Corrective Action Plans

FINDING 2023-002 Finding Subject: Water and Wastewater Disposal Systems for Rural Communities – Procurement Summary of Finding: One vendor was not procured according to the simplified acquisition threshold. Contact Person Responsible for Corrective Action: Tammy Selby Contact Phone Number and Email Address: 812-354-8511 tselby@petersburg.in.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: In the future, we will bid out all professional services. We will follow our same policies for bidding out to other vendors. Anticipated Completion Date: December 31, 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

FINDING 2023-002 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Procurement and Suspension and Debarment Summary of Finding: Material Weakness, Modified Opinion Contact Person Responsible for Corrective Action: Aaron Kaytar Contact Phone Number and Email Address: 317-852-1120 akaytar@brownsburg.org Views of Responsible Officials: We concur with the findings. Description of Corrective Action Plan: In 2023 a Purchasing Policy was implemented for all departments to follow. It states: 1. For Purchases Under $50,000 a. Purchases or Contracts of $1,000 or Less i. Shall be reviewed and approved by the designated Purchasing Agent. ii. The Department Head, Procurement Manager and Town Manager reserve the right to deny any Purchase. iii. Contracts should be submitted to the Clerk-Treasurer’s Office for retention. b. Purchases or Contract between $1,000 and $10,000 i. Shall be reviewed and approved via a Requisition Form by the Purchasing Agent/Department Head. ii. The Procurement Manager and Town Manager reserve the right to deny any Purchase. iii. Contracts should be submitted to the Clerk-Treasurer’s Office for retention. iv. Any new purchase that meets the asset requirement ($5,000 or more) MUST be reported to the Clerk-Treasurer’s Office. c. Purchases or Contracts between $10,000 and $50,000 i. Shall be reviewed and approved via a Requisition Form by the Department Head, Procurement Manager and Town Manager. ii. Should have (3) formal quotes from different vendors. iii. The Procurement Manager and Town Manager reserve the right to deny any Purchase. iv. Contracts should be submitted to the Clerk-Treasurer’s Office for retention. v. Any new purchase that meets the asset requirement ($5,000 or more) MUST be reported to the Clerk-Treasurer’s Office. d. Purchases of at Least $50,000 and Less Than $150,000 i. Shall be reviewed and approved by the Department Head, Procurement Manager, Town Manager and Town Council. ii. The information shall be presented to Town Council and should contain (3) formal quotes from different vendors. iii. Contracts should be submitted to the Clerk-Treasurer’s Office for retention. iv. Any new purchase that meets the asset requirement ($5,000 or more) MUST be reported to the Clerk-Treasurer’s Office. e. Purchases of $150,000 or More i. Shall be submitted via a formal bidding process. ii. Shall be reviewed by Department Heads, Procurement Manager, Town Manager and Town Council. iii. Contracts should be submitted to the Clerk-Treasurer’s Office for retention. iv. Any new purchase that meets the asset requirement ($5,000 or more) MUST be reported to the Clerk-Treasurer’s Office. 2. To provide services to the Town of Brownsburg, you must not be debarred, suspended, or otherwise be excluded from or ineligible for participation in federally assisted programs under Executive Order 12549. Anticipated Completion Date: Policy change 2023. Purchase order change 8/31/2024.

FINDING 2023-001 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Suspension and Debarment Summary of Finding: The County did not perform procedures to ensure vendors were not suspended, debarred, or otherwise excluded from or ineligible for participation in Federal assistance programs or activities. Additionally, the County did not have a formalized procurement policy outlining its processes and procedures with regards to the procurement of goods and services using federal grant funds. Contact Person Responsible for Corrective Action: Brenda J. Furry, County Auditor Contact Phone Number and Email Address: (765) 492-5300 / brenda.furry@vermillioncounty.in.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The process of ensuring the vendors that are being used by the County and paid for through Federal Funds, specifically ARPA funds, have been confirmed to be in good standing via Exclusions search on the SAM.gov website. A procurement policy with regards to the procurement of goods and services using federal grant funds is currently being written. Anticipated Completion Date: December 31, 2024

