Corrective Action Plans

Finding 2022-002: Procurement and Suspension and Debarment - Material Noncompliance Management?s Response: Our commitment to maintaining strong financial controls and compliance with grant reporting requirements remains unwavering. In response to the audit finding and in our ongoing efforts to continually improve our internal controls and procedures, we have developed a comprehensive corrective action plan to address the noncompliance and strengthen our procurement and suspension/debarment processes: Procurement Policy Update: We have initiated a review and update of our procurement policy to ensure alignment with the Uniform Guidance Procurement Standards. This updated policy will incorporate the necessary provisions and requirements outlined in government regulations. Vendor Review Process: We have implemented a formal process to review vendor suspension and debarment status within the SAM Exclusion system prior to contracting. This process will be integrated into our procurement procedures to ensure compliance with the Uniform Guidance Procurement Standards. Training and Awareness: We will provide training sessions to staff involved in procurement processes, emphasizing the importance of adhering to the updated procurement policy and conducting thorough vendor reviews within the SAM Exclusion system. This training will enhance their understanding of the regulatory requirements and their roles in compliance. Documentation and Record-Keeping: We have established procedures for documenting and retaining records of vendor reviews within the SAM Exclusion system. This documentation will serve as evidence of our due diligence and compliance with the Uniform Guidance Procurement Standards. Monitoring and Internal Controls: We will strengthen our monitoring procedures and internal controls to ensure ongoing compliance with procurement and suspension/debarment requirements. Regular reviews will be conducted to verify adherence to the updated procurement policy and vendor review processes. Continuous Improvement: We are committed to continuous improvement in our procurement and suspension/debarment processes. We will establish a mechanism for periodic reviews of our policies, procedures, and controls to identify areas for enhancement and ensure they remain effective and aligned with the Uniform Guidance Procurement Standards. Anticipated Completion Date: Already Implemented Responsible Contact Person: Dr Malik Mamoon Munir, Global Operations Officer, +1 678-580-0853

Contact Person Responsible for Corrective Action: Natalie McGinnis, School Lunch Treasurer and Joe Sheffer, School Lunch Coordinator Contact Phone Number: 812-358-4271 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Procurement: Simplified Acquisition - The Lunch Fund Treasurer and the Food Services Director will solicit bids for purchases that exceed the simplified acquisition threshold of $150,000 and in the event that two bids are not received, we will obtain documentation and will present bids and documentation to the Board of School Trustees for their approval. Small Purchases - The Lunch Fund Treasurer and the Food Services Director will solicit quotes for purchases that fall within the small purchase threshold of $10,000 to $150,000 and in the event that two quotes are not received, we will obtain documentation and will present quotes and documentation for review by other employee with knowledge of the compliance requirement will sign as proof of review. Suspension and Debarment: For transactions considered covered transactions (purchases to vendors exceeding $25,000), the Lunch Fund Treasurer will conduct a SAM search to ensure that the vendor is not suspended or debarred and is eligible to participate in federally funded programs. Should the vendor be suspended or debarred, a contract will not be awarded. A copy will be kept in the Food Service Department. The Lunch Fund Treasurer and Food Service Coordinator or other employee with knowledge of the compliance requirement will sign as proof of review. Anticipated Completion Date: Immediate

FINDING 2022-004 Contact Person Responsible for Corrective Action: Christopher Dixon, Director of Nutrition and Sheryl Graves, Purchasing Specialist Contact Phone Number: 574-533-8631 Views of Responsible Official: We concur with the finding. Micro-Purchases The School Corporation will document the review/oversight of disbursements from program funds prior to payment. Claims will be prepared and reviewed by Christopher Dixon, Director of Nutrition, or designee, and submitted to the Accounts Payable Specialist for payment. Claims will be initialed or signed demonstrating approval of disbursements. Accounts Payable Specialist will enter claims into the financial software and pays claims after approval by the Chief Financial Officer and School Board. Documentation for claims will be kept in the business office. Small Purchases For Small Purchases, the School Corporation will obtain 3 quotes. Documentation of the 3 quotes are kept within the financial software system or electronically. For purchases about $50,000, GCS will enter into a contract with the vendor, after verifying that the vendor is not suspended or disbarred on SAM.gov. The contract will be electronically maintained by the Purchasing Specialist and uploaded to Gateway. Exceeds Simplified Acquisitions Signed and approved contracts will be maintained and filed electronically by the Purchasing Specialist. Suspension and Debarment All contracts will include documentation from SAM.gov that the vendor has not been suspended or disbarred. Anticipated Completion Date: April 2023

