Corrective Action Plans

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.

The City recognizes the importance of internal controls and plans to enhance procedures to ensure that all purchases of goods and services under the federal award requiring a formal contract executes ones. The City believes it is prudent such awards have a contract to support purchase orders. Covid interruptions with related illnesses, early retirements, and hiring difficulties all contribute to a negative impact on productivity.

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.

Individuals Responsible for Corrective Action Plan Daniel Hall (Interim Vice President for Finance and Administration) Libby Shull, CPA (Controller) April Baur (Director of Student Financial Aid) Kevin Crider (Chief Information Officer) Vicky Wilson (Registrar) Finding 2023-008 The College did not have a formal procurement policy in place documenting procedures that conform to the procurement standards in the Uniform Guidance. Corrective Action Plan: The College obtained multiple quotes for a Wi-Fi refresh project. The Chief Information Officer, under the guidance of the Vice President of Finance and Administration, analyzed these quotes and determined that one of them most closely met the needs of the College. This quote was submitted to Laurens County as part of the ARP Infrastructure Application, prepared by the College’s Corporate & Foundation Relations Officer. After Laurens County granted the funding for the Wi-Fi project to the College, the College moved forward with the vendor and scope of work laid out in the quote. However, the College does recognize that it did not adhere to all aspects of the Federal Procurement Policy. The Vice President of Finance and Administration, along with the Controller, will both implement a procurement policy for any purchases made with Federal funds that satisfies the requirements laid out in the Federal Procurement Policy and also educate any faculty/staff involved in purchasing products/services involving Federal funds.

University of Maryland Medical System Corporation and Subsidiaries Corrective Action Plan Year Ended June 30, 2023 University of Maryland Medical System Corporation and Subsidiaries (the Corporation) respectfully submits the following corrective action plan for the year ended June 30,2023. Audit period: July 1, 2022 to June 30, 2023 FINDINGS—FEDERAL AWARD PROGRAMS AUDITS COMPLIANCE AND CONTROL DEFICIENCY IN INTERNAL CONTROL OVER COMPLIANCE 2023-001 Incomplete Federal Requirements Within Procurement Policies Assistance Listing # 21.027 – COVID-19 – Coronavirus State and Local Fiscal Recovery Funds Recommendation: The Corporation should update its procurement policy to include the provisions required by the Uniform Guidance for purchasing goods and/or services with federal funds Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: Updated Corporation Procurement Policies are drafted to satisfy the federal requirements and working through the necessary reviews. Planned completion date for corrective action plan: September 30, 2024 Name(s) of the contact person(s) responsible for corrective action: Jeff Chadwick, Financial Reporting Director, jeff.chadwick@umm.edu

Management’s Response: We concur. Views of Responsible Officials and Corrective Action: The District is actively working to develop written policies that will guide future procurement and selection of firms that participate in these federally-funded projects, including debarment and conflict of interest procedures. We plan to implement new policies by end of F& 23/24. Implementation Date: June 2024 Name of Responsible Person: Hugh Logan, General Manager

FINDING 2023-002 Finding Subject: Child Nutrition Cluster ‐ Procurement and Suspension and Debarment Summary of Finding: Procurement procedures not met – Suspension and Debarment not verified Contact Person Responsible for Corrective Action: Carrie Alford Contact Phone Number and Email Address: 812-254-5536 calford@wcs.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Washington Community Schools was under the impression that since Sodexo was the vendor for the purchases, the contract between Washington Community Schools and Sodexo was sufficient. Going forward, WCS will obtain contracts directly from the retailer even when Sodexo is the vendor in WCS files. If Sodexo makes purchases on behalf of WCS, they will obtain quotes from three retailers. WCS will request and maintain the quotes obtained by Sodexo. WCS will also check for any suspension and debarment for any vendor that Sodexo uses to purchase items for WCS. Anticipated Completion Date: 02/01/2024

