Corrective Action Plans

Program: Continuum of Care, Emergency Solutions Grant Program Federal Financial Assistance Listing No.:14.267, 14.231 Federal Agency: U.S. Department of Housing and Urban Development Pass-through: Sacramento Steps Forward, Sacramento County Department of Human Assistance Award Year: 2023 Compliance Requirement: Procurement, Suspension and Debarment Grant Award Number: CA0955L9T032108, CA0955L9T032209, CA0143L9T032114, CA0143L9T032215, CA1303L9T032107, CA1303L9T032208, DHA-NM-03-23, DHA-NM-03-24 Finding Summary: The Organization’s procurement policy did not include all the required elements as outlined in the Uniform Guidance. Additionally, the Organization did not retain documentation to support the procedures performed to ensure compliance with suspension and debarment requirements. Repeat Finding from Prior Years: Yes, Finding 2022-003 Management’s Response: We concur. Views of Responsible Officials and Corrective Action: • Management will update policies and procedures to ensure they confirm to the Uniform Guidance regarding procurement, suspension and debarment (2 CFR 200.317 through 200.327, 2 CFR 180). • Train grant staff on new policies and procedures. Name of Responsible Person: Bryan Wagner, CFO Projected Implementation Date: December 31, 2024

Corrective Action Plan Finding 2023-002 Criteria: Recipients of federal awards must follow the procurement standards set out at 2 CFR section 200.317 through 200.326. They must use their own documented procurement procedures, which reflect applicable State laws and regulations, provided that the procedures conform to applicable Federal law and the procurement requirements identified in 2 CFR part 200. Recipients “must maintain records sufficient to detail the history of procurement. These records will include, but are not necessarily limited to the following: rationale for the method of procurement, selection of contract type, contractor selection or rejection, and the basis for the contract price” 2 CFR section 200.318(i). Auditor Recommendation: We recommend the Academy ensure it 1) maintains documentation of the history of procurement and 2) monitors compliance with documentation requirements. Auditee Response/ Corrective Action Plan: The Academy will review its procurement policies and internal controls and ensure timely action is taken when noncompliance is identified. Person Responsible: Tim Stay, CEO Timeline: All future contract solicitations will follow the required procurement standards.

Finding 2022-07 Failure to Create and Implement a Suitable Procurement Policy Condition: The Organization created and implemented a procurement policy to govern its federal expenditures. The procurement policy implemented by the Organization failed to include several key elements, including clearly establishing and governing the various expenditure purchasing thresholds, documenting a sufficient bid process for competitive bid proposals, and standards of conduct covering conflict of interest for employees involved in the bid evaluation process. Further, while the policy was in place, the Organization failed to implement the elements of the policy into its procurement process. As part of audit procedures, 12 transactions were included in the testing population and all 12 were tested. Of the testing group, the auditor identified 4 transactions that required competitive bid procedures for which the Organization failed to conduct. The Organization also failed to document its rationale to limit competition for all items tested. Corrective Actions Taken or Planned: - VOICES will revise and implement a formal Procurement Policy that fully aligns with Uniform Guidance and federal regulations. The updated policy will include: + Clear Purchasing Thresholds: Establish thresholds for micro-purchases, small purchases, and formal procurements (e.g., competitive bidding for purchases exceeding $10,000 or other appropriate limits) - Implement a structured bid process that requires: + Multiple bids for purchases exceeding established thresholds. + Documentation of vendor selection rationale, including why competition was limited, if applicable. - Conduct mandatory training for all staff involved in procurement. - Require all vendors and contractors to be checked against the System for Award Management (SAM.gov) to confirm eligibility and compliance with federal procurement requirements.

All management will be educated on the procurement policy as well as the information noted from the CFR sections indicated in the findings by the Director of Finance. The Director of Finance will research and provide education to the Executive Leadership related to this finding during the Executive Leadership meeting. All Grants and cooperative agreements must be filed with the fiscal department. All expenditure must be approved prior to purchase / payment with sign off from Executive Director or Director of Finance.

