Corrective Action Plans

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)

Action taken in response to finding: 1. Review Current Procurement Policy: in progress a. Conduct a comprehensive review of Promise Healthcare’s existing procurement policy. b. Identify and revise and discrepancies or non-compliance with the requirements of the Uniform Guidance. c. Integrate industry best practices into revised policy to enhance compliance and efficiency 2. Training and Education: to start a. Provide training sessions for staff authorized to purchase along with relevant personnel on the revised procurement policy and procedures and raise awareness of the requirements of the Uniform Guidance and implications of non-compliance. b. Establish training on documentation standards for procurement activities including requisitions, solicitations, evaluations and contract awards. c. Establish training and procedure for retention of procurement-related documentation 3. Internal Controls and oversight: to start a. Implement mechanisms for monitoring and oversight to ensure compliance with the procurement policy. b. Conduct periodic internal audits to assess adherence to procurement procedures and identify areas for improvement or corrective action Name of the contact person responsible for corrective action: Keith Flores, CFO Planned completion date for corrective action plan: Winter 2025

Management Comments and Corrective Action: Due to the growing need to adequately care for the minors at SWK’s shelters coupled with the limitations of access to vendors caused by COVID-19, SWK utilized existing vendor to minimize significant disruptions to operations. The Organization is aware they are operating under contracts that were procured in previous years that may not have all the records maintained. Reprocuring all of these contracts at once would potentially cause disruptions in operations due to the products/services related to those vendors playing an important role in the Organization’s day-to-day operations. In April 2021, the Organization hired new procurement leadership and invested in Full Time Employees (FTEs) to develop a robust procurement department. Due to this procurement revamp, Procurement adopted a hybrid model, and Desktop Protocols were established to provide universal procedures to fulfill policy. Protocols instruct staff on obtaining three quotes and provide tools for selecting the vendor. In addition, quality protocols and tools are currently in development to verify a random sample of procurement transactions and files. The Organization still has several active contracts procured under the old policies that they are working on reprocuring as these contracts’ renewal dates arise, if not earlier. Proposed Implementation Date of Corrective Action: In process and to be completed by December 31, 2025. Person Responsible for Corrective Action: Steven Beckman, CFO

Contact Person – Scott Froemming Corrective Action Plan – Meeker Cooperative will create and implement a procurement policy that complies with state and local regulations as well as 2 CFR Part 200.317 through 200.327. Completion Date – October 31, 2024

Management will create a formal, written procurement policy. Management will also review the noncompetitive procurement procedures and will document how and why our vendor(s) meets these requirements, if applicable.

2023-001. Written Policies United States Department of Justice, Passed through New York State, Office of Victims Services Crime Victim Assistance ALN: 16.575 United States Department of Housing and Urban Development Continuum of Care Program ALN: 14.267 Condition: The Organization did not have written policies referencing these requirements. Recommendation: The Organization should update their policies and procedures manual to ensure compliance with the procurement requirements at 2 CFR 200.317-327, and the impact of 24 CFR 578.103(c). Corrective Action: The Organization will update the written policies and procedures to comply with the Uniform Guidance requirements. Responsible Contact Person(s): Dolores Kordon, Executive Director, will be responsible for resolving this matter. Anticipated Completion Date: December 31, 2024.

Views of Responsible Officials and Action Taken: We agree with the finding and recommendation and have implemented a verification step in our vendor approval and onboarding process which requires all vendors to be run through the SAM website and debarment search. We also require an annual verification to be performed for all vendors.

We value your guidance and are committed to enhancing our compliance with the Uniform Guidance. In response, we will: 1. Documentation Procedures: We will implement procedures to properly document procurement activities. This will help us maintain consistency and ensure compliance with the Uniform Guidance. 2. Monitoring and Accountability: Additionally, we will establish a system to regularly monitor our compliance with these policies and procedures. This will enable us to quickly address any issues that may arise. The Finance Department will be responsible for implementing these changes and will have everything ready before the end of 2024. We are dedicated to making these improvements and truly value your support as we work through this process. Personnel responsible: Eduardo Cedeno, Director of Finance Anticipated completion date: December 31, 2024

We understand how crucial it is to have strong policies and procedures in place. Here’s how we plan to move forward: 1. Review of Existing Policies and Procedures: We’re currently taking a close look at our existing policies and procedures to ensure they align with the Uniform Guidance. This will help us identify any gaps and make necessary updates so that we’re fully compliant. 2. Development of New Policies: Alongside this review, we will create clear and comprehensive written policies in key areas, such as: • Cash Management: Setting up procedures that comply with 2 CFR 200.305 to ensure timely payments. eCFR :: 2 CFR 200.305 -- Federal payment. • Allowability of Costs: Crafting guidelines that follow Subpart E—Cost Principles, so we can confidently determine which expenses are allowable. https://www.ecfr.gov/current/title-48/chapter-7/subchapter-E/part-731/subpart-731.7/section-731.770. • Conflict of Interest: Establishing standards of conduct that address potential conflicts and promote transparency. • Equipment and Real Property Management: Developing policies for managing equipment acquired under federal awards in line with 2 CFR 200.313(b). eCFR :: 2 CFR 200.313 -- Equipment. • Procurement Procedures: Creating clear procurement guidelines that align with 2 CFR 200.318 through 200.326 to ensure fairness and oversight. eCFR :: 2 CFR 200.318 -- General procurement standards. 3. Training and Communication: The Finance Department will be responsible for training all staff involved in managing federal awards. Training sessions will ensure that everyone understands the requirements and their roles in maintaining compliance. This training will be completed by December 31, 2024. Personnel responsible: Eduardo Cedeno, Director of Finance Anticipated completion date: December 31, 2024

