Corrective Action Plans

Finding 2023-003 – COVID 19 – Coronavirus State and Local Fiscal Recovery Fund - AL No. 21.027 U.S. Department of Treasury Noncompliance and Material Weakness Related to Internal Control over Compliance of the Major Program Criteria: Non‐federal entities other than states, including those operating federal programs as subrecipients of states, must follow the procurement standards set out at 2 CFR sections 200.318 through 200.326. They must use their own documented procurement procedures, which reflect applicable state and local laws and regulations, provided that the procurements conform to applicable federal statutes and the procurement requirements identified in 2 CFR Part 200. As governmental subrecipients of states they are also required to use the same state procurement policies and procedures for federal funds as for non‐federal funds, the Town is required to follow Massachusetts General Laws, Chapter (MGL) 30(b). MGL 30(b) requires the solicitation of three written or oral quotes for procurements of supplies between $10,000 and $49,999 and sealed bids or proposals for procurements of supplies $50,000 and over. Management of the Town is also responsible for establishing and maintaining effective internal control over compliance with federal requirements that have a direct and material effect on a federal program. However, A deficiency in internal control over compliance exists when the design or operation of a control over compliance does not allow management or employees, in the normal course of performing their assigned functions, to prevent, or detect and correct, noncompliance with a type of compliance requirement of a federal program on a timely basis. Condition and Context: During fiscal year 2023, the Town did not comply with the required procurement policies and procedures in place as it related to one of the expenses charged to the major program. As the expense tested was for engineering services that would have been exempt under Massachusetts General Laws, Chapter (MGL) 30(b) (State Procurement Requirement), under federal statutes and procurement requirements for engineering services identified in 2 CFR Part 200, the Town would have been required to go out to bid for the services. Questioned Costs: $413,477.78. Cause: The noncompliance occurred because the organization mistakenly relied on Massachusetts Chapter 30B exemptions, which govern state and local procurements, and did not recognize the need to comply with the more stringent federal procurement requirements for federal fund usage. Staff members were not sufficiently aware of the specific requirements under 2 CFR Part 200 and the precedence of federal procurement regulations over state law in this context. Effect or Potential Effect: There is a risk that amounts charged to federal awards may not be in accordance with procurement, suspension, and debarment principles. Identification as a Repeat Finding: N/A Recommendation: The Town of Bellingham should address noncompliance and material weaknesses in internal controls noted above in order to ensure that procurements are conducted in accordance with federal and state requirements. Responsible for Corrective Plan: CFO Estimated Completion Date: January 2025 Action Taken: We acknowledge the audit finding regarding our reliance on Massachusetts Chapter 30B exemptions for procurement involving federal funds. We understand that federal procurement regulations under 2 CFR Part 200 take precedence over state law and that we failed fully to comply with federal requirements for competitive bidding, sole-source justification, and documentation. We are committed to addressing this issue by reviewing our procurement policies to clearly differentiate between state and federal requirements, ensuring that federal standards govern all procurement involving federal funds. We will provide additional training to staff, implement stronger documentation procedures, and review past procurement to ensure full compliance moving forward.

Plan of Action: Provided policy F2.0 Materials Management, F2.01 Vendor Selection & Discount – currently being reviewed with the board for updates, and F2.03 Inventory and Supplies, which were not provided to the auditor due to the organization’s operational error in financial policy classification. Additionally, the F2.02 Capital and Equipment policy was drafted in 2021 will be reviewed and signed by the organizational board on Aug 26, 2024. The organization acknowledges that the procurement policy was not followed for one vendor procurement in 2022 due to an administrative error. This policy will be implemented and strictly followed immediately.

Plan: Contracts are reviewed and updated annually by the compliance officer. Anticipated Date of Completion: 4/28/2025 Name of Contact Persons: Michael Holmes Management Response: Due to the repeated extensions of certain government grants and contracts, there were delays in securing contract renewals with updated budget allocations. This issue has now been addressed with the completion and submission of revised budgets and grants.