U.S Department of Treasury COVID 19 – Coronavirus State and Local Fisal Recovery Funds – 21.027 Management’s Response: The amount of the expense with this vendor was below $5,000 for three separate invoices and events. The Unified Government’s purchasing policy does not require competitive quotes for purchases under $5,000. However, we understand that we should be viewing these expenses in the aggregate not as individual transactions. We will work with the department to ensure these are competitively procured going forward. Views of Responsible Officials and Corrective Action: Departments have been informed of the procurement requirements and the procurement policy will be adhered to on a go forward basis. Management will ensure this is addressed by December 31, 2025. Responsible Official: Dr. Shelley Kneuvean Chief Financial Officer Unified Government of Wyandotte County & Kansas City KS

The Program will develop an internal procurement policy with reference to the appropriate Federal, State, and local laws, regulations, and standards. The documented policy will be used when initiating and approving purchases under Federal grant programs. Individual(s) Responsible Sherry Bradley Completion Date The plan was implemented.

Management Response #2023-007: Due to staff shortages and turnover, the company lacked adequate personnel to effectively monitor or document grant activity. Additionally, formal documentation of policies and procedures was insufficient, and supporting documents were not stored in a centralized location, creating challenges in retrieving necessary information. Corrective Action Plan: In response to these issues, the company implemented the following corrective measures starting in mid-2023: • The Corporation established comprehensive, formal policies and procedures that document the current compliance practices. These procedures have been disseminated across the organization and incorporated into training programs to ensure all employees are aligned with the updated standards. • A procedure enhancement has been implemented in the procurement process, which requires the procurement manager to obtain three bids prior to the creation of certain purchase orders. This ensures competitive bidding and transparency in vendor selection. • Once a vendor is selected, the procurement manager will forward the vendor’s details to the compliance department. The compliance team will then verify the vendor's debarment status and federal eligibility to ensure compliance with all regulatory requirements. • A central repository platform has been created to store all vendor bids, price analyses, and related procurement documentation. This ensures that all relevant information is easily accessible and properly organized. • All accounts payable invoices designated for grant funding are now routed for prior approval to the respective grant program manager via the WorkPlace software before any payments are processed. This ensures proper oversight and alignment with grant requirements. These corrective actions aim to strengthen compliance, improve document management, and streamline oversight processes to prevent future issues related to grant monitoring and procurement. Responsible Party: Tamara Barnes, CFO

Assistance listing number and program name: 14.267 Continuum of Care Program Agency: Arizona Department of Housing (DOH) Name of contact person and title: Lori Moreno, DOH Human Resources and Procurement Administrator Anticipated completion date: March 31, 2025 Agency’s Response: Concur The Department will update written policies and procedures related to procurement to incorporate applicable aspects of Federal Regulations 2 CFR §§200.321, 200.322, 200.323, and 200.327. The updated policy will address competition through competitive bids, sole source selections, and retention of procurement documents. In addition, the policy will state the Federal requirements that are to be included in purchase orders and contracts.

Auditor’s Recommendation: The Organization should develop and document procurement procedures that meet state, local, and Uniform Guidance requirements. 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. Corrective Action: Implement Policy A10 – “Grant Management Protocols.” Utilize Donor Database for managing subawards. Responsible for Corrective Action: Finance Team (Outsourced accounting firm, Operations Manager, Executive Director) Anticipated Completion Date: December 31 2024

Finding 2023-005: Internal Control Deficiency and Noncompliance Over Procurement Federal Grantor: United States Department of Health and Human Services Assistance Listing No.: 93.048 Summary of Finding: AdviseWell, Inc. did not have internal controls in place throughout the audit period to sufficiently document the history of procurement, including the rationale for the method of procurement, selection of contract type, contractor selection or rejection, and the basis for the contract price or sole source justification if warranted. Additionally, management did not have evidence of internal controls being in place throughout the audit period to document that vendors were not suspended or debarred prior to entering into a procurement transaction. AdviseWell, Inc. did not have or use documented procurements procedures throughout the audit period. Corrective Action Plan: Internal controls were implemented in October 2023 following the 2022-04 finding, to ensure that sufficient documentation of history of procurement, including the rationale for the method of procurement, selection of contract type, contractor selection or rejection of, and the basis for contract price; ensure vendors are not suspended or debarred prior to entering into the procurement process; and document these procurement procedures with an annual review of these with staff. Responsible Party: Sonja Landry, Executive Director Anticipated Completion Date: Completed October 2023

