Corrective Action Plans

FINDING 2022-002 Contact Person Responsible for Corrective Action: Jami Parks Contact Phone Number: 812-794-8750 Views of Responsible Official: We concur with the finding Description of Corrective Action Plan: The School Corporation will sign agreements with Food2School for all Food Service contracts to obtain quotes, these quotes will meet Procurement, Micro purchases and simplified acquisition requirements. Food2Schools will also obtain and share documentation with the school showing vendors meet suspension and disbarment requirements. Anticipated Completion Date: August 01, 2023 (Beginning of the 23/24 school years)

2022-024 Oregon Housing and Community Services Subrecipients need to be monitored to ensure compliance with procurement standards Federal Awarding Agency: U.S. Department of Housing and Urban Development Assistance Listing Number and Name: 14.231 Emergency Solutions Grants Program (COVID-19) Federal Award Numbers and Years: E-20-DW-41-0001, 2020 (COVID-19) Compliance Requirement: Procurement, and Suspension and Debarment Type of Finding: Significant Deficiency; Noncompliance Prior Year Finding: N/A Questioned Costs: N/A Criteria: 2 CFR 200.317 - .327; 2 CFR 200.332(d) Federal regulations state that non-federal entities, including subrecipients, are required to have and use procurement procedures consistent with state and local laws and regulations and that conform to the federal procurement standards identified in 2 CFR 200.317 - .327. Pass-through entities, like the department, are required to monitor subrecipients for compliance with federal regulations and the terms and conditions of the award. Inquiries and testing determined the department?s fiscal monitoring procedures, which normally include review of compliance with procurement standards, were not fully performed during the fiscal year and only 6 of 45 subrecipients were reviewed. As a result, subrecipients could be out of compliance with procurement requirements. We recommend the department ensure subrecipients are monitored for compliance with procurement requirements. MANAGEMENT RESPONSE: We agree with this recommendation. OHCS had significant staff turnover in FY22, and that coupled with the substantively increased number of subrecipients, lead to a lack of monitoring. OHCS has subsequently hired staff and established vendor relationships to perform fiscal monitoring as a backup for when staff vacancies exist. Additionally, OHCS is on track to complete fiscal and program monitoring for all subrecipients of ESG funds in FY23. Anticipated Completion Date: June 30, 2023 Contact: Dean Criscola, Controller

Audit Finding Reference Number: 2022-003 Recommendation - South Shore should develop a documented procurement policy in accordance with the uniform guidance. Corrective Action Plan - We will develop a policy as part of our overall Policy & Procedure Manual that matches all uniform guidance regulations related to procurement.