Finding 2022-003 Procurement, Suspension, and Debarment Material Noncompliance and Material Weakness in Internal Control over Compliance Federal Agency Name: Department of Agriculture Program Name: Child Nutrition Cluster CFDA Number: 10.553/10.555/10.555C/10.555S/10.559 Finding Summary: Eide Bailly LLP identified that the requirements of 2 CFR 200.317 through 2 CFR 200.327 were not satisfied, and the grant requirements for the procurement of food service related services were not followed. Responsible Individuals: Dr. Cory Steiner, Superintendent Corrective Action Plan: The District will review the requirements of 2 CFR 200.317 through 2 CFR 200.327 and grant provisions to ensure that all requirements are met for future periods. Anticipated Completion Date: June 30, 2023

Finding 2022-005 Procurement, Suspension and Debarment Material Weakness in Internal Control over Compliance Finding Summary: The College?s procurement policy did not include all the required elements as outlined in the Uniform Guidance. Additionally, two vendors were not verified against the central contractor registry prior to expenses incurred to ensure the vendor was not suspended or debarred. Responsible Individuals: Dr. Lane Azure, President Corrective Action Plan: Rarely does the college use unknown vendors that have been used by the college in the past. However, we will now check with SAM to determine if vendors have been debarred or suspended. Anticipated Completion Date: July 1, 2022

County Judge/Executive?s Response: The two purchases made by the county were made at different times for different items. Although both purchases were paid for at the same time, due to the fiscal court approval needed to pay the bills, neither of them separately required a bid process. The County does acknowledge the $29,999.00 price tag being close to the allowable amount to spend without bidding, however, the county would state that the purchase price was agreed upon out of good faith and with no attempt to circumvent the bidding requirements. The final $30,000.00 accounted for in this section was for the rental of a dozer. The anticipated rental time and need far exceeded initial estimates. During the initial rental period, the dozer was rented to level the new soccer field, during the work on the soccer field the adjacent land was given to the county and the work on that field exceeded the initial estimates, leading to the overage. Upon realizing the amount was getting close to the $30,000.00 bid requirement the county contacted the owner of the dozer and explained the situation. At that point the owner of the dozer made an offer to sell the dozer to the county at a discounted price which would include a portion of the balance the county already owed. The county bid the purchase of a new dozer. The only bid received by the county for a dozer was from the rented dozer's owner. The county has put into place controls that will require opening of bids no matter the anticipated and/or expected outcomes in adherence to all statutory authority.

Federal Award Finding: 2022-001 Material Weakness in Compliance and Internal Control over Compliance ? Procurement, Suspension and Debarment Standards Name and Contact Person: Sara Kinjo-Hischer, Tribal Administrator Corrective Action: Skagway Traditional Council will complete a checklist for procurement, based of Skagway Traditional Council?s procurement policies, to ensure that policies and procedures are followed including record retention to address procurement, suspension, and debarment standards of the Uniform Guidance. Proposed Completion Date: June 30, 2023

Finding 2022-001 Procurement, Suspension and Debarment (Repeat Finding 2021-001) Federal Agency: U.S. Department of the Treasury Federal Program: 21.027 Coronavirus State and Local Fiscal Recovery Funds (CSLFRF) Questioned Cost: N/A Corrective Action: We agree with the auditor?s comments, and actions stated in the recommendation. The City of Evanston will: a. Implement structures to monitor external procurement service providers to ensure their procurement methods comply with applicable federal compliance requirements by: When using an external procurement services provider, Departments will review and retain procurement method and accompanying support, specifically: method of procurement (Bid, RFP, RFQ), history of procurement and accompanying support. b. Further expand Purchasing Manual to include policies and procedures for suspension and debarment searches and retaining support for suspension and debarment check by: The Purchasing Manual was revised during 2023 to incorporate procedures relating to suspension and debarment checks. The City will expand the Purchasing Manual to require suspension and debarment check support be retained in the vendor file. c. Communicate and reinforce its procurement policies and procedures to ensure compliance with applicable requirements by: Provide revised Purchasing Manual to staff with yearly reminder from Purchasing and Community Development Federal Grants Manager. d. Centralize the procurement process to ensure all departments are following applicable procedures in a uniform manner by: City staff will work with the City?s Purchasing Department to follow and adhere to applicable Procurement procedures. Contact Person: Hitesh Desai, Chief Financial Officer Anticipated Completion Date: December 31, 2023

The GMHA procurement policy will be updated to follow the current uniform guidance guidelines. The Housing Authority will increase the dollar amount thresholds within this policy to reflect the uniform guidelines. This policy will be revised by November 30, 2023.

