F.R. Part 200, Appendix II (1) and 2 C.F.R. §§ 180.220 and 180.300. Before final selection, the Business Manager or the Special Projects Manager will perform a search on the General Services Administration Excluded Parties List System (EPLS) (http://www.sam.gov). Results of the screenings should be printed and placed in the procurement file. Suspension and debarment checks will be updated annually and will remain documented in the procurement file in line with NCSHPO’s document retention policy. The ED ensures this is completed during inspection and approval of procurement. Implementation date: 04/30/2025

Views of Responsible Officials: HIAS management accepts this comment and is finalizing a new comprehensive policy on the vetting of contractors and other third parties.

The American Immunization Registry Association (AIRA) respectfully submits the following corrective action plan for the year ending September 30, 2024. Independent public accounting firm: HAN GROUP, LLC, Washington, DC Audit period: Year ending September 30, 2024 The finding from the year ending September 30, 2024, Schedule of Findings and Questioned Costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. 2024-001 – Procurement, Suspension and Debarment. Audit Recommendation – Strengthen internal controls over procurement documentation by: 1. Implementing a standardized procurement checklist to ensure all required documentation is maintained. 2. Establishing a formal review process to verify and document vendor eligibility through SAM.gov before awarding federally funded contracts. 3. Conducting regular training for staff involved in procurement to reinforce federal compliance requirements. Management Response – AIRA acknowledges the finding and will implement the following: 1. Procurement Checklist: A standardized procurement checklist will be developed and required for all federally funded procurements. This checklist will help ensure consistent documentation practices and that all necessary procurement steps and compliance elements are completed and retained. Documentation of the completed checklist will be retained in the procurement file. 2. Vendor Eligibility Verification: A formal review process will be established to verify and document vendor eligibility through SAM.gov before awarding any contracts funded with federal funds. Documentation of the eligibility check will be retained in the procurement file. 3. Staff Training: Targeted training sessions will be conducted on a recurring basis for all staff involved in the procurement process. These trainings will reinforce federal compliance requirements, including proper documentation practices and suspension/debarment verification. Training completion will be tracked and documented. Implementation Timeline – As of March 18, 2025, AIRA has implemented a verification of vendor eligibility process using SAM.gov. The procurement checklist will be developed and implemented by April 30, 2025, and regular trainings will commence by May 31, 2025. We are committed to ensuring full compliance with federal procurement requirements. Please contact the Business and Operations Director at 202-552-0208 with any questions.

Planned Corrective Action: It is the policy of the Seattle Indian Health Board to retain documentation that a new vendor is not debarred from doing business with the federal government. In certain circumstances, due to the age of the vendor or other reasons, the documentation was not maintained. Management has engaged the accounts payable team to perform a review of all vendors accounts to assure all required documentation is on file and to continue this review on an annual basis. Name of Responsible Party: Brian Jonas., Controller Anticipated Completion Date: September 30, 2025

Views of Responsible Officials: Working diligently with NIH team to put policies and procedures in place to conduct the proper screenings for vendors, suppliers and consultants.

Based on the nature of this finding, it has been determined that this finding has been isolated to the Harris County Purchasing Department who has the oversight of issuing all purchase orders pertaining to Countywide grants. The Harris County Purchasing Department along with each sub-awarded County department will work to ensure the suspension and debarment requirements will be met as indicated in the Harris County Federal Procurement Policy Manual, adopted by Commissioners Court on March 8, 2022. The County Purchasing Agent shall work to implement the following controls to ensure all federal procurement requirements will be followed: • Obtain funding information from using departments to determine whether the procurement falls under federal funds. • If the procurement does fall under federal funds, a SAM.gov verification requirement will occur prior to processing the request for Commissioners court approval and/or approving a purchase order. • Require the purchase order requestor and/or purchasing agent to capture the date and website information to confirm the SAM.gov verification was performed in a timely manner. The County Purchasing Agent recognizes the importance of having debarment and suspension verifications included in the procurement file. The Harris County Purchasing Department is in the process of revising our internal procedure for Suspension and Debarments (SAMS) for contracts both below and above the $50,000 threshold. The existing internal procedure, last updated in 2018, is no longer adequate. By revising this procedure, we will ensure compliance with federal, state, and local procurement regulations.