FINDING 2023-004 Finding Subject: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds – Procurement and Suspension and Debarment Summary of Finding: Suspension and Debarment – Allen County did not have documentation that vendors’ suspension and debarment status were verified through either a) checking the Excluded Parties List System (EPLS), b) collecting a certification, or c) adding a clause or condition to the covered transaction agreement. Procurement – Allen County did not ensure purchases between $10,000 and $150,000 had received the adequate number of quotes or documented why an adequate number of quotes was not received. Contact Person Responsible for Corrective Action: Chris Cloud, Chief of Staff Contact Phone Number and Email Address: 260-449-4752 / chris.cloud@allencounty.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: To correct Finding 2023-004 for Suspension and Debarment, the Chief of Staff to the Board of Commissioners will check the EPLS on SAM.gov every time a contract is placed before the Board of Commissioners for signature not containing the appropriate suspension and debarment language or a county department starts a project with a vendor using State and Local Fiscal Recovery Funds (SLFRF). If a vendor is not found in EPLS, a certification will be solicited from the vendor prior to contract signing or purchase of goods or services verifying that they have not been suspended or disbarred. A new verification must be sought for every contract or purchase. Documentation will be kept on file by the Controller to the Board of Commissioners who is responsible for reviewing claims submitted for payment utilizing SLFRF. To correct Finding 2023-004 for Procurement, the Chief of Staff to the Board of Commissioners will instruct departments who may be spending between $10,000-$150,000 of SLFRF that price or rate quotations must be obtained from an adequate number of qualified sources. When departments submit a claim to the Controller of the Board of Commissioners for payment, they must also provide a cover sheet outlining a) rationale for the method of procurement, b) copies of quotes received, and c) a justification for the selected vendor. This information will be reviewed and if everything is in order, the cover sheet will be uploaded, along with the accompanying invoices, in the Workflow payment system as part of the record. Anticipated Completion Date: This CAP will be completed by December 31, 2024

Significant Deficiency and Noncompliance – Procurement Documentation Statement of Condition/Criteria: Delta County is not following its procurement policy and is therefore not meeting the requirements of 2 CFR section 200.318 to use documented procurement procedures. The County does not have controls in place to ensure that written records are maintained sufficient to detail the history of procurement including the rationale for the method of procurement, selection of contract type, contractor selection or rejection, and the basis for the contract price. The County did not maintain documentation to sufficiently support a written price analysis on one procurement tested. The County was unable to provide proposals from nonwinning bidders and/or a price analysis when only one bid was received on two contracts tested. The County does not have formal procedures or controls in place to ensure written documentation of a cost analysis or a contract file are maintained. Planned Corrective Action: County management has started to develop controls to ensure the procurement policy is followed and will continue to develop controls to ensure that complete contract files with a price analysis are maintained. Contact person responsible for corrective action: Ashleigh Young, County Controller/Administrator Anticipated Completion Date: March 2025

CLIENT PLANNED ACTION: When a new federally funded construction project or purchase is in the planning stage that is in the price range of $10,000 to $250,000(a small purchase), the Director of Facilities and/or the Purchasing agent will send out solicitations including specs via letter, email or by phone to multiple vendors. They may also look up vendor pricing on the internet. After the quotes are received, they will forward them to the CFO or Director of Finance who will then evaluate the quotes and decide on a vendor. Before the vendor is notified, the business office staff will check SAM.gov for federal disbarment or suspension. The SAM.gov verification will be saved in the accounting vendor files. Copies of the quotes will also be filed in the accounting office. CLIENT RESPONSIBLE PARTY: Name of Contact Person: David A. Goff, MBA Vice President of Administration and Chief Financial Officer. 4851 Independence Street, Wheat Ridge, CO 80033. 303-432-5164, Davidg@jcmh.org COMPLETION DATE: 9/1/2024

