Corrective Action Plans

Views of Auditee and Planned Corrective Actions: Starting in April 2024, GMHA incorporated the Certificate Regarding Debarment, Suspension, Ineligibility, and Voluntary Exclusion for Covered Contracts and Grants in all of its Invitation for Bids and Request for Proposals. Proposed Completion Date: Completed. Name of Contact Person: Yukari Hechanova, Chief Financial Officer

Views of Responsible Officials and Action Taken: We agree with the finding and recommendation and have implemented a verification step in our vendor approval and onboarding process which requires all vendors to be run through the SAM website and debarment search. We also require an annual verification to be performed for all vendors.

Finding 2023-001 Grantor: Department of Health and Human Services Federal Program: Various Assistance Listing #: Various Title: Suspension and Debarment Award Year: Fiscal year 2023 1/1/2023 – 12/31/2023 Award Number: None Corrective Action Plan and Anticipate Completion Date Nationwide Children’s Hospital (the Corporation) uses a third-party to perform its suspension and debarment checks on a monthly basis. However, we noted the following matters: • The Corporation did not retain the monthly supporting documentation related to the monthly suspension and debarment check. The suspension and debarment checks performed at year-end were retained. o Management Response: In September 2023, E&Y rendered the same finding and recommendation for the 2022 calendar year audit. The finding has already been remediated. Upon finalization of the remediation details from the September 2023 finding, Management implemented remediation in Q4 2023 to address this finding. • The Corporation does not have a process to reconcile the vendor list provided to the third-party vendor with the results received from the third-party vendor after the suspension and debarment checks are performed to ensure the listing is complete. o Management Response: In September 2023, E&Y rendered the same finding and recommendation for the 2022 calendar year audit. The finding has already been remediated. Upon finalization of the remediation details from the September 2023 finding, Management implemented remediation to address this finding for the annual screening that was performed in Q1 2024 for year 2023. Management also implemented a monthly reconciliation process as quickly as practicable, beginning with January 2024 data. • The third-party vendor does not have a SOC 1 (System and Organization Controls) Report. The Corporation relied on the results of the suspension and debarment checks performed by the third-party vendor without implementing an internal process to ensure the results provided by the third-party vendor were accurate. o Management Response: In September 2023, E&Y rendered the same finding and recommendation for the 2022 calendar year audit. The finding has already been remediated. Management implemented a process to verify the accuracy of the results produced by the third-party vendor. Management implemented the remediation to address the finding in the first quarter of 2024 for 4th quarter 2023 results. Responsible Person: Kathleen Dunn, JD – VP and Chief Compliance Officer Completion Date: January 31, 2024 • In addition, the Corporation performs a suspension and debarment check of all new vendors prior to activating them in the procurement system. The Corporation did not consistently maintain supporting documentation to support the vendor was checked for suspension and debarment before the “new”-vendor was set up in the procurement system. o Management Response In September 2023, E&Y rendered the same finding and recommendation for the 2022 calendar year audit. The finding has already been remediated. Management implemented an audit process to ensure that screening documentation is maintained. This audit process flagged 2 of these 3 deficient documentation results, and documentation was subsequently uploaded to the file. The third vendor was an insurance company, which prior to mid-2023 was not screened at the time of setup based on vendor type. As of mid-2023, all vendors regardless of vendor type, are being screened at setup. Responsible Person: Mary Beth Colatruglio, CPA – Director of Accounting Completion Date: January 31, 2024

Suspension and Debarment State and Local Fiscal Recovery Funds – Assistance Listing No. 21.027 Recommendation: We recommend that the City review its policies over suspension and debarment review to ensure they are maintaining compliance and controls over verifying or contracting with vendors that are allowable. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We will take actual computer image snips of the search results. Name(s) of the contact person(s) responsible for corrective action: Maryanne Groat Planned completion date for corrective action plan: 9/30/2024