FINDING 2023-008 Finding Subject: Special Education Cluster - Procurement and Suspension and Debarment Summary of Finding: An effective internal control system, which would include segregation of duties, was not in place at the School Corporation in order to ensure compliance with requirements related to the grant agreement and the Procurement and Suspension and Debarment compliance requirement. Procurement Federal regulations allow for informal procurement methods when the value of the procurement for property or services does not exceed the simplified acquisition threshold, which is set at $250,000 unless a lower, more restrictive threshold is set by a non-Federal entity. As Indiana Code has set a more restrictive threshold of $150,000, informal procurement methods are permitted when the value of the procurement does not exceed $150,000. This informal process allows for methods other than the formal bid process. The informal process is divided between two methods based on thresholds. Micro-purchases, typically for those purchases $10,000 or under, and small purchase procedures for those purchases above the micro purchase threshold, but below the simplified acquisition threshold. Micro-purchases may be awarded without soliciting competitive price rate quotations. If small purchase procedures are used, then price or rate quotations must be obtained from an adequate number of qualified sources. The School Corporation had not designed or implemented a procurement policy for the purchases in the audit period. In addition, the school corporation did not award a contract for a purchase of $75,387. Suspension and Debarment Prior to entering into subawards and covered transactions with federal award funds, recipients are required to verify that such contractors and subrecipients are not suspended, debarred, or otherwise excluded. "Covered transactions" include, but are not limited to, contracts for goods and services awarded under a non-procurement transaction (i.e., grant agreement) that are expected to equal or exceed $25,000. The verification is to be done by checking the SAMs exclusions, collecting a certification from that vendor, or adding a clause or condition to the covered transaction with that vendor. 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 $75,387; the School Corporation did not verify the vendor’s suspension and debarment status prior to payment. The lack of internal controls and noncompliance were systemic issues throughout the audit period. Contact Person Responsible for Corrective Action: Amy K. Sivley Contact Phone Number and Email Address: 260-563-2151; sivleya@apaches.k12.in.us INDIANA STATE BOARD OF ACCOUNTS 50 Views of Responsible Officials: We concur with the finding. Explanation and Reasons for Disagreement: n/a Description of Corrective Action Plan: Create internal controls (using either SAMS website, certification from vendor, or clause/condition in contract) to ensure that vendors have been vetted and have not been suspended or debarred. Also develop processes to ensure that contracts for purchases over $50,000 are approved by the School Board. Anticipated Completion Date: To begin immediately, March 2024

FINDING 2023-004 Finding Subject: Child Nutrition Cluster - Procurement and Suspension and Debarment Summary of Finding: The School Corporation had not properly designed or implemented a system of internal controls, which would include appropriate segregation of duties, that would likely be effective in preventing, or detecting and correcting, noncompliance for Procurement and Suspension and Debarment. For covered transactions, the School Corporation is required to verify that the person with whom they wish to do business with is not excluded or disqualified. In Fiscal Year 2022, there was one vendor where the School Corporation had one covered transaction in the amount of $55,285, and in Fiscal Year 2023, there were two vendors where the School Corporation had four covered transactions in the amount of $130,257. During testing and inquiry of the School Corporation, it was determined that for all three vendors who had a total of five covered transactions in the amount of $185,542 during the audit period, the School Corporation did not verify if they were excluded or disqualified prior to entering into a covered transaction. In Fiscal Year 2022, the School Corporation purchased a box truck in the amount of $55,285; however, the School Corporation did not award a contract to the vendor per Indiana Code and the School Corporation was unable to provide supporting documentation to support that three quotes were obtained prior to purchasing the box truck. Contact Person Responsible for Corrective Action: Amy K. Sivley Contact Phone Number and Email Address: 260-563-2151; sivleya@apaches.k12.in.us Views of Responsible Officials: We concur with the finding. Explanation and Reasons for Disagreement: n/a Description of Corrective Action Plan: Create internal controls (using either SAMS website, certification from vendor, or clause/condition in contract) to ensure that vendors have been vetted and have not been suspended or debarred. Also develop processes to ensure that contracts for purchases over $50,000 are approved by the School Board. Anticipated Completion Date: To begin immediately, March 2024