ALN: 20.509, Corrective Action Plan: Noncompliance with Federal Procurement Requirements - MDT - The Montana Department of Transportation has hired new leadership for the Transit Section, who are actively working with the Federal Transit Administration (FTA) and the subrecipients to formalize procedures, document oversight measures, and correct the deficiencies. Person(s) Responsible for Corrective Measures: Rob Stapley, Administrator, Montana Department of Transportation, Target Date: 06/30/2025

1) Management will review procurement policies with staff 2) Timely action will be taken to solicit bids for contracts that exceed District thresholds. 3) To ensure full and open competition takes place, management will routinely review current contracts and spending reports to identify expenditures that exceed the dollar amount threshold to individual vendors. Anticipated completion date: June 30, 2024 Responsible contact person: Emily Johnson

The City will update it’s polices and procedures to help ensure the procurement standards are followed when expending federal monies.

Management thought the bidding for the Township engineer a number of years ago, met the bidding requirements. In the future, if the Township obtains any federal grant that requires engineering services, the Township will make sure that we bid engineering services. The anticpated completion date is prior to receiving another federal grant award requiring engineering services.

Capital Fund Program – CFDA 14.872 Recommendation: The Commission should implement policies and procedures to ensure all federal compliances are followed pertaining to procurement and suspension and debarment. Action Taken: New Management has taken over as of March 2023 and will review and implement stronger policies and procedures pertaining to capital fund grants. Anticipated Completion Date of Action: December 31, 2024

Finding 2023-004 – Procurement Policy Criteria: In accordance with Uniform Guidance 2 CFR, Part §200.318 "General Procurement Standards", the non-federal entity must have and use documented procedures, consistent with State, local, and tribal laws and regulations and the standards of this section, for the acquisition of property or services required under a federal award or subaward. The non-federal entity's document procedures must conform to the procurement standards identified in 2 CFR, Part §200.317 - §200.327. Condition: During our review of the Coalition's Policies and Procedures, we determined that the Coalition's Procurement policy does not comply with 2 CFR, Part §200.317 - §200.327 Questioned Costs: None Cause: The Coalition was unaware of the changes in General Procurement Standards within Uniform Guidance and therefore does not have sufficiently established control policies and procedures to comply with 2 CFR, Part §200.317 - §200.327. Effect: The Coalition does not have the ability to determine if disbursements, projects, and bids comply with 2 CFR, Part §200.317 - §200.327. Recommendation: We recommend the Coalition becomes familiar with requirements of 2 CFR, Part §200.317 - §200.327. and establishes appropriate internal control policies and procedures related to procurement and that all staff be trained in those policies and procedures, so they are familiar with the requirements. We further recommend no contract or agreement be awarded by the Coalition in which appropriate procurement policies have not been followed Corrective Action: In response to the finding regarding non-compliance with procurement policies as outlined in 2 CFR, Part §200.317 - §200.327, the Coalition will take the following corrective actions: 1. Review and Update Procurement Policies: o The Coalition will conduct a comprehensive review of its current procurement policies and procedures. We will update these policies to ensure full compliance with Uniform Guidance 2 CFR, Part §200.317 - §200.327, as well as any relevant state, local, and tribal laws and regulations. o We will review and update detailed procedures. These procedures will be clearly aligned with the standards identified in 2 CFR, Part §200.317 - §200.327. 2. Training and Education: o All staff involved in the procurement process will receive training on the updated procurement policies and procedures. This training will ensure that all relevant personnel are familiar with the requirements of Uniform Guidance 2 CFR, Part §200.317 - §200.327, and understand their responsibilities in adhering to these standards. 3. Implementation of Internal Controls: o The Coalition will implement internal controls to ensure compliance with the updated procurement policies and procedures. This will include establishing a review and approval process for all procurements to verify adherence to the new standards. 4. Monitoring and Compliance Checks: o We will establish a system for ongoing monitoring and compliance checks to ensure that all disbursements, projects, and bids comply with 2 CFR, Part §200.317 - §200.327. Quarterly audits will be conducted to identify and address any deviations from the established policies and procedures. Timeline for Implementation: The corrective actions outlined above will be implemented within the next 30 days. The review and update of procurement policies and procedures will be completed within this period, and training sessions for relevant staff will be conducted immediately following the implementation of these changes. Internal controls and monitoring systems will be established concurrently. Contact Information: For further information or questions regarding this corrective action plan, please contact: Carlett Gregory, CFO, Email: cgregory@nuihc.com, 402-346-0902 x 204. Carlett Gregory Carlett Gregory CFO

