Corrective Action Plans

FINDING 2022-002 Contact Person Responsible for Corrective Action: LaGrange County Auditor Contact Phone Number: (260) 499-6310 Views of Responsible Official: We concur with the findings from SBOA The County will establish a internal control system of checking Excluded Parties List System, collecting a certification from that person or adding a clause or condition to the covered transaction with that person for all vendors equal to or in excess of $25,000 for SLFRF award funds to ensure such contractors and subrecipients are not suspended, debarred or otherwise excluded. Copies of supporting documents to be retained. Anticipated Completion Date: Implementation will begin immediately.

Finding Number: 2022-003 Condition: The City had no controls in place, as required by the Uniform Guidance, to ensure that all parties that the City enters into covered transactions with are eligible for participation in federal assistance programs or activities. However, during our testing, we found that all covered transactions entered into by the City were with eligible parties. Planned Corrective Action: The City has adopted a procurement policy on 10/03/22, which states that the City will only hire contractors which are eligible for participation in federal assistance programs or activities. Contact person responsible for corrective action: Kathryn Beemer, City Administrator Email: kbeemer@fennville.com Office Phone: 269-561-8321 Cell Phone: 269-543-2645 Anticipated Completion Date: 10/03/2023

Finding 2022-002 Procurement and Suspension and Debarment Management?s or Department?s Response: Management agrees. Views of Responsible Officials and Corrective Action: On October 19, 2022, CPMM proactively conducted a check on all active procurements to ensure a SAM report was pulled. If one was not present in the file, CPMM pulled a SAM report. Going forward, CPMM will use the checklist to ensure a SAM report is pulled for all future procurements. SCRRA has already implemented the use of the checklist for all the required documents associated with a procurement. The checklist includes all required documents to complete a procurement including the verification of suspension and debarment documentation. Name of Responsible Person: Cynthia Minix Implementation Date: June 30, 2023