FINDING 2023-005 Finding Subject: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds – Procurement and Suspension and Debarment Summary of Finding: Procurement - Policy The County had not established a purchasing policy that would reflect applicable state laws and regulations including procedures to avoid acquisition of unnecessary or duplicative items, procedures to ensure that all solicitations incorporate a clear and accurate description of the technical requirements for the material, product, or service to be procured and did not maintain written standards of conduct covering conflicts of interest and governing actions of its employees engaged in the selection, award, and administration of contracts. Procurement – Small Purchases The County had one vendor that was identified as being less than the simplified acquisition threshold of $150,000 but exceeding the $50,000 micro-purchase threshold. The one vendor was selected for testing. For the one vendor, the County did not obtain price or rate quotes nor was there documentation detailing the history of procurement, which must include the reason for the procurement method used. Suspension and Debarment One covered transaction paid with SLFRF grant funds was identified during the audit period. The covered transaction totaled $66,000 with $46,752 paid in the audit period. Upon review, the County had not performed procedures to ensure the vendor was not suspended or debarred, or otherwise excluded or disqualified, from participation in federal assistance programs or activities at any time during the audit period Contact Person Responsible for Corrective Action: Bryan Lewis Contact Phone Number and Email Address: 574-223-4764 and blewis@co.fulton.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The County will work on establishing a purchasing policy which will address federal procurement requirements. Before entering into contracts we will ensure the procurement procedures in the policy are followed and obtain quotes for vendors that meet the small purchase threshold as well as verify the suspension and debarment status. The Commissioners and Auditor’s office will work together to ensure requirements are met before payment is processed. Anticipated Completion Date: No later than December 31, 2024

FINDING 2023-003 Subject: COVID 19 - Coronavirus State and Local Fiscal Recovery Funds - Suspension and Debarment Summary of Finding: The ineffective internal controls resulting in a failure of having processes and procedures in place to prohibit from contracting with or making subawards under covered transactions to parties that are suspended and debarred or whose principals are suspended or debarred. Contact Person Responsible for Corrective Action: Kristinia L. Hammack, Perry County Auditor Contact Phone Number: (812) 547-6427 Views of Responsible Official: We concur with the audit finding. Description of Corrective Action Plan: Currently, the County requires all new vendors to complete a “Vendor Registration Form”. A new step that Procurement implemented as of September 30, 2024 will be verification of vendor’s status on sam.gov and attaching the screenshot to the LOW system. Procurement will update their vendor policy to specifically include this step. The Auditor’s Office will check incoming contracts from departments to ensure proper documentation is attached that verifies the vendor has been checked through sam.gov and in.gov. Once the contract has been approved by the Commissioners, the Auditor’s office will then upload the contract and supporting documents into Gateway. Anticipated Completion Date: September 30, 2024

Bronx Community Health Network, Inc. (“BCHN”) Corrective Action Plan For the Year Ended December 31, 2023 Health Resources and Services Administration (“HRSA”) Federal Award Finding Finding 2023-003 – Procurement and Suspension and Debarment – Significant Deficiency Description of Finding: BCHN did not perform a timely check at the System for Award Management Exclusions (sam.gov) to verify whether an employee or a vendor had been suspended or debarred before being hired. Statement of Concurrence: We concur with the finding above. Corrective Action: BCHN will check sam.gov and the Office of Inspector General, to screen all potential employees, contractors/consultants, and vendors, prior to the commencement of their affiliation with BCHN and maintain evidence of the results. BCHN will also screen all employees, contractors, consultants, and vendors on an annual basis thereafter and maintain evidence of the results. Completion Date: August 26, 2024. Name of Contact Person: James Paine, Ph.D Chief Executive Officer Tel. No.: (646) 678-6711 E-mail: jpaine@bchnhealth.org If HRSA has questions regarding this Corrective Action Plan, please call James Paine at (646) 678-6711. Sincerely yours, _________________________ James Paine, Ph.D. Chef Executive Officer

93.493 Congressional Directives Complete documentation of vendor suspension and disbarment verification was not maintained. While outside vendor verification services were performed monthly, adequate documentation for all vendors is not provided, only vendors with suspension or disbarment issues are identified and communicated to management. Management will coordinate with appropriate departments to review federal provisions for grant procurement and adjust policies and procedures to comply. Management will work with appropriate departments and the outside vendor to identify all grant related vendors and request positive verification monthly. All grant project directors will be educated on the procurement requirements for all federal awards. Contact Person: Jane Hardy – VP Corporate Accounting jane.hardy@childrens.com Expected Completion Date: December 31, 2024

FINDING 2023-002 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Suspension and Debarment Summary of Finding: Of the three covered transaction tested, one did not follow the County’s procedures as outlined above. The one covered transaction, totaling $47,283, did not include the appropriate provisions in the contracts nor did the County require a certification or check the EPLS to ensure the entity was not suspended or debarred prior to making payment. Contact Person Responsible for Corrective Action: Jessica Secrease Contact Phone Number and Email Address: 765-456-2804 Jessica.secrease@howardcountyin.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The County will continue to review any vendors paid with federal grant funding on SAM.gov to see if they are suspended or debarred. This is tracked on a spreadsheet in the Auditor’s Office. One employee reviews the vendor on SAM.gov, and another employee verifies the information. We will ensure this internal control is implemented. Anticipated Completion Date: September 2024

Views of Responsible Officials: Management concurs with and has already implemented the recommendation. See the corrective action plan.