2CFR 320, Methods of Procurement Standards are to be followed by each department requesting federal award. The County Auditor has instructed our employees and admin people of the changes made to our system to be followed for methods of procurements. County Auditors have provided an easy sheet to be followed and dated to be turned into the auditor's office to be approved prior to purchases as to see all steps have been completed of the procurement policy prior of purchasing items on any federal award. All items by County Auditor will be processed and looked at again prior to a check written.

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

Corrective Action Planned: Management concurs with the finding. The District’s policies will be updated and approved to conform to federal guidance. Additionally, management will begin paying all vendors awarded through competitive procurement, on projects paid with federal funds, directly from the District’s bank accounts and not through a third part grant administrator. Lastly, Management of MSIDD has since obtained express authorization from the pass-through entity to use ED3 as a sole source vendor.

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

U.S. Department of Health and Human Services Southern Illinois Healthcare Foundation respectfully submits the following corrective action plan for the year ended December 31, 2023. Audit period: January 1, 2023 – December 31, 2023 The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS—FEDERAL AWARD PROGRAMS AUDITS DEPARTMENT OF HEALTH AND HUMAN SERVICES 2023 – 001 Consolidated Health Centers 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: The Hospital will ensure that controls are put into place to ensure procurement procedures are followed. Name of the contact person responsible for corrective action: John Jeffries, CFO. Planned completion date for corrective action plan: January 1, 2024. If the Department of Health and Human Services has questions regarding this plan, please call John Jeffries at 618-332-5324.

Recommendation: We recommend that the Organization update its procurement policy to include all federally required elements of such policies for federal award recipients under the Uniform Guidance. We also recommend that the Organization document and maintain evidence of its suspension and debarment procedures to be in compliance with requirements specified in the Uniform Guidance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization will review and update its procurement policy to incorporate all federally required elements of the Uniform Guidance. The Organization will also document its suspension and debarment procedures and maintain evidence of the performance of such procedures. Name of the contact person responsible for corrective action: Ali Butler, Director of Finance Planned completion date for corrective action plan: July 2024 If the Department of Interior has questions regarding this schedule, please call Ali Butler at 720-865-3770 or ali.butler@botanicgardens.org.

Personnel Responsible for Corrective Action: Policies and procedures will be supervised by COO, Tracie Thomas, Facilities Operations Manager, Tiffany Durr, Senior Accounting Specialist, Laura Froese, and Grants Specialist, Westen Gehring Anticipated Completion Date: Policies and procedures will be reviewed, drafted, and implemented by May 30, 2024 and reflected in the 2024 audit. Corrective Action Plan: To ensure compliance with federal procurement standards, by 05/30/2024 The Land Institute will develop more robust policies and procedures for tracking purchases in accordance with uniform guidance standards for formal federal procurement and noncompetitive procurement of equipment with federal funds. Updated policies will apply to micro-purchases above the threshold of $10,000 and will include requirement of documentation demonstrating that TLI checked the vendor’s status to ensure they were not suspended or debarred. A sole source justification form will be drafted and made available upon request for purchases where noncompetitive procurement was deemed necessary. These changes will be reflected in an updated procurement policy document as well as the development of a sole source justification template.

Recommendation: The organization should develop and document procurement procedures that meet state, local, and Uniform Guidance requirements. The conflict-of-interest policy should be updated to include standards of conduct for those involved in procuring and to include organizational conflicts of interest. Internal controls should be designed, implemented, and documented within the procurement procedures to ensure compliance with 2 CFR sections 200.317 through 200.327. At a minimum, the procurement history including rationale for the method, procurement method support, contract selections and rejections, suspension and debarment, and bases for contract prices should be documented. Ac􀆟on Taken: BGCDC has already established a Uniform Guidance worthy procurement policy and is currently working on an update to the Conflict-of-Interest policy. These will go to our Finance Committee and Board soon for full approval as well as implementation. Leadership has been informed of this change and is already starting on the implementation as far as seeking out bids, documenting rationale, and making informed decisions. The contact person responsible for the corrective action is Wendi Speed, CFO. The anticipated completion date is June 30, 2025.