Contact Person LeAnn Littlewolf, Executive Director Corrective Action Plan We are in the process of updating the Organization’s written policies and procedures to include the requirements of the Uniform Guidance. Completion Date Fiscal year end 2024

CORRECTIVE ACTION PLAN (Concerning Finding 2023-007) Contact Person Responsible for Corrective Action: Carrie Castonguay, Town Manager Corrective Action: The Treasurer, Town Manager and Select Board will take the following actions to address finding 2023-007 The current Town Manager was appointed by the Select Board on August 14, 2023, and had no knowledge of this material weakness. She is an experienced Manager and drafted, has had approved, and has implemented the new Procurement Policy that addresses this deficiency. Anticipated Completion Date: This was completed January 23, 2024

CORRECTIVE ACTION PLAN (Concerning Finding 2023-004) Contact Person Responsible for Corrective Action: Carrie Castonguay, Town Manager Corrective Action: The Treasurer, Town Manager and Select Board will take the following actions to address finding 2023-004 The current Town Manager was appointed by the Select Board on August 14, 2023, and had no knowledge of this material weakness. She is an experienced Manager and has drafted, had approved and is using the new Procurement Policy that addresses this deficiency. Anticipated Completion Date: This was completed January 23, 2024.

Condition: The Authority did not utilize federal procurement requirements cited above for the tele-health services and SUD Peer Recovery Service contracted service providers utilized for the Certified Community Behavioral Health Clinics project. (no documentation for sole source, no proof that it was advertised, google search was provided from 7/24/24 is not sufficient, board cannot waive federal requirement). Recommendation: The Authority follow federal procurement as required in 2 CFR 200.319(d) for all contracts reimbursed with federal funds. Planned Corrective Action: Going forward the Authority will follow federal procurement as required in 2 CFR 200.319(d) for all contracts reimbursed with federal funds. Contact Person: Anthony Shaver, Chief Financial Officer Anticipated Completion Date: 9/30/2024

FINDING 2023-003 Finding Subject: Special Education Cluster (IDEA) - Procurement Summary of Finding: The School Corporation’s management had not developed a system of internal controls that would ensure compliance with procurement and suspension and debarment compliance requirement. Contact Person Responsible for Corrective Action: Tracey Haas, Deputy Treasurer Contact Phone Number and Email Address: thaas@mcas.k12.in.us (219)873-2000 ext. 8346 Views of Responsible Officials: We concur with this finding. We are working on establishing a proper system of internal controls and develop policies and procedures to ensure there are appropriate procurement procedures for goods and services. Description of Corrective Action Plan: We are working on establishing a proper system of internal control and developing policies and procedures to ensure there are appropriate procurement procedures for goods and services. We are working on a checklist for procurement for all federal grants. Moving forward we will ensure required bids and quotes are attached to the claim for payment. Anticipated Completion Date: The Anticipated date of completion for this correction is January 1, 2025.

Correction Action Planned: The contract in question was for a vendor (Healthsource Solutions) already under contract with Lubbock County Hospital District dba University Medical Center prior to the grant application. The vendor in question had been used since at least 2010, with the most recent contract for the current wellness portal (Wellness +) beginning in 2017. Because of the success of the wellness portal and established relationship with the vendor, University Medical Center included expansion of existing platforms and additional services provided by Healthsource Solutions as a large component of the Methodology/Approach in the proposed activities of the grant narrative submitted. Use of this vendor and its applications were specifically outlined in the grant project narrative and a critical component of meeting grant objectives. University Medical Center follows the Lubbock County Purchasing Guidelines, which conform to the Uniform Guidance procurement standards. University Medical Center has reviewed the specified requirements of the Office of Management and Budget Uniform Guidance for procurement standards, specifically related to noncompetitive procurement and concurs that formal procurement methods were not used for expansion of new services with this existing vendor or adequate documentation was provided for noncompetitive procurement. In order to ensure compliance with the Uniform Guidance, the University Medical Center will provide training to existing grant Program Managers on Uniform Guidance procurement standards. Additionally, if a new grant is being pursued the grant committee should receive training on Uniform Guidance procurement standards before completing grant applications. On existing or future grants, any potential contracts or purchases over $75,000 should be reviewed by the grant Program Manager (or Grant Committee lead if a Program Manager has yet been assigned) to ensure all procurement guidelines are followed and sufficient documentation is obtained prior to purchase or contract execution. Contact Person (s) Responsible for Corrective Action: Aaron Davis, VP & Chief Experience Officer Anticipated Completion Date: The Corrective Action will be immediately implemented in response to the auditors’ recommendation.