FINDING 2023-05 Finding Subject: COVID-19 Coronavirus State and Local Fiscal Recovery Funds – Procurement and Suspension and Debarment Summary of Finding: No procurement policy is in place and vendors were not confirmed to not be suspended or debarred. Contact Person Responsible for Corrective Action: Amy L. Glackman Contact Phone Number: 317-392-6310 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Control procedures will be put into place effective immediately. The Auditor will start checking all vendors paid from grants for suspension, debarred or excluded from being able to enter into contracts. Additionally, a procurement policy will be put into place. Anticipated Completion Date: August 30, 2024

2023-004 Federal Grants Management – Procurement Policy Recommendation: We recommend County use sam.gov or the ELPS listing to review clients at the beginning of the year or before a transaction is incurred in accordance with the Uniform Guidance requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: Train staff on 1. Sam.gov and ELPS sites 2. Collecting a certification from entity (SBA Form 1624, Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion Lower Tier Covered Transactions) 3. Adding a clause or condition to the covered transaction with entity (2 CFR section 180.300) Name(s) of the contact person(s) responsible for corrective action: Kim Merrill, Finance Manager Planned completion date for corrective action plan: Staff Training – November 2024

The county will implement procedures to ensure when a contractor is paid with federal funds, sam.gov will be utilized to verify the entity has not been suspended or disbarred and such procedure will be documented.

Views of Responsible Officials: The Center will implement internal controls to ensure that all vendors, contractors, and consultants are screened for suspension and debarment prior to entering into any executed contract. A policy will also be formalized and staff trained on new procedures. Name and Title of Responsible Official(s): Vibha Bhatia, Vice President of Finance and Operations Anticipated Completion Date: September 30, 2024

Finding 2023-004 Finding Subject: Covid-19 – Coronavirus State and Local Fiscal Recovery Funds – Procurement and Suspension and Debarment Summary of Findings: The County did not have a Board approved procurement policy that would reflect applicable state laws and regulations including procedures to avoid acquisition of unnecessary or duplicative items and procedures to ensure that all solicitations incorporate a clear and accurate description of the technical requirements for the material, product, or service to be procured. The County had five vendors that qualified for testing under small purchase procurement requirements (vendors paid $10,000-$150,000). Of the two chosen for testing, one was awarded a contract without the County obtaining quotes. The contract awarded was $31,000 for engineering services related to drain construction. Contact Person Responsible for Corrective Action: Debbie Morton-Crum, County Auditor Contact Phone Number: 765-482-2940 Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The process was not clear to the Auditor’s Office or the departments submitting the claims for payment. We are more aware of the correct process and procedures that need to take place and will add those procedures to our Internal Control policy to ensure that the vendor is not suspended or debarred. Anticipated Completion Date: October 2024

US Department of Treasury Coronavirus State and Local Recovery Funds Assistance Listing No. 21.027 Type of Finding: Significant Deficiency in Internal Control over Compliance Recommendation: We recommend the Town implement control to ensure adherence to the suspension and debarment requirements of the Uniform Guidance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: A debarment policy in conformance with 2 CFR Part 200.24 has been instituted. Appropriate management personnel will review procurement procedures to ensure that all expenditures of federal funds is in compliance with 2 CFR Part 200 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Award. Name(s) of the contact person(s) responsible for corrective action: John Townsend Deputy Town Administrator and Director of Finance Planned completion date for corrective action plan: October 1, 2024

Recommendation: We recommend the Town enhance procedures and controls to ensure verifications of suspension and debarment statuses are obtained and documented prior to executing transactions with vendors. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Mashpee Public Schools will document the verification that all the vendors are not suspended or debarred from participation in the Federal assistance programs or activities. At a minimum the verification will happen once per fiscal year by the Director of Finance or their representative. Name(s) of the contact person(s) responsible for corrective action: Ashley Lopes – Director of Finance – 508-539-1500 – alopes@mpspk12.org Planned completion date for corrective action plan: December 31, 2024