The following is Management's Response to the Findings Required to be Reported by the Uniform Guidance. This document was prepared by management of Oklahoma Mental Health Council d/b/a Red Rock Behavioral Health Services. 2022-001 Substance Abuse and Mental Health Services Projects of Regional and National Significance, Assistance Listing Number 93.243, U.S. Department of Health and Human Services, Award Year 2022 Finding Summary: Red Rock's procurement procedures were not adequate to meet the requirements of 2 CFR ? 200.317- .327; 2 CFR ? 200.214 - Procurement, Suspension, and Debarment Explanation of Agreement/Disagreement: Management concurs with the finding and will change Red Rock's procurement policy. Officials Responsible for Ensuring Corrective Action: Kile Kuykendall, Chief Financial Officer E-mail - kilek@red-rock.com Planned Completion for Corrective Action: Corrective action will be completed in FY 2023. Action in response to finding: Purchasing staff will be trained on federal procurement requirements and will be provided a copy of the new policy.

Finding 2022-004 Department of Education Education Stabilization Fund - Higher Education Emergency Relief Fund - Student Portion Federal Financial Assistance Listing #84.425F P425F200756-20A and P425F200756-20B Procurement, Suspension and Debarment Finding Summary: Eide Bailly LLP found that the University's procurement policy did not include all of the required elements as outlined in Uniform Guidance. Additionally, the University did not retain documentation to support the procedures it performed to ensure compliance with procurement, suspension, and debarment. Responsible Individuals: Michael Van Surksum, Vice President for Business and Finance; Elizabeth Porteous, Accountant Corrective Action Plan: Management is reviewing the Uniform Guidance set out in 2 CFR 200.317 through 200.327. 2 CFR 200 Appendix II and 2 CFR 180 and will update their policies for detailed use going forward. Anticipated Completion Date: Management hopes to have the new policy in place by December 31, 2022.

CORRECTIVE ACTION PLAN (CAP): 1. Explanation of Disagreement with Audit Finding There is no disagreement with the audit finding. 2. Actions Planned in Response to Finding High School for Recording Arts agrees with the finding and will adopt a documented procurement policy consistent with the standards of 2 CFR section 200.317 through 200.320 to use for procurement of the acquisition of property or services required under federal awards or sub-awards. 3. Official Responsible for Ensuring CAP The Executive Director and Director of Operations are responsible for ensuring corrective action of the deficiency. 4. Planned Completion Date for CAP The planned completion date for the CAP is June 30, 2023. 5. Plan to Monitor Completion of CAP The School Board Chair will be monitoring this CAP.

CORRECTIVE ACTION PLAN JUNE 30, 2022 REFERENCE: 2022-101 CFDA NUMBER 84.425D ? COVID 19 ? EDUCATION STABILIZATION FUND CFDA NUMBER 84.425U ? COVID 19 ? EDUCATION STABILIZATION FUND U.S. DEPARTMENT OF EDUCATION ? 2021 PASSED THROUGH ARIZONA STATE DEPARTMENT OF EDUCATION GRANT NUMBER: S425D210038 & S425U210038 CLIENT RESPONSE AND CORRECTIVE ACTION PLAN We concur with the condition. 1. Name of the contact person responsible for corrective action: Wendi Allardice - Superintendent Karen Hancock - Title I/ESSER Grants Manager 2. Corrective action planned: A. Protocols developed to obtain at least 3 vendor quotes for any items over 10,000 with an analysis and justification of vendor chosen. B. Protocol in place for checking for vendor suspensions or debarment prior to purchase approval. C. Monthly meeting for comparison of proposed and estimated purchases and actual purchases and charges to the Grant. 3. Anticipated completion date: Anticipated completion date for above listed plan: 08/31/2022