Respectfully, the school corporation does not agree with several of the findings in regards to segregation of duties and purchases. First, the SBOA auditors' told the school corporation during the 2019 audit that operating the school lunch program through the extracurricular account was not legal. The school corporation was informed that this account must be transferred to Central Office and a Corrective Action Plan must be in place. This directive was incorrect and pointed out in the official response from November 5, 2019 under IC 20-26-5-4(a)(l l). Second, segregation of duties, oversight, and approval of functions existed in 2019 and are presently occurring daily, weekly, and monthly within the cafeteria program under the corporation accounts and supervision of Central Office. Cafeteria workers record and submit timesheets of duties performed during each payroll period. The Cafeteria Director verifies and signs timesheets to be submitted to the Treasurer and Deputy Treasurer for review and payment from the Cafeteria account. A payroll docket report is sent to the Superintendent prior to payment from the bank. Prior to the 2019 audit, the High School Treasurer spent approximately two hours per day counting cash received each day from school lunches purchased. She also receipted those funds it into the software system, made deposits to the bank, paid invoices for food expenses, and processed part of payroll. Tasks conducted by the High School Treasurer were segregated by a timesheet and supervised by the High School Principal. All those tasks were shifted to Central Office in 2020 and are now segregated to the Treasurer and Deputy Treasurer. The Treasurer documents hours spent on Cafeteria accounts on a timesheet for review and signature by the Superintendent. Financial reports of expenditures and revenues are provided for review and oversight to the Superintendent and School Board at monthly board meetings. Third, RSSC has a small Central Office consisting of a Superintendent, Treasurer, Deputy Treasurer, and Secretary. It has no Assistant Superintendents, Human Resources Director, or Business Manager. Each person in Central Office wears multiple hats and performs multiple duties each day. It was noted in the Audit Report filed from July 1, 2008 to June 30, 2010 that " ...Randolph Southern School Corporation is unable, due to financial limitations, to employ additional personnel to segregate duties in our receipts and cash and investment balances. This statement would apply to all of our internal controls. " The circumstances for RSSC have not changed in the audit periods from July 1, 2010 through June 30, 2022. Corrective Action Plan: The School Board had chosen not to add additional staffing due to costs. RSSC is still unable to segregate duties for financial transactions and reporting. Fourth, the Cafeteria Program only has one full-time staff member, the Cafeteria Director. Eight part-time cafeteria workers prepare and feed up to 300 students each day. This food service program is one of the best run programs in the State oflndiana. It has not had one food preparation or sanitation violation from IDOE or Department of Health in the last 12 years. Fifth, the Cafeteria Program is economically efficient and fiscally responsible. The account carries at least a 3-month cash balance at all times. This success is a direct result of oversight by the combination of the Superintendent, Treasurer, and Cafeteria Director. RSSC adopted board policy 6114 Cost Principles-Spending Federal Funds on May 9, 2016. RSSC has had an Indirect Cost Rate in place since 2013. The adopted policy allows the school corporation to apply Indirect Costs to all federal funds including the Cafeteria account. On December 5, 2019, email communications between the Dr. Donnie Bowsman, Superintendent and Tina Herzog, IDOE Assistant Director of Operations and Food Distributions clearly state the school corporation can apply the Indirect Cost Rate to the Cafeteria account. The email communication clearly states that the high cash balance was a result of not applying the Indirect Cost Rate to the Cafeteria account (See Exhibit 1 Emails). The Indirect Rate was approved by the IDOE Office of School Finance and existed prior to the audit years being referenced in the finding. Technically, the prospective portion (going forward for the next school year) as referenced on pages 24-25 of USDA Indirect Cost Guidance Manual pertains to the 2013 Fiscal Year. Moreover, the fact was reiterated by the IDOE School Nutrition Office with email communications on December 5, 2019, not 2021 or 2022 as referenced in the finding. RSSC has not charged or recouped the Cafeteria Account the Indirect Cost rate for many years and has subsidized this account which should be independent and self-sufficient. The School Corporation did not apply the Indirect Cost Rate in 2020 or 2021 because we were not sure how many students would be eating and how fiscally sound the account would be due to students not attending school because of COVID. Corrective Action Plan: The Indirect Cost Rate will be applied and collected in the future prior to June 30 of each current fiscal year. It should also be noted that in 2021, RSSC purchased a new cafeteria dishwasher utilizing ESSER II funds. This unit was 20+ years old and needed to be replaced in order to continue feeding children and to run the food service program. This expense could have been and should have been a direct cost of $58,189 to the Cafeteria account. However, due to the unknown circumstances of COVID, the RSSC could not take a chance. The ESSER II grant is still open and we are now questioning whether this expense could be charged directly to the Cafeteria account. Those ESSER II fund could be utilized for staffing to support student learning loss and remediation. Sixth, COVID caused this financial account to increase exponentially from 2020 to 2021. ESSER funds were provided by the federal government to provide free lunches to every child which paid the food operations expenses for two school years. Student participation of eating school lunches increased during these time periods. Additionally, staff members were receiving hazard pay incentives on top of their regular hourly rate. Further, the School Corporation and Cafeteria Program took on the enormous task of feeding children over the summers of 2020 and 2021 when COVID cases were at its peak. The cafeteria personnel fed 5286 and 5740 students respectfully during those summers. The number of meals served during the summer almost equaled the total amount of meals served during the entire school year for each respective academic year. These additional meals created additional unexpected revenues for the fiscal year. The school corporation did not charge mileage for satellite lunches being delivered or indirect costs.