Finding: 2023-036 - For one of five procurement contracts selected for testing, the State could not provide documentation of the procurement method chosen and the procurement exceeded the threshold required for competitive bidding procedures. Questioned Costs: None Assistance Listing Number: 10.557 Assistance Listing Title: Special Supplemental Nutrition Program for Women, Infants, and Children Views of Responsible Officials (state whether your agency agrees or disagrees with the finding; if you disagree, briefly explain why): DOH agrees with the finding. Corrective Action (corrective action planned): A thorough review of procurement processes and procedures is being arranged. A comprehensive staff training plan will ensure understanding and adherence to State of Alaska procurement policies. Completion Date (list anticipated completion date): DOH anticipates the finding will be resolved in FY2024. Agency Contact (name of person responsible for corrective action): Josie Stern, Assistant Commissioner

The School District will follow proper procurement procedures related to food purchases.

2023-016 Oregon Housing and Community Services Verification that subrecipients have not been suspended or debarred needs to be retained MANAGEMENT RESPONSE: We agree with this recommendation. Since the original findings in 2022, we have added the SAM check as a mandatory review activity in our agreement trackers and have provided training and guidance as to the retention of the screenshots of the SAM check as of 6/30/2023. As we have experienced some additional staff turnover since then, we will reiterate that guidance; document the requirement in a team procedure; and provide a refresher as to the necessity of this document retention on a recurring basis. This will currently be in the Procurement Administrative files but is subject to change as there is a project in motion at OHCS for a Grant Management System that may inform a procedural change as to how and where we retain and archive agreement documentation. Anticipated Completion Date: June 30, 2024 Contact person: Liz Weber, Chief Policy Officer

2023-015 Oregon Housing and Community Services Fully implement controls to ensure subrecipients are in compliance with program requirements MANAGEMENT RESPONSE: We agree with this recommendation. OHCS has hired an outside contractor to complete the requested work. Contractor was not in place in time to complete action prior to end of audit work, however work will be finalized prior to the end of the current fiscal year. Anticipated Completion Date: June 30, 2024 Contact person: Dean Criscola, Controller

April 15, 2024 Donovans CPA www.cpadonovan.com RE: Findings 2023-001 Procurement Assistance Listing Number 84.282A Dear Sirs; Lawrence County Independent Schools has implemented the following Corrective Action Plan in response to the finding of the Single Audit for fiscal years ending 2023. Corrective Action Plan 1. The LCIS Procurement Policy has been updated by the Director of Schools, Joanne Symcox, under the non-Federal entity (Per 2 CFR 200.318) to conform to procurement standards identified in 200.317 through 200.327. 2. The updated policy will be presented at the March 21, 2024 Board Meeting for review and approval. 3. The corrective action plan was implemented beginning Mar 13, 2024. 4. The Director of Schools, Joanne Symcox is responsible for plan implementation and adherence. Sincerely, Joanne Symcox

Finding 2023-002: Procurement Suspension and Debarment Audit Finding: While the Fund adopted an updated procurement policy during 2023, testing of the Fund’s controls on compliance over procurement and suspension and debarment identified transactions under the old policy. The Fund did not have a procurement policy in place for the full year that is in compliance with prescribed standards in the Uniform Guidance; therefore, prior to the adoption of the updated procurement policy, suspension and debarment verifications were not performed prior to entering a covered transaction. Corrective Action Plan: See status of Prior Year Finding 2002-002. Management believes the corrective actions taken in 2023 have remediated this finding and will monitor for compliance and to identify any additional training needs in 2024. Person(s) responsible for implementation of the corrective action plan: Monica A. Garrison, Senior Vice President Finance & Treasurer. Hillina Fetehawoke, Director of Accounting & Financial Reporting. Anticipated completion date: June 2024

Contact Person Neil Breidenbach Planned Corrective Action The District will create and approve a procurement policy that adheres to state and local regulations as well as 2 CFR Part 200.317 through 200.327. Planned Completion Date December 31, 2024.