Finding No. 2024-002: Procurement – Material Weakness in Internal Control Over Compliance Contact for Corrective Action: Jayson Tischler, Chief Operating Officer The Organization needed to sole source its architectural firm because it was mission-critical on a compressed timeline with the New Markets Tax Credit financing process. The Organization’s construction owner’s representative firm, D3 Development, LLC, undertook a market review that confirmed fair and reasonable pricing and service for the selected architectural services. The Organization then subsequently received a federal grant after the construction project began, which allowed the Organization to reimburse for architectural expenses. The Organization was able to reimburse through budget approval from HUD for those retroactive expenses, where competitive bidding had not been a requirement for the organization for any existing federal grants or awards. To ensure future compliance with federal procurement requirements, the Organization will revise its procurement policy to require a competitive bidding process, and proper documentation and record keeping of such, for all vendors eligible for reimbursement under federal programs. Additionally, the Organization will include suspension and debarment confirmation through the System for Award Management (SAM) in its procurement policy for all contractors. The Organization believes that these steps outlined above address this corrective action. Expected Completion Date: April 2025

SIGNIFICANT DEFICIENCY 2024-001 – The Organization did not have a process to determine if vendors were suspended or barred from receiving federal funds Auditor’s Recommendation:

It is recommended that The ONCAC develop and implement a comprehensive suspension and debarment procedure to review the eligibility of vendors before entering into contracts. Training should be provided to all relevant staff to ensure awareness and compliance with federal requirements. Additionally, periodic monitoring and internal audits should be conducted to ensure adherence to the established procedures. Views of Responsible Officials and Planned Corrective Actions: Management acknowledges the finding and agrees with the recommendation. ONCAC will develop and implement a formal suspension and debarment procedure within the next three months. Training sessions will be conducted for all procurement staff to ensure understanding and compliance with the new procedure. Furthermore, periodic reviews will be instituted to monitor adherence to these requirements and to prevent the recurrence of this issue.

Finding No. 2024-003: Procurement – Material Weakness in Internal Control Over Compliance Contact for Corrective Action: Matt Bergheiser, President The procurement policy for the organization will be updated to include a search of the suspension and debarment list as a first step towards compliance. UCD will implement and adhere to a strict protocol for verifying suspension and debarment status and conduct an open and competitive bidding process prior to awarding any contracts or subawards under federal programs as is outlined in our procurement policy document. All of the results of the process will be documented and submitted to the Finance department prior to the selection of a new vendor, in order to remain in compliance. Expected Completion Date: 3/31/2025

DCHS has reviewed its procedures and will ensure that awards are reported timely and accurately to FSRS and that documenation of compliance will be available for review.

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.

2023 – 004: Procurement and Suspension and Debarment (Compliance; Internal Controls Over Compliance) (Repeat Finding: 2021-004 and 2022-004) Material Weakness – 93.U01 Title V Condition: The Organization was unable to provide sufficient documentation to support compliance with federal procurement and suspension and debarment requirements for purchases made under the Title V program. The general ledger did not allow for sufficient identification of transactions related to the Title V program as all expenditures were recorded through journal entries without supporting transaction-level detail. Due to this limitation, we were unable to select procurement transactions for testing or verify whether vendors had been screened for suspension and debarment before contracts were awarded. Corrective Action Plan: As of October 1, 2024, the start of FY25 QuickBooks has been the only software used, and Revenue and Disbursements are being classed by Fund. General ledgers are reconciled monthly. The following are updated procedures that are now in place: All purchases must come with a purchase order request and be signed by the supervisor prior to purchase. All purchases over $1,000 must be CEO approved too. All purchases over $5,000 must have 3 bids and be Board approved. All purchase orders must be completed completely in all fields to know what grant/funding source is covering the cost for draw downs. Anyone who uses the SDUIH credit cards must sign a credit card statement. Vendor suspension and debarment status will be verified and documented prior to awarding federally funded contracts.