Finding 2022-002: Procurement and Suspension and Debarment - Material Noncompliance Management?s Response: Our commitment to maintaining strong financial controls and compliance with grant reporting requirements remains unwavering. In response to the audit finding and in our ongoing efforts to continually improve our internal controls and procedures, we have developed a comprehensive corrective action plan to address the noncompliance and strengthen our procurement and suspension/debarment processes: Procurement Policy Update: We have initiated a review and update of our procurement policy to ensure alignment with the Uniform Guidance Procurement Standards. This updated policy will incorporate the necessary provisions and requirements outlined in government regulations. Vendor Review Process: We have implemented a formal process to review vendor suspension and debarment status within the SAM Exclusion system prior to contracting. This process will be integrated into our procurement procedures to ensure compliance with the Uniform Guidance Procurement Standards. Training and Awareness: We will provide training sessions to staff involved in procurement processes, emphasizing the importance of adhering to the updated procurement policy and conducting thorough vendor reviews within the SAM Exclusion system. This training will enhance their understanding of the regulatory requirements and their roles in compliance. Documentation and Record-Keeping: We have established procedures for documenting and retaining records of vendor reviews within the SAM Exclusion system. This documentation will serve as evidence of our due diligence and compliance with the Uniform Guidance Procurement Standards. Monitoring and Internal Controls: We will strengthen our monitoring procedures and internal controls to ensure ongoing compliance with procurement and suspension/debarment requirements. Regular reviews will be conducted to verify adherence to the updated procurement policy and vendor review processes. Continuous Improvement: We are committed to continuous improvement in our procurement and suspension/debarment processes. We will establish a mechanism for periodic reviews of our policies, procedures, and controls to identify areas for enhancement and ensure they remain effective and aligned with the Uniform Guidance Procurement Standards. Anticipated Completion Date: Already Implemented Responsible Contact Person: Dr Malik Mamoon Munir, Global Operations Officer, +1 678-580-0853

The Town of Winchester, Massachusetts respectfully submits the following corrective action plan for the year ended June 30, 2022. Audit period: July 1, 2021 ? June 30, 2022 The finding from the schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. FINDINGS?FEDERAL AWARD PROGRAMS AUDITS DEPARTMENT OF AGRICULTURE 2022-001 Child Nutrition Cluster ? Assistance Listing Numbers 10.553 and 10.555 Recommendation: We recommend procedures be implemented to annually (at a minimum) 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: Winchester Public Schools complies with the Audit Recommendation. Due to the change in leadership in the FY22 school year the department was late in receiving the required documentation. Name(s) of the contact person(s) responsible for corrective action: Finance Director Planned completion date for corrective action plan: FY23

Identifying Number: 2022-003: U.S. Department of Education: Education Stabilization Fund: Student Aid Portion ? 84.425E (HEERF); U.S. Department of Agriculture: Child Nutrition Cluster ? 10.553, 10.555, and 10.559 (CNC) Finding: For one vendor paid with HEERF funding and one vendor paid from CNC funding, there was no documentation to support that the District had verified that the vendors were not suspended or debarred prior to purchases. Corrective Action Taken or Planned: This relates to the Entity Exclusion (Suspension/Debarment) list maintained on the federal SAM.GOV website. Access to the website and specifically the Entity search functions is limited to authorized/registered users. The corrective action plan for HEERF will include the designation of a Southeast Technical College employee with SAM.GOV access that will be the initial point of contact for vendor exclusion information for all Southeast Technical College employees. Additionally, the designated employee will periodically download, and post debarment lists to the Southeast Technical College internal website (myTech) that will be available to all employees purchasing goods/services that would be charged to federal programs. Additional corrective actions will include a review of existing Southeast Technical College procurement policies contained within Section D: Fiscal Management. Policies will be reviewed/revised to expand and reflect current federal procurement requirements under 2CRF200. Revised policies, debarment lists, and training will be provided to all employees on a periodic and ongoing basis. For the Child Nutrition Cluster, this particular vendor was not expected to go over $25,000 and was used for emergency purchases that did not go over $25,000 until the last purchase in June, 2022. It was recommended that all purchases with amounts expected to go over $25,000 be vetted through the District?s purchase order process. Since this vendor was not expected to go over $25,000, it did not go through the purchase order process. The District will continue to use the purchase order process for vendors expected to go over $25,000 to ensure debarment requirements are being followed. Contact person: HEERF: Rich Kluin, Vice President ? Finance and Operations, Southeast Technical College. CNC: Gay Anderson, Child Nutrition Supervisor. Status of finding ? HEERF procedures will continue to be followed. The CNC procedures will continue to be followed.

