Corrective Action Plans

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.

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.