Finding 2022-002: Procurement Policy (Material Weakness) Information on the Federal Program: U.S. Department of State ALN 19.040 Criteria or Specific Requirement: 2 CFR Section 200.318 requires that the non-Federal entity must have and use documented procurement 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 documented procurement procedures must conform to the procurement standards identified in ?? 200.317 through 200.327. Condition: FCE does not have a formal written procurement policy that conforms to the requirements of the Uniform Guidance. As a result, no procurement files were maintained to document FCE's procurement actions. Cause: FCE has no accounting policies and procedures in place to provide guidance to management on the documentary evidence requirements in accordance with proper internal controls and the Uniform Guidance. Effect or Potential Effect: Without either a procurement policy or procurement documentation, there is a risk that FCE did not perform a proper evaluation of each potential vendor whose costs were charged to federal programs. Recommendation: FCE should develop accounting policies and procedures to provide guidance to management regarding the proper internal controls over both financial reporting and compliance with federal awards. Included in those policies and procedures should be a procurement policy that conforms to the requirements of the Uniform Guidance. Furthermore, FCE should maintain documentation in its files to provide evidence to support that it followed the procurement policy. Action Taken: FCE acknowledges the requirements of the Uniform Guidance and the non-compliance implication for Federal awards. FCE is in the process of developing and implementing a procurement policy to ensure proper competitive procedures are followed with respect to its procurements, specifically its vendors. FCE will ensure that proper documentation is maintained in its files in accordance with the policy to be implemented.

2022-004: Procurement (Significant Deficiency) Views of Responsible Officials and Planned Corrective Actions: Management concurs with the finding. The Authority implemented a procurement policy effective January 2022. Completion Date ? January 2022 Contact Person ? Jami Blosmo, Accounting Manager

FINDING 2022-007: Procurement Controls and Compliance Response: The district will comply with all regulations regarding advertisement for bid proposals in the future. This occurred during the tenure of a past Business Manager and was intended to be under the $80,000 limit. Unfortunately, the final expenditure exceeded the limit. Although the district did seek out multiple bids, it was not advertised appropriately and will be rectified in all future procurements.

DHS agrees with the finding and recommendation. DHS will remind staff via electronic memoranda to ensure compliance with federal and County procurement requirements and maintain records sufficient to detail the history of the procurement.

FINDING 2022-002 (Auditor Assigned Reference Number) Contact Person Responsible for Corrective Action: Greg Elkins, CFO Contact Phone Number: 317-485-3100 Views of Responsible Official : We concur with the finding Description of Corrective Action Plan: The Food Service Director (FSD), with assistance from the CFO, will develop a plan to secure a third vendor for kitchen equipment repairs, both for emergencies or regular maintenance repairs. The FSD and CFO will also develop a plan to solicit service plan proposals from qualified providers. The FSD and CFO will utilize approved service agreements through purchasing cooperatives, if available or, solicit responses through the public works bidding process. If a responsive responsible bidder can be secured, the service contract will be approved by the school board of trustees. Anticipated Completion Date: 7/1/2023

MCADV will make the necessary correction for compliance. As a result of the finding, Wendy Mahoney will be responsible for developing a procurement policy to guide the selection of vendors. MCADV will ensure the policy includes the periodic review of those vendors against the federal list of suspensions and debarments published on the System for Award Management website at https:sam.gov/content/exclusions. Anticipated completion date: September 30, 2023.

FINDING 2022-002 Contact Person Responsible for Corrective Action: Jim Evans Contact Phone Number: (574) 875-5161 Views of Responsible Official: We concur with the finding Description of Corrective Action Plan: This finding has been corrected by discontinuing purchases from the vendor in question for the remainder of the 2022-2023 school year. In future years, future purchases from this vendor will be limited to $9,000.00 per fiscal year. The purchases will be monitored by the Food Service Director and the Food Service Managers in each building. Anticipated Completion Date: This finding has been corrected.

FINDING 2022-002 (Auditor Assigned Reference Number) Contact Person Responsible for Corrective Action: Brook Cleaver Contact Phone Number: (765) 675-2147 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Superintendent and Treasurer will work to ensure that bids are sought and kept on file for projects exceeding the simplified acquisition threshold. Once a vendor is selected, Treasurer will search exclusions in the Sam.gov portal for vendors that may be suspended or debarred from participation in federal assistance programs and keep said documentation on file. Anticipated Completion Date: Immediately.