FINDING 2022-001 (Auditor Assigned Reference Number) Contact Person Responsible for Corrective Action: Angela C. Birchmeier, County Auditor Contact Phone Number: (574) 935-8555 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The County and Auditor?s office were unaware of the requirement that a contract over $25,000 needed verification that the contractor had not been suspended or disbarred. Now that we are aware, each contract will be verified by either checking the EPLS (Excluded Parties List System) or that the clause for disbarment or suspension is included in the contract. The Department requesting the contract will verify if the clause is in the contract. The Claims Deputy will also verify during the claims process for payment and the 1st Deputy will also verify. Anticipated Completion Date: We have already implemented this procedure effective April 2023.

The following is Management's Response to the Findings Required to be Reported by the Uniform Guidance. This document was prepared by management of Oklahoma Mental Health Council d/b/a Red Rock Behavioral Health Services. 2022-001 Substance Abuse and Mental Health Services Projects of Regional and National Significance, Assistance Listing Number 93.243, U.S. Department of Health and Human Services, Award Year 2022 Finding Summary: Red Rock's procurement procedures were not adequate to meet the requirements of 2 CFR ? 200.317- .327; 2 CFR ? 200.214 - Procurement, Suspension, and Debarment Explanation of Agreement/Disagreement: Management concurs with the finding and will change Red Rock's procurement policy. Officials Responsible for Ensuring Corrective Action: Kile Kuykendall, Chief Financial Officer E-mail - kilek@red-rock.com Planned Completion for Corrective Action: Corrective action will be completed in FY 2023. Action in response to finding: Purchasing staff will be trained on federal procurement requirements and will be provided a copy of the new policy.

2022-011 ? Suspension and Debarment (Significant Deficiency) Governor?s Office care of State Department of Budget and Finance AL Number: 21.027 Program Title: Coronavirus State and Local Fiscal Recovery Fund Direct Award from: U.S. Department of Treasury Condition 2 CFR Section 200.214 requires non federal entities to comply with non-procurement debarment and suspension regulations. The regulations in 2 CFR Part 180 restrict 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. The auditing firm selected a sample of subawards that were open in FY 2022. There was no evidence of a suspension or debarment review for 100% (7 out of 7) of the sample of subawards tested. The auditing firm was unable to verify that the State had checked whether the entities were federally suspended or debarred on the SAM.gov website prior to executing the subawards. Current Status of Corrective Action Plan Concur. B&F will modify its procedures to check for debarment or suspension on SAM.gov prior to issuing a subaward to an entity and retain evidence of the verification including who performed the check and the date performed. Person Responsible Mark K. Anderson, Office of Federal Awards Management, Administrator Anticipated Date of Completion July 1, 2023

CORRECTIVE ACTION PLAN JUNE 30, 2022 REFERENCE: 2022-101 CFDA NUMBER 84.425D ? COVID 19 ? EDUCATION STABILIZATION FUND CFDA NUMBER 84.425U ? COVID 19 ? EDUCATION STABILIZATION FUND U.S. DEPARTMENT OF EDUCATION ? 2021 PASSED THROUGH ARIZONA STATE DEPARTMENT OF EDUCATION GRANT NUMBER: S425D210038 & S425U210038 CLIENT RESPONSE AND CORRECTIVE ACTION PLAN We concur with the condition. 1. Name of the contact person responsible for corrective action: Wendi Allardice - Superintendent Karen Hancock - Title I/ESSER Grants Manager 2. Corrective action planned: A. Protocols developed to obtain at least 3 vendor quotes for any items over 10,000 with an analysis and justification of vendor chosen. B. Protocol in place for checking for vendor suspensions or debarment prior to purchase approval. C. Monthly meeting for comparison of proposed and estimated purchases and actual purchases and charges to the Grant. 3. Anticipated completion date: Anticipated completion date for above listed plan: 08/31/2022