Federal Program Information Federal Agencies: Department of Health and Human Services (“HHS”) Pass-Through Entity: Virginia Department of Health Pass-Through Entity Number: Not Applicable Awards: Assistance Listing Number 93.918 - Grants to Provide Outpatient Early Intervention Services with Respect to HIV Disease (Part C) Award Periods: May 1, 2022 to April 30, 2023; May 1, 2023 to April 30, 2024 Description: Documentation of Procurement and Suspension and Debarment Type of Finding: Material Weakness in Internal Control Over Compliance Recommendation: The System should update its process to ensure documentation is retained consistent with the procurement policy and suspension and debarment for purchasing goods and/or services with federal funds. View of responsible officials: Management concurs with the finding and will implement procedures to documentation is retained to support procurement and suspension and debarment. Name(s) of the Contact Person(s) Responsible for Corrective Action: Mara Carter, Senior Director Community Health, 703-321-2687. Corrective Action Planned: Management will design and ensure written policies and procedures will be created outlining processes and control activities around procurement and suspension and debarment for purchasing goods and/or services with federal funds. Inova Juniper will ensure that documentation associated with small purchases will be maintained to include the appropriate number of quotes, contract documents and invoices. Planned Completion Date for Corrective Action Planned: Ongoing with completion date of December 31, 2024.

2023-007: Lack of Formally Adopted Procurement Policy Corrective Action: The organization has since adopted a procurement policy for federal funding in adherence with uniform guidance requirements. Given the additional policy in the organization’s fiscal policies and procedures documents, we do not anticipate any issues in lacking a formally adopted procurement policy moving forward.

Action taken: The Home will update its purchasing policy to ensure the procurement standards in 2 CFR 200.317 – 200.326 are incorporated.

FINDING 2023-004 Subject: Child Nutrition Cluster – Procurement and Suspension and Debarment Summary of Finding: The School Corporation had not designed or implemented internal controls, policies, or procedures to ensure that proper procurement procedures for small purchases were followed. Due to the lack of oversight or implemented controls small purchases paid to eight vendors totaling $180,015 were made without obtaining price or rate quotes. The School Corporation had not designed or implemented internal controls, policies, or procedures to ensure that vendors were not suspended or debarred prior to entering into a covered transaction. One covered transaction that equaled or exceeded $25,000 was identified and selected for testing. Transactions to the vendor totaled $81,295; the School Corporation did not verify the vendor’s suspension and debarment status prior to payment. Contact Person Responsible for Corrective Action: Juli Windsor Contact Phone Number:765-689-9131 Views of Responsible Official: We concur with the finding Description of Corrective Action Plan: The corporation will have adequate internal control in place and the corporation will develop a procedure to ensure rate or priced quotes are obtained for small purchases and ensure contractors are not suspended, debarred, or otherwise excluded prior to entering into any contracts or subawards. Anticipated Completion Date: April 2024

9/11 Day takes great care in evaluating and selecting vendors that support its programs, both in terms of the vendors’ abilities to deliver high quality services and their ability to do so cost effectively. For all major expenses we require advance cost estimates and competitively evaluate them. To comply fully with 2 CFR 200 9/11 Day is now in the process of adopting a formal procurement policy. It is the intention of 9/11 Day to finalize and adopt that process by 12/31/2024, and will apply it on a go forward basis to all future federally-supported procurement activities.

Incorporate a Federal Procurement Policy (Res # 24-11)