March 10, 2023 Federal Audit Clearinghouse Re: Corrective Action Plan for Community Action Partnership of Mercer County To whom it may concern: Views of Responsible Officials and Planned Corrective Actions: 2022-01 There is no disagreement with the audit finding regarding our procurement policies and the lack of documentation in the Weatherization file that was reviewed. The Organization will review the Procurement policies and make necessary adjustments to how we acquire services from contractors and what the thresholds are. We will also be reviewing our documentation policies in Weatherization and making the adjustments to what documents go into the consumer file. Employee Responsible for Corrective Action: Michelle Clarke Completion Date: May 31, 2023 Respectfully Submitted, Michelle Clarke VP/CFO

FINDING 2022-003 CONTACT PERSON RESPONSIBLE FOR CORRECTIVE ACTION: Lacey Sturgeon/Melissa Bell CONTACT PHONE NUMBER: 765-762-2500 VIEWS OF RESPONSIBLE OFFICIAL: We concur with the finding. DESCRIPTION OF CORRECTIVE ACTION PLAN: The Director of Food Service and Assistant Director of Food Service will review the SAM Exclusions prior to entering a financial agreement with the vendor. The Child Nutrition Secretary will review all claims to ensure no contractors are subject to non-procurement debarment suspension are used. The acquisition threshold will be monitored for all vendors by the Director of Food Service and Assistant Director. Formal bid process and awarding of contracts will be followed as federal regulations required. ANTICIPATED COMPLETION DATE: March 2023

Responsible Contact Person(s): Melinda Raines, Director of Human Resources Karen Holt, Human Resources Business Process Consultant Corrective Action Planned: Corrective Action Plan: In 2018, the Virginia Department of Social Services (DSS) implemented written procedures to administer the Conflict of Interests Act (COIA) as outlined in the Code of Virginia. While an SOEI policy was not created, the procedures were clear, documented, and administered. DSS continues to refine its written procedures and correct identified deficiencies to meet compliance with the COIA. In January 2022, DSS began the process to have oversight responsibility for the COIA reassigned to another Human Resources (HR) unit. HR continues to evaluate and update the approach used to identify and track employees in a position of trust upon hire or change in responsibilities. Prior to the annual disclosure process the SOEI coordinator will review positions against Executive Order 18 (2022) to confirm positions within the agency that are designated as positions of trust. Division directors from various areas will be consulted with to determine if any positions involving contracts, licenses, audits, budgets, policy, or grants should be designated in a position of trust. Team members from HR will review the designation list and any additions or removals from the prior year will be updated in the economic interest field in the statewide accounting system. To capture new hires and transfers in a position of trust throughout the year, the SOEI coordinator will review the new hire and transfer report for the agency twice per month. When a new hire or transfer is moving into a position of trust the employee?s information will be added into the Conflict of Interest Disclosure System. Notifications will be sent requesting the disclosure form is completed on or prior to the employee?s start date. The system will be monitored to track progress of completion. Should the employee not complete the financial disclosure, the employee?s supervisor will be notified. When new employees in a position of trust receive access to the Commonwealth of Virginia Learning Center (COVLC), they are enrolled into the conflict of interest (COI) training and provided a deadline for completing the course. The SOEI coordinator will monitor the COVLC system for completion. Should the employee not complete the orientation training, the employee?s supervisor will be notified. To improve monitoring and tracking of COI training every two years, a spreadsheet will be maintained listing training completion dates. The report will be monitored on the same schedule as the new hire and transfer report. The spreadsheet will flag a filer?s record when the most recent training date approaches the two year mark and needs to be retaken. HR will then enroll the employee in the COI training, notify the employee and the employee?s manager of the training requirement, and monitor for completion. Reassigning oversight of the COIA to another HR unit and following the updated written procedures should show considerable improvement and compliance with the agency?s monitoring of the COIA by April 1, 2024. Estimated Completion Date: 4/1/2024

2022-002 Health Centers Cluster ? Assistance Listing No. 93.224 and 93.527 Health Center Infrastructure Support ? Assistance Listing No. 93.526 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: 1) Procurement ? missing documentation for sole source purchase justification or price comparisons. Heartland?s purchasing policies and procedures were reviewed for content and clarity. In addition to the policy and procedure review, we will implement a more robust documentation, review, and approval process regarding larger purchases and sole sourcing. Purchases that are grant related and > $2,500 where the 3 bid minimum decision-making process is being waived and sole source is being utilized will be documented by the purchasing manager and reviewed, approved, and signed by our CEO as to why this is the optimal vendor (1). (See attached template) 2) Suspension and Debarment- missing documentation for quarterly review of vendors. Vendors will be reviewed on a quarterly basis to ensure that they are not on the exclusion list. The Accounting Specialist will report to the Controller on a quarterly basis regarding the status of the vendor review, and documentation of the review will be provided to the Controller at that time. Name(s) of the contact person(s) responsible for corrective action: Michael Cohlman, CFO and Tony Bartlett, Controller Planned completion date for corrective action plan: 4/1/23