Finding 2022-003: Procurement, Suspension, and Debarment (Material Weakness) Information on the Federal Program: U.S. Department of State ALN 19.040 Criteria or Specific Requirement: 2 CFR Section 200.214 requires that, for covered transactions, a non-Federal entity must verify that entities are not suspended, debarred or otherwise excluded. This verification may be accomplished by checking the System for Award Management (SAM) website maintained by the General Services Administration. Condition: For all disbursements tested, FCE could not provide documentation of their verification, prior to payment, that the vendors were not suspended, debarred or otherwise excluded. Cause: FCE did not require evidence of SAM checks be maintained in its vendor files. As a result, FCE did not maintain adequate support to provide evidence that appropriate suspension and debarment searches were performed. Despite the lack of documentation, a search was performed after the fact to verify that the vendors or individuals in our sample were not suspended, debarred or otherwise excluded. Therefore, no questioned costs have been reported related to the sample that was tested. Effect or Potential Effect: FCE was not in compliance with the procurement documentation requirements of the Uniform Guidance. As a result, FCE could not readily provide evidence that it had assessed whether or not its vendors were suspended, debarred, or otherwise excluded. As a result, the potential for payments to suspended, debarred, or otherwise excluded vendors and individuals exists. Recommendation: FCE should establish internal controls to ensure proper documentation is maintained as evidence to support that it performed the required suspension and debarment searches on the SAM website. Action Taken: FCE acknowledges the importance of proper vetting procedures and shall implement policies and procedures with respect to screening potential vendors. The policy will include the requirement to consult the System for Award Management (SAM) website to ensure a potential vendor is not suspended, debarred, or otherwise excluded from qualification to receive Federal award funds. Proper documentation to support the completion of the required suspension and debarment searches will be maintained in accordance with the policy.

2022-005: Suspension and Debarment (Significant Deficiency) Views of Responsible Officials and Planned Corrective Actions: Management concurs with the finding. The Authority expanded its policies and procedures related to suspension and debarment to all grant expenditures effective January 2022. Completion Date ? January 2022 Contact Person ? Jami Blosmo, Accounting Manager

vendors prior to commencement of their affiliation with PCC and simultaneously adding all new vendors to the existing monthly search for suspended and debarred vendors in the federal exclusions database with the Senior Executive Assistant responsible for queries. The Senior Executive Assistant to review entire list of vendors on a monthly basis to ensure all current vendors have been added to the master list prior to running query each month. The Senior Executive Assistant will work with CEO to identify any new vendors prior to commencement of their affiliation with PCC in a timely manner.

U.S. Department of Health and Human Services 2022-002 Health Center Cluster ? Assistance Listing Numbers 93.224 & 93.527 Recommendation: As the policy has already been revised, we recommend the Center follow the requirements under the new policy and ensure documentation is maintained as appropriate to support vendor checks against the SAM Exclusions list. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: Management has revised the suspension and debarment policies and procedures to meet Uniform Guidance requirements, and will ensure the new policy and procedures are followed moving forward. The Center also had a call with Keith Schwartz, HRSA Program specialist to discuss the progress made on the prior findings on April 25, 2023. Name(s) of the contact person(s) responsible for corrective action: Jennifer Beckius, CFO Planned completion date for corrective action plan: New policy was implemented in June 2022

The Board Trustees has authorized a reorganization of the Fiscal Services department that includes adding Purchasing Manager and Purchasing Technician to ensure the District follows all purchasing guidelines and compliance requirements related to purchasing. The Purchasing Manager will also be responsible for our warehouse and inventory processes. This reorganization was approved effective July 1, 2023. Recruitment has begun for these positions.

2022-001: Procurement and Suspension and Debarment Corrective Action: Northwest College will perform a review of its current procurement policy, including purchasing thresholds, record retention of supporting documentation regarding method of procurement utilized, and maintaining supporting documentation regarding suspension and debarment for all contracts or purchases expected to equal or exceed $25,000 of Federal funds. Northwest College will revise its procurement policy as determined necessary and in accordance with Northwest College?s policies. Anticipated Completion Date: June 30, 2023 Contact Persons: Brad Bowen, Finance Director

