Corrective Action Plans

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.

Finding Summary: The County's procurement procedures do not include procedures for vetting vendors with regard to suspension and debarment from participating in federal assistance programs. Responsible Individuals: County Attorney and County Judge Corrective Action Plan: Any future relevant procurement will include vetting procedures to prevent those who are suspended and/or debarred from participating in the project. Anticipated Completion Date: Ongoing

Finding Summary: County should comply with Uniform Guidance regarding procurement Responsible Individuals: County Attorney and County Judge Corrective Action Plan: Recent developments have resulted in a change in personnel. Individuals now involved in any grant funded procurement will be tasked with monitoring our procurement procedures for compliance with Uniform Guidance principles. Additionally, a follow up with the project contractor revealed that no ineligible vendors were, in fact, selected or used. Anticipated Completion Date: Ongoing

Failure to Follow Procurement Policy Finding 2023-003 Auditor Description of Condition and Effect: The Authority did not comply with the current procurement policy as procedures were not fully followed and required forms were not completed. The following forms required by either 2 CFR 200 and/or the Authority’s own procurement policy were not completed for the current year capital asset purchases: Written Record of Procurement Checklist Form, Method of Procurement Decision Matrix, Advertisement and Solicitation Form, Bid Quotations, Fewer Than 3 Offers Received Evaluation if applicable, Proposal Tabulation, Certification of Compliance with Federal Clauses for the assets less than $25,000, Responsibility Determination (sam.gov debarred verification), and Cost/Price Analysis. Also, as stated in the prior finding, the procurement policy needs to be updated. As a result, the Authority is noncompliant with 2 CFR 200 and its own procurement policy. Auditor Recommendation: We direct the Authority to implement procedures to ensure that the fiscal year 2022 is certified within the required nine-month deadline. Corrective Action Plan: The Authority will review and update its procurement policy to comply with federal requirements. The Authority’s management, consultant, and finance director will review the procedures in the policy to ensure they are being acted upon accordingly going forward. Responsible Official: Contact person is Rufus Adams, Executive Director,275 East Wall Street, P.O. Box 837, Benton Harbor, Michigan 49023. Telephone (269) 927-2268. Due Date: September 30, 2024

Federal Program Information Federal Agencies: U.S. Department of Health and Human Services and U.S. Department of Defense Federal Cluster: Research and Development (R&D) Pass-Through Entity: The University of Texas Health (93.853, NS119834) Assistance Listing Nos.: 12.420, 93.310, 93.353, 93.393, and 93.853 Award Numbers: W81XWH-15-1-0292 (12.420), OD23121 (93.310), CA246568 (93.353), CA259201 (93.393), NS119834 (93.853), NS122096 (93.853) Award Periods: Various Corrective Action Planned Management conducted an education and training session for procurement teams in June 2024 to reinforce procurement requirements and documentation standards. Management will implement an independent sanction and debarment check for suppliers as part of existing quarterly audits over Supplier AP vendor master tables and related changes to those tables. Persons Responsible for Corrective Action Daniel Schmitz, Division Chair - Supply Chain Management Scott Hammer, Director - Supply Chain Management Target Completion Date June 30, 2024

Views of Responsible Officials: NFHA previously had a process in place, but it was not implemented properly during this fiscal year by the person to whom the responsibility was transferred. NFHA has resumed the process to perform checks in SAM.gov as part of the onboarding process for all new vendors. NFHA will also perform reviews of existing vendors on an annual basis and maintain evidence of these checks with the appropriate vendor files.

Finding 2023-029 Coronavirus State and Local Fiscal Recovery Funds, ALN 21.027 - Suspension and Debarment Process Management Views MDE agrees with the finding. Planned Corrective Action MDE and MiLEAP will update all grant agreements to include specific suspension and debarment language to comply with 2 CFR 200.214. Anticipated Completion Date October 1, 2024 Responsible Individual(s) Spencer Simmons, MDE Juan Suasto, MDE Richard Lower, MiLEAP

Community Mental Health Services of Livingston County Single Audit Report: Corrective Action Plan Year ended September 30, 2023 Finding 2023-001- Suspension and Debarment Requirement: As required by 2 CFR 200.214, Non-Federal entities are subject to the non-procurement debarment and suspension regulations implementing Executive Orders 12549 and 12689, 2 CFR part 180. 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. Finding: Vendor was not checked for suspension and debarment prior to execution of the contract. Also, the contract did not include certification that vendor was not suspended or debarred. Questioned Cost: None. Recommendation: Contract language should be updated to include certification that vendor is not suspended or debarred. Corrective Action Plan LCCMHA is committed to addressing the concern raised by RPC and agrees with the above recommendation. The Contract Manager will modify existing contract language to include certification that vendors are not suspended or debarred. This change will be implemented for fiscal year 2025 commencing 10/01/24.