Management agrees with the finding. Management will update current policies and procedures and review and enforce the polices. Management will be responsible for proper documentation and confirmation that all policies and procedures are followed. Management will confirm that all agreements, purchase orders, and contracts are properly reviewed, signed, and documented. Management will require all departments to document all procurements for goods and services with written cost and price analysis based on AAPT's dollar thresholds. Policies are in force now and documentation will be updated by the end of November 2024

Management will develop, adopt and implement a procurement policy for federal purchases that aligns with the requirement of the 2 CFR 200 Uniform Guidance. This process will include steps within the interview and application process to ensure contractors and subrecipients are eligible (not suspended, debarred, or otherwise excluded) to enter into an agreement, contract, or subaward with the City. The process will also include steps to ensure all necessary language, such as the Buy America Build America Provisions are included in the final contracts.

Management of the Town will work to adopt a formal procurement policy that is in compliance with Federal Uniform Guidance and State requirement. The Town will also assign a federal procurement leader that will help determine requirements for federal versus nonfederal awards as well as ensuring the Town's new procurement policy is followed.

Management of the City will work to adopt a formal procurement policy that is in compliance with Federal Uniform Guidance and State requirements. The City will also assign a federal procurement leader that will help determine requirements for federal versus nonfederal awards as well as ensuring the City’s new procurement policy is followed.

Finding 2023-003: Procurement The auditors noted the following areas for improvement: ● The SDA did not perform timely debarment or suspension checks for some contractors hired. ● The SDA could not justify the rationale for selection of 2 awarded contracts as part of the BGS request for qualification process. ● Note: The auditors provided a suggested recommendation to update all 1099 contract language to include reference to the specific 2 CFR 200 Appendix II reference. The auditors recommend the following: 1. Management should adhere to written procurement policies and maintain sufficient documentation, including justification memos and debarment/suspension verification, to support federally funded procurement decisions. SDA Response The SDA accepts the above findings with notes on those findings, and would like to add the following information for context: • Stronger implementation and compliance efforts are required from Management to ensure the adopted procurement procedures are followed. SDA Corrective Actions The SDA is implementing a new checklist tool to bolster compliance. This checklist will help the Director of Finance and Administration identify and correct any missing compliance well in advance of the next audit. In addition, Management is implementing a new quarterly review process to assess both compliance and financial accounts. The new quarterly review process will ensure documentation is maintained and accounted for each transaction, particularly for restricted grants, to minimize any post-close adjustments. The combination of both the new checklist tool and review process will support continued timeliness and eliminate this finding in future audits. The Director of Finance and Administration will also meet with all business line leads to provide additional training and support on the procurement process, including requesting additional information for all active contracts for 2024. Lastly, Management will immediately update 1099 contract agreements to include specific CFR language in 1099 as suggested by the auditors.

Condition Found: Vernon Homes made attempts to obtain bids for the federally funded project, however, procurement policy testing was not able to be completed as the client does not have a formal procurement policy. Individual(s) Responsible for Corrective Action: M. Bradford Ellis, Executive Director and Corby Mousseau, Director of Finance Planned Corrective Action: Vernon Homes will implement a formal procurement policy as required and outlined in the 2 CFR 200 Subpart D Section 200.317. Anticipated Completion Date: December 31, 2024

Corrective Action Planned: We will review the Uniform Guidance Standards and update the procedures needed to be in full accordance. Name(s) of Contact Person(s) Responsible for Corrective Action: Lynette Bacchus will make the changes and John Pinto and Lawrence Boord will approve. Anticipated Completion Date: October 31, 2024.

FINDING 2023-002 (Auditor Assigned Reference Number) Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds – Procurement and Suspension and Debarment Summary of Finding: The Town's policies related to SLFRF suspension and debarment requirement did not include checking the EPLS for vendor suspension and debarment. All three covered transactions tested did not have documentation provided to show the vendor was checked for suspension and debarment. Additionally, the Town did not have a formalized procurement policy outlining its processes and procedures with regards to the procurement of goods and services using federal grant funds. Contact Person Responsible for Corrective Action: Matt Sumner Contact Phone Number and Email Address: 317-732-4532, msumner@whitestown.in.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: We will be more diligent in finding out if our grants are federal and what requirements they have for us to follow. We will check applicable vendors for suspension and debarment and implement a control/review over those searches. Anticipated Completion Date: November 1, 2024

Additional training and review of the procurement process will take place. This office will coordinate with other departments with training and expectations.