2022-002 Health Centers Cluster ? Assistance Listing No. 93.224 and 93.527 Health Center Infrastructure Support ? Assistance Listing No. 93.526 Recommendation: Management should adhere to or revise the Organization?s existing procurement policy and implement a system of processes and internal controls to ensure that the appropriate level of documentation is maintained based on the procurement methodology selected for a transaction of contract. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: 1) Procurement ? missing documentation for sole source purchase justification or price comparisons. Heartland?s purchasing policies and procedures were reviewed for content and clarity. In addition to the policy and procedure review, we will implement a more robust documentation, review, and approval process regarding larger purchases and sole sourcing. Purchases that are grant related and > $2,500 where the 3 bid minimum decision-making process is being waived and sole source is being utilized will be documented by the purchasing manager and reviewed, approved, and signed by our CEO as to why this is the optimal vendor (1). (See attached template) 2) Suspension and Debarment- missing documentation for quarterly review of vendors. Vendors will be reviewed on a quarterly basis to ensure that they are not on the exclusion list. The Accounting Specialist will report to the Controller on a quarterly basis regarding the status of the vendor review, and documentation of the review will be provided to the Controller at that time. Name(s) of the contact person(s) responsible for corrective action: Michael Cohlman, CFO and Tony Bartlett, Controller Planned completion date for corrective action plan: 4/1/23

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 2023

FINDING 2022-003 Contact Person Responsible for Corrective Action: Auditor Mark Hoelscher Contact Phone Number: 765-973-9318 Views of Responsible Official: We concur with the findings. Wayne County Auditor's office will begin checking all contracts for suspended, debarred, or otherwise excluded from or ineligible for participation in federal assistance programs prior to the purchase. Anticipated Completion Date: December 31, 2023

FINDING 2022-002 Contact Person Responsible for Corrective Action: Tammy Chavis, Superintendent Contact Phone Number: 765-647-4128 Views of Responsible Official: As Superintendent, I concur with the finding that an effective internal control system was not in place at the School Corporation in order to ensure compliance with requirements related to the grant agreement and the Procurement and Suspension and Debarment compliance requirement. Description of Corrective Action Plan: The Superintendent will be in close contact with the Special Education Co-Op, and require all supporting documentation of Procurement and Suspension and Debarment. Anticipated Completion Date: March 16, 2023 Tammy Chavis Superintendent March 16, 2023

FINDING 2022-001 Contact Person Responsible for Corrective Action: Lisa McCormick Contact Phone Number: 260-824-6474 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Wording will be included in all bid packets requesting suspended or disbarred status from all vendors prior to issuing contracts. Also, wording will be added to bid packets asking vendors to notify Wells County if they become suspended or disbarred during the life of the contract. Anticipated Completion Date: Immediately

Views of Responsible Officials and Planned Corrective Action: Management agrees with the above finding and will amend the Procurement Policy to include a vetting process to avoid a selection of a contractor /vendor that has been suspended or debarred from working on Federal Contracts.

2022-002 - ALN 21.027 - Coronavirus State and Local Fiscal Recovery Funds - Procurement, Suspension, and Debarment: Lack of Controls for Suspension and Debarment (New Comment) Auditor's Comment: According to the Coronavirus State and Local Recover Funds (CSLRF) Final Rule, Suspension and Debarment is covered under CFR 200.214 in Subpart C, which is fully applicable under the revenue replacement method. As such, suspension and debarment should be evaluated and documented for all non-payroll expenditures under this program. Management's Response: The City will create internal control procedures to ensure evaluation and documentation relating to Final Rule, Suspension and Debarment as required under CPF 200.214 in Subpart C.

FINDING 2022-001 (Auditor Assigned Reference Number) Contact Person Responsible for Corrective Action: Debra A. Carnes Contact Phone Number: 317.477.1105 We concur with the finding As a pass-through entity for Federal ARPA funds, the Hancock County Auditor will design and implement a system of internal controls related to suspension and debarment procedures to ensure entities are neither suspended nor debarred or otherwise excluded or disqualified prior to entering any covered transactions. All current recipients of ARPA funds will be verified and documented as well. These controls will be utilized for all State and Federal grant funds that will be disbursed. Anticipated Completion Date: July 31,2023