Finding NO. 2023-002 View of University of Guam and Corrective Action Plan: The University acknowledges the finding. While the University regularly performs verification of vendors against the SAM Exclusions list via www.sam.gov, the process is not consistently documented. Effective immediately, the University has implemented procedures to ensure proper documentation and maintenance of vendor verifications via the SAM Exclusions list. This procedure includes the following steps: • Obtaining the debarred vendor listing from SAM.GOV monthly and reviewing vendors’ status. • Checking new vendors against the downloaded list for the month when creating new vendors in the system. • Including a memorandum or statement indicating the verification process and status of vendors for purchases $25,000 and above. Name of Contact Person: Abigail Martin, Comptroller Proposed Completion Date: Completed on May 14, 2024.

The Organization is in the process of developing a procurement policy and suspension and debarment policies that aligns with Uniform Guidance.

Finding 2023-002 Condition: Suspension and debarment compliance was not verified for six covered transactions. Corrective Action Planned: The District has incorporated the language into contracts beginning with school year 2024. The language is not in the 2023 food service contracts. Anticipated Completion Date: Completed Contact: Ellen Finelli, MS. RD., Director of Food and Nutrition

2023-002 Material Weakness in Internal Controls – Procurement, Suspension and Debarment Funding Agency: Department of Education Program: Innovative Approaches to Literacy; Promise Neighborhoods; Full-Service Community Schools; and Congressionally Direct Spending for Elementary and Secondary Education Community Projects Assistance Listing Number: 84.215K Condition: None of the five samples selected for testing had appropriate suspension and debarment checks prior to entering into the subawards. Criteria or Specific Requirement: Criteria or specific requirement: 2 CFR 200.318(i) states that "non-Federal entities are subject to the non-procurement debarment and suspension regulations implementing Executive Orders 12549 and 12689, 2 CFR part 180. 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. Effect: The Organization was unaware of the requirement to perform suspension and debarment checks on subrecipients. Without proper controls the Organization could enter award subrecipients with entities that are suspended or debarred. Cause: The Organization was unaware of the requirement to perform suspension and debarment checks on subrecipients. Without proper controls the Organization could enter award subrecipients with entities that are suspended or debarred. Recommendation: The Organization should implement policies and procedures for performing suspension and debarment checks for all covered transactions, including subrecipients. Questioned Costs: None View of Responsible Official and Corrective Action Management accepts the finding and is taking the following corrective action to prevent recurrence: • Procurement training planned throughout the agency to ensure that personnel authorized to initiate procurement transactions are aware of organizational policies and have the guidance necessary to comply with procurement rules. Anticipated Completion Date: Corrective action is currently being implemented.

Finding 2023-003 Condition: Documentation of the solicitation of quotes for one purchase totaling $16,700 could not be found in Department files. Also, a written determination related to a sole source procurement totaling $15,460 was not in the Department files. Corrective Action Plan: The School District has implemented new policies and procedures surrounding the documentation of procurement to better ensure compliance with federal procurement requirements. Anticipated Completion Date: 5/31/2024 Contact Information: Keith Buday, Assistant Superintendent – Finance & Operations

Finding 2023-002 Condition: Procurement documentation could not be found in Department files related to purchases of pizza making supplies from a vendor. Corrective Action Plan: The School Lunch Department has implemented new policies and procedures surrounding documentation of procurement, including the adoption of new standardized procurement forms based on templates provided by the state, to ensure compliance with federal procurement requirements. Anticipated Completion Date: 5/31/2024 Contact Information: Keith Buday, Assistant Superintendent – Finance & Operations

The Town of Swansea immediately took corrective action by establishing a Town wide policy which requires the procurement of certain documents. The implementation has already taken place on all projects concerning ARPA funds.

Hood River County has developed procedures to ensure the suspended and debarred listing is checked prior to awarding contracts to outside parties. In addition, the County is maintaining documentation of a second check being performed before the vendor can be entered into the payment system. We expect this to be running without exception by 12/31/2024.

