Corrective Action Plans

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.

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

Finding ref number: 2023-002 Finding caption: The County’s internal controls were inadequate for ensuring compliance with federal suspension and debarment requirements. Name, address, and telephone of County contact person: Leo Kim, Chief Financial Officer 411 N 5th Street Shelton, WA 98584 (360)427-9670 Corrective action the auditee plans to take in response to the finding: The County is committed to ensuring internal controls are adequate for compliance with federal suspension and debarment requirements. Management understands the seriousness of potentially awarding federal funds to ineligible parties and has taken steps to confirm that compliance is followed in future purchases using federal funds. An updated purchasing and contracting policy and procedures was adopted by the Board of County Commissioners in December of 2023. The document includes an updated section on suspension and debarment regulations implementing Executive Orders 12549 and 12689, 2 CFR Part 180, per §200.213. County offices and departments will ensure and document that no agreement for goods or services is entered into with any entity or person who has been disqualified from participation in Federal programs or activities. Program staff will do this by checking the federal System for Award Management (SAM.gov) prior to the contract execution date. If the contractor is not listed in SAM.gov, the County created a “Certification of no debarment or suspension form” that the contractor can attest and/or the attestation may be added to the contract. Both the SAM.gov check and/or the “Certification of no debarment form” must be completed at or before contract execution and documentation will be maintained in each contract file. The County is committed to providing training on federal grants at least annually to all county staff that work with them and anticipates full compliance with the suspension and debarment requirements moving forward. Anticipated date to complete the corrective action: 8/7/2024

Views of Responsible Officials: The Organizations concur with the auditor's assessment and are in the process of implementing a formal procedure that documents their Suspension and Debarment screening practices.

Views of Responsible Officials: New audit procedures were established for the FY 2023 audit related to federal procurement testing that generated these findings. Management is aligned with the findings from the audit firm. We have the following takeaways. Vendor Screenings: Vendor screening procedures are part of our current procedures, but we will make process improvements:  In accordance with the Suspension and Debarment compliance requirements (section M-12 & M-14) of the USAID Cooperative Agreement, JGI-USA and JGI-Tanzania will process and retain vendor screenings before payment to vendors.  The following sources will be used for screenings:  SAM.gov  OFAC sanctions list  UN List  We will retain the evidence of the screenings, including the dates of the screenings, within our files and these will be available for subsequent audit procedures.  Our Procurement Policy in Tanzania and the USA will be updated to include these required procedures. Procurement Documentation: JGI-USA and JGI-Tanzania have procurement procedures and policies in place, but our procedures need to be updated to include some specific considerations:  When a partner or vendor is included in a proposal by name, we must prepare documentation that supports sole source procurement or a bid analysis to justify the selection of this partner. Alternatively, we may work with the donor to obtain written approval to proceed with the vendor used in proposal.  We will update our procurement manuals to include templates for sole source justifications and bid analysis to justify vendor selection and fully comply with §200.320.  Our Procurement Policies will be updated to fully comply with §200.320 and §200.213

American Diabetes Association (ADA) is committed to ensuring the appropriate documentation is in place to adhere to federal regulations regarding procurement, suspension, and debarment. In response to the audit finding, ADA is taking the following corrective actions to address the audit recommendations: 1) Financial Services will communicate annual reminders of the existing policy relating to procurement policies including the requirement to evaluate a firms status relating to federal suspension and debarment. 2) Federal grant program management will develop and utilize a checklist to ensure that all procurement steps are completed prior to forming a relationship with a potential vendor.

2023-006 - Internal Control Over Compliance and Compliance – Procurement, Suspension and Debarment Contact: Jordan Kramer Title: Chief Financial Officer Phone Number: 202-624-7787 Anticipated Completion Date: July 2024 Management’s Corrective Action Plan NGA has always mandated that all vendors paid using federal funds be checked on SAM.gov for debarment or other issues. NGA believes this finding reflects a single isolated incident in which this check was completed, but records were not saved as a PDF within our vendor records. NGA has reiterated and retrained staff on the importance of documentation retention and ensuring that accounting staff consistently retrain these records. NGA expects this issue to have been fully addressed as of July 2024.

Finding 2023-002 Issue: For the procurement samples tested, Management did not provide adequate supporting documentation for the procurement including ensuring proper suspension and debarment checks were performed. Recommendation: We recommend that the Organization establish written procurement policies and procedures to ensure that Organization is in compliance with the Uniform Guidance and that all staff are trained on this policy to ensure compliance and related internal controls over compliance are operating effectively. Action Taken: Current MGHPCC policy states that criteria for approval of Purchase Orders above $25,000 include a check to ensure that the vendors are not suspended disbarred, or otherwise excluded from participating in a covered transaction as defined in 2CFR 180.220 and 2CFR 180.300. Policy has been updated to require that the check be documented by capturing a copy of the entity information database entry at www.sam.gov as part of the Purchase Order approval process for vendors who exceed the threshold defined in 2CFR 180.220 and 2CFR 180.300. The entity information database report includes a time stamp, which serves as an indication of when the database entry was checked. Completion date: The MGHPCC Controls for Federal program document was updated on March 15, 2024, and documentation has been retained for all relevant Purchase Orders subsequent to that date. If the National Science Foundation has questions regarding this plan, please contact John Goodhue by telephone at 413-552-4900 or by email at jtgoodhue@mghpcc.org.

Sanford Corrective Action Plan December 31, 2023 Finding 2023-001 – Suspension and Debarment/Procurement Information on the federal program: Federal Agency: United States Department of Health and Human Services, Health Resources and Services Administration (HRSA) Assistance Listing: 93.155 Award Year: 2021 Planned corrective actions: As it relates to the reliance on the third-party vendor that conducts suspension and debarment -party vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) Report and therefore did not provide this level of report to Sanford. To provide context on scale of vendors subject to suspension and debarment, Sanford paid a total of 23,754 vendors in 2023. There were three vendors identified through the vendor setup and monitoring process to be suspended or debarred. None of those vendors were associated with the programs funded with federal funds. Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendor is effectively mitigated through existing preventive and detective internal controls. In August 2023, Sanford began documenting a periodic validation of the suspension and debarment search results performed by the third-party vendor for vendor searches that yield no suspension and debarment match. In addition, Sanford enhanced its procedural documentation regarding retention of evidence related to reconciliation of vendor list when discrepancies are identified and the suspension and debarment results generated through the vendor setup process. Responsible official: Tracy Sattler, Director of Compliance and Melanie Paape, Vice President of Supply Chain Operations As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls. To provide context on the scale of procurement under the program $2,298,733 in expenditures exceeded the micro purchase threshold and $307,249 were found to have inadequate documents for sole source. Sanford will provide education to applicable departments related to the compliance requirements subject to procurement. Sanford will document the procurement process from the initial approval to potential sale/disposition items. Responsible official: Kristi Crawford, Director of Office of Grants Anticipated completion date: June 30, 2024

Views of Responsible Officials: Management will ensure trainings are conducted to ensure staff understand the current policy and specifically communicate that screenings should be conducted prior to contract signing or payment. Additionally, CVT should revise their suspension and debarment policy to include the requirement that screenings be conducted on expatriate employees.

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

Views of Responsible Officials: The Foundation will conduct screenings on all vendors, suppliers and consultants. The Foundation will also ensure that the screening date is documented prior to payment or signing of the contract.

Views of Responsible Officials: Management acknowledges the comment and has subsequently established policies and procedures to ensure suspension and debarment checks of vendors, supplies, contractors, and sub-contractors/grantees are done in accordance with the recommended threshold.