ALN: 93.423, Corrective Action Plan: Unperformed Duties for Waiver Program Subgrants - SAO - The Montana State Auditor's Office's calendar of required tasks has since been updated to include the additional federal requirements. The calendar lists each requirement, the timeline of completion, and the assigned individual or team. The calendar includes searching SAM.gov for debarment status, making subaward disclosures to the association, and ensuring Federal Funding Accounting and Transparency Act (FFATA) reports are filed. These measures are in addition to existing oversight, which has included regularly communicating with the association's board chair and administrator and attending quarterly meetings as an ex officio member per § 33-22-1307(1)(e), MCA. Prior to its creation by 2019 Montana Senate Bill 125, the association was not (and practically could not be) debarred from federal contracting, nor has the association been debarred from federal contracting at any time since its creation. In addition, the association has obtained a Unique Entity Identifier. Person(s) Responsible for Corrective Measures: Amber Long-Thorvilson, Chief Financial Officer, Montana State Auditor's Office, Target Date: Completed

Action taken in response to finding: Dickinson County will use sam.gov or the ELPS listing to review clients at the beginning of the year or before a transaction is incurred in accordance with Uniform Guidance requirements. Name of the contact person responsible for corrective action: Brian Bousley, Controller/Administrator Planned completion date for corrective action plan: December 31, 2024

The County Finance Director has assigned the County Grants Manager with the duty to check the federal system for suspension or disbarment for any check written over $25,000 related to County grants that involve federal funding. The file for paperwork proving that the County has checked for each vendor will be printed and maintained at the time an invoice is submitted for payment.

2023-006 – Program: COVID-19 Coronavirus State and Local Fiscal Recovery Funds Federal Financial Assistance Listing Number: 21.027 Federal Grantor: U.S. Department of Treasury Award No. and Year: 2021 Finding Summary: Compliance Requirements: Procurement and Suspension and Debarment Type of Finding: Material Weakness in Internal Control over Compliance Corrective Action Plan: The City’s Purchasing Department has taken two steps to address this finding. First, the Purchasing Manager is currently checking for debarment and suspension prior to contract issuance. Second, the city’s standard contract is being revised to include language that requires contractors to affirm that they are not debarred or suspended. Responsible Individual(s): Lincoln Bogard, Administrative Services Director; A’ja Wallace, Deputy Finance Director; and Barbara Mason, Purchasing Manager Anticipated Completion Date: December 2024

CONDITION: In connection with the Cambria Heights School District’s RTU Replacement Project, the District did not perform debarment and suspension checks for contractors through SAM.gov. This is a repeat finding (2022-009) from the previous fiscal year. CRITERIA: In accordance with Section 2 CFR 200.214 of the Uniform Guidance, the District is subject to the non-procurement debarment and suspension regulations implementing Executive Orders 12549 and 12689, 2 CFR part 180. These regulations restrict the awarding of contracts to certain parties that are debarred, suspended, or otherwise ineligible to participate in federal assistance programs. RECOMMENDATION: I am recommending that the management of the School District utilize the SAM.gov website for determining whether contractors/vendors are debarred or suspended from participating in federal assistance programs on all future applicable contract awards to ensure compliance with Section 2 CFR 200.214 of the Uniform Guidance. MANAGEMENT’S CORRECTIVE ACTION PLAN: Effective immediately, management will implement the practice of properly vetting future third-party contractors for debarment and suspension in federal assistance programs by utilizing the SAM.gov website, to ensure compliance with Section 2 CFR 200.214 of the Uniform Guidance and Executive Orders 12549 and 12689, 2 CFR part 180.

Responsible Official and Corrective Action Plan: NMHC management is in agreement with this finding. Management has reviewed the existing federal procurement policies and procedures found in 2 CFR 200 and will enforce the policies and procedures to ensure existing suspension and debarment policies and procedures are followed. NMHC’s Executive Director or Deputy Director will review all potential purchases and contracts for compliance with the policies. The Executive Director or Deputy Director will also provide an additional check by reviewing all vendors paid $25,000 or more against the SAM website. Proof of the SAM website review and approval will be maintained in each vendor file. All future contracts of any size will also include a clause or condition to the covered transaction with the contractor/vendor that must be signed by that person. The Executive Director will update the existing NMHC policies and procedures manual by adding the new thresholds for micro-purchases and small purchases. The Executive Director will also add explicit reference to the $25,000 threshold for vendors under procurement regulations regarding debarment and suspension. Corrective Action Plan Timeline: Management anticipates the above corrective action plan to be fully implemented by July 31, 2024. Designation Of Employee Position Responsible For Meeting Deadline: Personnel responsible for ensuring implementation include the Executive Director and Deputy Director.