Views of Responsible Officials: IW will initiate a thorough review and revision of our procurement policy to ensure full compliance with the Uniform Guidance. This revision process includes adding documentation of the procurement process. In addition, it will address how we incorporate specific procedures for conducting and documenting checks against the System for Award Management (SAM) to verify the status of vendors prior to engaging in covered transactions. We will implement a standardized documentation process to maintain evidence of SAM checks within our vendor files. This includes a detailed log of each check performed, the date, the name of the entity checked, and the outcome. These records will be retained as part of our procurement files for audit and review purposes.

NONCOMPLIANCE WITH PROCUREMENT, SUSPENSION & DEBARMENT REQUIREMENTS, CORONAVIRUS STATE AND LOCAL FISCAL RECOVERY FUNDS; AL No. 21.027, YEAR ENDED JUNE 30 2023 Name of contact person: Kristen Galbraith, GPC Corrective Action: The Grants Department will develop procedures that will provide reasonable assurance that procurement of goods and services are made in compliance with applicable federal regulations and other procurement requirements specific to a federal award or subaward, and that no subaward, contract, or agreement for purchase of goods or services is made with any suspended or debarred party. Proposed Completion Date: Immediately

NONCOMPLIANCE WITH PROCUREMENT AND SUSPENSION AND DEBARMENT REQUIREMENTS, CORONAVIRUS STATE AND LOCAL FISCAL RECOVERY FUNDS; AL No. 21.027; GRANT No. Direct and AM-23-0287 Name of contact person: Kelly Strecker Corrective Action: The City commits to ensuring that a procurement policy be put in place that will allow it to comply with procurement standards outlined in the Uniform Guidance. Proposed Completion Date: December 1, 2024

CORONAVIRUS STATE AND LOCAL FISCAL RECOVERY FUNDS, ASSISTANCE LISTING No. 21.027, PROCUREMENT AND SUSPENSION AND DEBARMENT Name of contact person: County Commissioners Corrective Action: Roosevelt County will follow the procedure of verifying contractors through SAM or GSA Websites when using SLFRF funds. Proposed Completion Date: Immediately.

Program: AL 21.027 – COVID-19 – Coronavirus State and Local Fiscal Recovery Funds – Suspension and Debarment Corrective Action Planned: 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 debarred and such procedure will be adequately documented. Anticipated Completion Date: Ongoing Responsible Party: Phil Hardenburger, Saline County Board of Commissioners, Chairperson

2023-003 Child Nutrition Cluster – Assistance Listing No. 10.553 and 10.555 Recommendation: We recommend the District design controls to ensure an adequate documentation of control and review of potential contractors to determine they are not suspended or debarred is retained for all applicable vendor relationships. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We will review vendor suspension and debarment evaluation policies and purchasing policies and implement polices and controls to ensure that District policies and controls comply with Uniform Guidance requirements. Name(s) of the contact person(s) responsible for corrective action: Brenda Arnett Planned completion date for corrective action plan: June 30, 2024

Finding 2023-001-Procurement, Suspension and Debarment Finding: The Foundation does not have a formal procurement policy under requirements of 2 CFR 200.317 through 200.327. The Foundation established policies and procedures over suspension and debarment, including checking all vendors against the government suspension and debarment listing. We noted as part of our testing that there was no documentation that these policies and procedures were being followed. Corrective Actions Taken or Planned: The Foundation is in the process of developing a formal procurement policy to conform to 2 CFR 200.317 through 200.327. Further, the National Association of Social Workers, the supported affiliate of the Foundation has posted a position to hire a senior grants accountant who will be assisting in the development and implementation of policies and procedures around grants. The position will be reporting to the Accounting Manager and ultimately the Chief Financial Officer. Sekou Murphy, Chief Financial Officer, will be responsible for the corrective action plan that is anticipated to be completed by October 2024.

COVID 19 - Demonstration Programs to Improve Community Mental Health Services 93.829 Recommendation: We recommend internal controls over suspension and debarment be implemented. This could include following checklist which includes procedures for verification of whether a vendor is suspended or debarred and having that checklist be required to be reviewed by the program manager prior to entry into a covered transaction. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: A process of more comprehensive review of program requirements will be put in place. Name of the contact person responsible for corrective action: Lisa Katz, Chief Program Officer Planned completion date for corrective action plan: Currently underway and planned to be completed by June 30, 2024.