Corrective Action Plans

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.

Finding Reference: 2023-003 Coronavirus State and Local Fiscal Recovery Funds Description: During our discussions with management and testing of the major program, we noted that the Town is not verifying the eligibility of vendors to participate in Federal assistance programs. Recommendation: We recommend that the Town review the requirements of 2 CFR Section 200.213 and ensure that a review of the eligibility of potential vendors to participate in Federal assistance programs or activities is performed prior to disbursing funds to the vendor. Corrective Action: Moving forward, the Town of Guilderland will ensure that vendors are not included on the suspended or debarred list to ensure compliance with the requirements noted above. Person(s) Responsible for Corrective Action: Darci Efaw, Comptroller & Jessica Gulliksen, Fiscal Officer Anticipated Completion Date for Corrective Action: The practice noted above was implemented during September of 2024.

The County will implement a new policy to verify vendors are not suspended or debarred.

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.