Respectfully, the school corporation does not agree with several of the findings in regards to segregation of duties and purchases. First, the SBOA auditors' told the school corporation during the 2019 audit that operating the school lunch program through the extracurricular account was not legal. The school corporation was informed that this account must be transferred to Central Office and a Corrective Action Plan must be in place. This directive was incorrect and pointed out in the official response from November 5, 2019 under IC 20-26-5-4(a)(l l). Second, segregation of duties, oversight, and approval of functions existed in 2019 and are presently occurring daily, weekly, and monthly within the cafeteria program under the corporation accounts and supervision of Central Office. Cafeteria workers record and submit timesheets of duties performed during each payroll period. The Cafeteria Director verifies and signs timesheets to be submitted to the Treasurer and Deputy Treasurer for review and payment from the Cafeteria account. A payroll docket report is sent to the Superintendent prior to payment from the bank. Prior to the 2019 audit, the High School Treasurer spent approximately two hours per day counting cash received each day from school lunches purchased. She also receipted those funds it into the software system, made deposits to the bank, paid invoices for food expenses, and processed part of payroll. Tasks conducted by the High School Treasurer were segregated by a timesheet and supervised by the High School Principal. All those tasks were shifted to Central Office in 2020 and are now segregated to the Treasurer and Deputy Treasurer. The Treasurer documents hours spent on Cafeteria accounts on a timesheet for review and signature by the Superintendent. Financial reports of expenditures and revenues are provided for review and oversight to the Superintendent and School Board at monthly board meetings. Third, RSSC has a small Central Office consisting of a Superintendent, Treasurer, Deputy Treasurer, and Secretary. It has no Assistant Superintendents, Human Resources Director, or Business Manager. Each person in Central Office wears multiple hats and performs multiple duties each day. It was noted in the Audit Report filed from July 1, 2008 to June 30, 2010 that " ...Randolph Southern School Corporation is unable, due to financial limitations, to employ additional personnel to segregate duties in our receipts and cash and investment balances. This statement would apply to all of our internal controls. " The circumstances for RSSC have not changed in the audit periods from July 1, 2010 through June 30, 2022. Corrective Action Plan: The School Board had chosen not to add additional staffing due to costs. RSSC is still unable to segregate duties for financial transactions and reporting. Fourth, the Cafeteria Program only has one full-time staff member, the Cafeteria Director. Eight part-time cafeteria workers prepare and feed up to 300 students each day. This food service program is one of the best run programs in the State oflndiana. It has not had one food preparation or sanitation violation from IDOE or Department of Health in the last 12 years. Fifth, the Cafeteria Program is economically efficient and fiscally responsible. The account carries at least a 3-month cash balance at all times. This success is a direct result of oversight by the combination of the Superintendent, Treasurer, and Cafeteria Director. RSSC adopted board policy 6114 Cost Principles-Spending Federal Funds on May 9, 2016. RSSC has had an Indirect Cost Rate in place since 2013. The adopted policy allows the school corporation to apply Indirect Costs to all federal funds including the Cafeteria account. On December 5, 2019, email communications between the Dr. Donnie Bowsman, Superintendent and Tina Herzog, IDOE Assistant Director of Operations and Food Distributions clearly state the school corporation can apply the Indirect Cost Rate to the Cafeteria account. The email communication clearly states that the high cash balance was a result of not applying the Indirect Cost Rate to the Cafeteria account (See Exhibit 1 Emails). The Indirect Rate was approved by the IDOE Office of School Finance and existed prior to the audit years being referenced in the finding. Technically, the prospective portion (going forward for the next school year) as referenced on pages 24-25 of USDA Indirect Cost Guidance Manual pertains to the 2013 Fiscal Year. Moreover, the fact was reiterated by the IDOE School Nutrition Office with email communications on December 5, 2019, not 2021 or 2022 as referenced in the finding. RSSC has not charged or recouped the Cafeteria Account the Indirect Cost rate for many years and has subsidized this account which should be independent and self-sufficient. The School Corporation did not apply the Indirect Cost Rate in 2020 or 2021 because we were not sure how many students would be eating and how fiscally sound the account would be due to students not attending school because of COVID. Corrective Action Plan: The Indirect Cost Rate will be applied and collected in the future prior to June 30 of each current fiscal year. It should also be noted that in 2021, RSSC purchased a new cafeteria dishwasher utilizing ESSER II funds. This unit was 20+ years old and needed to be replaced in order to continue feeding children and to run the food service program. This expense could have been and should have been a direct cost of $58,189 to the Cafeteria account. However, due to the unknown circumstances of COVID, the RSSC could not take a chance. The ESSER II grant is still open and we are now questioning whether this expense could be charged directly to the Cafeteria account. Those ESSER II fund could be utilized for staffing to support student learning loss and remediation. Sixth, COVID caused this financial account to increase exponentially from 2020 to 2021. ESSER funds were provided by the federal government to provide free lunches to every child which paid the food operations expenses for two school years. Student participation of eating school lunches increased during these time periods. Additionally, staff members were receiving hazard pay incentives on top of their regular hourly rate. Further, the School Corporation and Cafeteria Program took on the enormous task of feeding children over the summers of 2020 and 2021 when COVID cases were at its peak. The cafeteria personnel fed 5286 and 5740 students respectfully during those summers. The number of meals served during the summer almost equaled the total amount of meals served during the entire school year for each respective academic year. These additional meals created additional unexpected revenues for the fiscal year. The school corporation did not charge mileage for satellite lunches being delivered or indirect costs.

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.