Criteria: According to 2 CFR section 200.318(c) and 48 CFR sections 52.203-13 and 52.303-16, an entity should have written standards of conduct to cover conflicts of interest and govern the performance of its employees engaged in the selection, award, and administration of contracts. According to 2 CFR section 200.214, an entity is subject to the non-procurement debarment and suspension regulations. Condition: During our testing of federal award expenditures, it was noted that there were no formal written policies in place for standards of conducts covering conflict of interests for employees engaged in the selection, award, and administration of contracts nor to determine if a vendor is suspended or disbarred. Recommendation: The City should create policies and procedures for applicable requirements in order to comply with Federal regulations including procedures that cover conflicts of interest and govern the performance of its employees engaged in the selection, award, and administration of contracts and for procedures to determine whether vendors have been suspended or debarred prior to entering into contracts or purchase orders for all transactions and maintain documentation supporting this verification View of Responsible Officials and Planned Corrective Action: 1. Develop Comprehensive Policies and Procedures:  Policy Development: Create policies that align with federal, state, and municipal regulations governing conflicts of interest and employee conduct in contract selection, award, and administration.  Conflicts of Interest Policy: Define clear guidelines and procedures for identifying, disclosing, managing, and mitigating conflicts of interest among employees involved in contracting activities.  Contract Administration Procedures: Establish detailed procedures that encompass the entire contract lifecycle, ensuring compliance with federal, state, and municipal requirements at every stage.  Training and Awareness: Conduct training sessions for employees involved in contracting to ensure understanding and adherence to the newly developed policies, procedures and current bid law regulations set forth by the State of Alabama. 2. Implement Procedures for Vendor Evaluation and Debarment Checks:  Vendor Evaluation Process: Develop standardized procedures for evaluating vendors before entering into contracts, including criteria for assessing qualifications, capabilities, and compliance with regulatory requirements.  Debarment Check Procedure: Establish a systematic procedure to verify whether potential vendors have been suspended or debarred by federal, state, or municipal authorities prior to initiating contract negotiations.  Documentation Requirements: Specify the documentation that must be collected and maintained to demonstrate compliance with vendor evaluation and debarment check procedures. 3. Maintain Comprehensive Documentation:  Document Retention Policy: Create a policy outlining requirements for retaining all documentation related to contracts, including vendor evaluations, debarment checks, contract awards, modifications, and performance records.  Centralized Documentation Management: Implement a centralized system or repository for storing and managing contract-related documentation, ensuring accessibility, security, and compliance with retention policies.  Audit Trail: Maintain a clear audit trail for all contract-related activities, documenting decisionmaking processes and actions taken to ensure accountability and compliance. 4. Monitoring and Compliance Oversight:  Monitoring Mechanisms: Establish mechanisms for ongoing monitoring of compliance with federal, state, and municipal regulations, as well as internal policies related to conflicts of interest, contract administration, and vendor debarment checks.  Regular Audits: Conduct regular audits of contract management practices and documentation to identify any deviations from established procedures and regulatory requirements.  Reporting and Accountability: Implement a reporting structure that provides regular updates to management and stakeholders on compliance status, audit findings, and corrective actions taken to address deficiencies. 5. Continuous Improvement and Adaptation:  Feedback and Review: Encourage feedback from employees involved in contract management to identify opportunities for improving policies, procedures, and compliance practices.  Benchmarking: Benchmark contract management practices against industry standards, best practices, and regulatory changes to continuously enhance processes and ensure alignment with evolving requirements.  Adaptation to Changes: Stay informed about updates and changes in federal, state, and municipal regulations impacting conflicts of interest, contract administration, and vendor management, and update policies and procedures accordingly.

Management’s Response - This has been corrected. The City Council approved an amendment to the City’s Purchasing Policies and Procedures Manual at their May 6, 2024 meeting to add a suspension and debarment certification requirement for all formal procurement processes. Vendors selected via the formal bid process (over $25,000) are required to submit the signed suspension and debarment certification.