2023‐010 Procurement (Material Weakness/ Material Non‐Compliance): Since taking office in fiscal year 2024, the current Finance Director has implemented a Standard Operating Procedure (SOP) in alignment with the Procurement Policy adopted in 2022 to ensure compliance with the State Procurement Code, internal controls, and the proper segregation of duties in procurement. This SOP outlines the specific roles and responsibilities of the Certified Procurement Officer (CPO), Finance Director, City Manager, and City Council when applicable in the procurement process. In addition, a procurement workflow has been created to be utilized by the (CPO) to ensure compliance with the City of Espanola’s procurement policy, the State Procurement Code, and appropriate checks and balances at varying thresholds. The (CPO) is responsible for ensuring all policies and state procurement laws are followed throughout the process. Additionally, all documentation from initiation to the issuance of a Purchase Order (PO) is retained electronically in a complete packet for record-keeping and audit purposes. In order to address direct payment voucher controls, the City has restricted the use of direct payment vouchers for high-volume purchases. All procurements must follow the purchase order process, unless an exception is authorized in accordance with policy. The finance department has also implemented issuing procurement violations to any department head or staff who authorizes a purchase in the absence of an approved purchase order, which aligns with the 2022 Adopted Procurement Policy. By enforcing these measures, the City ensures procurement policy compliance, transparency, and financial accountability, thereby addressing the audit findings and preventing future violations.

Views of Responsible Officials: The procurement policy will be expanded for all re-procuring of longterm contracts procedures. All contracts with service providers or contractors will be reviewed and a renewal or re-procurement process will be taken care accordingly.

The College will retain all procurement documentation going forward.

Recommendation: CLA recommends ICEDC to update the procurement policy to be compliance in with Uniform Guidance and to include more rigorous documentation as required by 2 CFR sections 200.318-200.327. ICEDC needs to ensure that policy includes the need for suspension and debarment checks to be done prior to entering into a covered transaction. CLA also recommends emphasizing the importance of the procurement standards and established policy to all authorized purchasers within ICEDC. There is no disagreement with the audit finding. Action taken in response to finding: ICEDC acknowledges CLA’s recommendation regarding the need to update the procurement policy to ensure full compliance with the Uniform Guidance, specifically in accordance with 2 CFR Sections 200.318-200.327. ICEDC will further align policy with the requirements outlined in 2 CFR Sections 200.318-200.327, ensuring that all procurement processes are conducted in accordance with federal regulations. The updated policy will require that all suspension and debarment checks are conducted as per the applicable regulations and will ensure all authorized purchasers within ICEDC receive training in procurement policies when engaging in grant activities. Name(s) of the contact person(s) responsible for corrective action: Kristina Hines Planned completion date for corrective action plan: 8/31/2025

Management response/corrective action plan: The District will revise its Procurement and Purchasing policy (GAUD Policy #5, revised 7/17/2023) to ensure compliance with the Uniform Guidance Procurement Standards 2 CFR Sections 200.318 through 200.327.

The Wilmington Land Bank rectified this finding during 2024. The Land Bank Board of Directors adopted a new procurement policy that complies with federal requirements in 2 CFR Part 200 Subpart D as well as local and state requirements. The Land Bank is maintaining a procurement file as required by this policy.

Community Health Centers of Arkansas, Inc. Responsible Party: Tafta McCain Audit Period Ending: June 30, 2023 Management's Response to Audit Condition Reference Number: 2023-005 Criteria – Procurement (2 CFR 200.318) The recipient or subrecipient must maintain and use documented procedures for procurement transactions under a Federal award or subaward, including for acquisition of property or services. Condition Identified – The Organization was unable to provide evidence it was in compliance with its procurement policy. Records sufficient to detail the history of procurement including the rationale for the method of procurement, selection of contract type, contractor selection or rejection and the basis for the contract price were not retained. Management's Response – Management acknowledges the audit finding related to procurement compliance under Federal Program: Grant for New and Expanded Services under the Health Center Program (Federal Assistance Listing Number 93.527; Federal Award Year 2022-2023). We are committed to implementing corrective measures to address the identified deficiencies and ensure full compliance with 2 CFR 200.318 regulations. Corrective Actions Taken: 1. Established & Implemented Detailed Record-Keeping for Procurement Transactions: o A new accounting system with a centralized procurement tracking system has been implemented and is currently being used. Bill.com is used to record vendor invoices and procurement transactions in real time and syncs with Sage Intacct, the new accounting software implemented in January 2024. o Detailed records of all federal grant expenditures are maintained in Bill.com and monthly reconciliations are conducted in the general ledger to ensure all procurement transactions are properly classified to their specific grant by their grant ID. We believe that these actions will significantly mitigate the risks associated with the identified conditions and strengthen our internal control environment and align our procurement practices with federal regulations.

CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE Town of Eatonville January 1, 2023 through December 31, 2023 This schedule presents the corrective action the Town is planning to take for findings included in this report in accordance with Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance). Finding ref number: 2023-001 Finding caption: The Town did not have adequate internal controls for ensuring compliance with federal procurement requirements. Name, address, and telephone of Town contact person: Miranda Doll 201 Center St. W Eatonville, WA 98328 (360) 832-3361 Corrective action the auditee plans to take in response to the finding: The Town commits to developing written procurement standards in Uniform Guidance (2 CFR 200.318-327) and implementing internal controls to ensure compliance with federal procurement requirements at the Town staff level rather than relying so heavily on consultants. Anticipated date to complete the corrective action: July 1, 2025

Views of Responsible Officials and Planned Corrective Actions: The Organization will review CFR Sections 200.138 and 300.327 and develop written policies that align with the compliance requirements. Monique Johnson, Executive Director of Allen County Drug & Alcohol Consortium, is responsible for this corrective action. The anticipated completion date is June 30, 2025.

NONCOMPLIANCE WITH PROCUREMENT, SUSPENSION & DEBARMENT REQUIREMENTS, CORONAVIRUS STATE AND LOCAL FISCAL RECOVERY FUNDS, AL No. 21.027 Name of Contact Person: Michael Opie Corrective Action: Big Horn County will pass an updated Management of Federal grant Awards policy. Proposed Completion Date: March 31, 2024

CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE City of Ferndale January 1, 2023 through December 31, 2023 This schedule presents the corrective action the City is planning to take for findings included in this report in accordance with Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance). Finding ref number: 2023-001 Finding caption: The City did not have adequate internal controls for ensuring compliance with federal procurement requirements. Name, address, and telephone of City’s contact person: Finance Director Danielle Ingham 2095 Main Street Ferndale, WA 98248 (360) 384-4302 Corrective action the auditee plans to take in response to the finding: The City is currently in the process of adopting a comprehensive purchasing and procurement policy, with the goal of implementing the major components of these policies by the end of April 2025. Although the City has consistently followed established purchasing procedures, including redundant reviews and purchasing limits, these practices have occasionally varied across departments and have not been formally codified. The City acknowledges that formal adoption of purchasing policies not only ensures consistency in procurement practices across the organization but also serves as a valuable resource for employee training, particularly when making purchasing decisions that are uncommon for the jurisdiction. In recent years, the City has reexamined its broad range of financial responsibilities, including procurement, and has considered delaying the adoption of new policies until the landscape of these changes stabilizes. However, in its ongoing commitment to continuous improvement, the City has determined that adopting purchasing and procurement policies that address the majority of the City’s procurement decisions is the most effective course of action. These policies will be subject to ongoing refinement and updates over time. The City remains receptive to insights and recommendations, such as those provided by the SAO, which contribute to the enhancement of its processes. Anticipated date to complete the corrective action: April 2025.

CONDITION: The School District of the City of Monessen contracted with Johnson Controls for fire alarm upgrades, and Dagostino Electronic Services for the installation of exterior cameras. These contracts individually exceeded the Uniform Guidance micro purchase threshold of $10,000, but did not exceed the Simplified Acquisition Threshold of $250,000. The District was unable to 1) provide records sufficient to detail the history of procurement for these two contracts and 2) provide documentation to verify that price or rate quotations were obtained from an adequate number of qualified sources. CRITERIA: 24 Pa. Statutes 8.807.1 and Section 2 CFR 200.320(a)(2)(i) of the Uniform Guidance prescribes the bidding requirements for equipment, supplies, and work of any nature made by a non-federal entity whereby the cost exceeds certain dollar thresholds as adjusted periodically. In instances where the cost incurred exceeds the Uniform Guidance micro purchase threshold of $10,000 but does not exceed the Simplified Acquisition Threshold of $250,000, price or rate quotations must be obtained from an adequate number of qualified sources. In addition, as specified in 2 CFR 200. 318(i) of the Uniform Guidance, the District must maintain sufficient records to detail the history of procurement. MANAGEMENT’S CORRECTIVE ACTION PLAN: Management of the School District will review and update as necessary its procurement policies to ensure In instances where the procurement cost incurred for goods and/or services exceeds the Uniform Guidance micro purchase threshold of $10,000 but does not exceed the Simplified Acquisition Threshold of $250,000, that 1) price or rate quotations are obtained from an adequate number of qualified sources, and 2) sufficient records are maintained to detail the history of procurement. All future procurements will involve a collaboration between the District’s business office and federal programs department to ensure compliance with the District’s updated procurement policies.

CONDITION: The School District of the City of Monessen contracted with a third-party vendor (TRANE) for the performance of a construction project at the District. The contract with the third-party vendor, which was procured through a cooperative purchasing group, exceeded the threshold for competitive procurement. The District was unable to provide documentation to verify that the third-party procurement contract was competitively procured, such as a bid evaluation and public solicitation. This is a repeat finding from the 2021-2022 fiscal year – Finding 2022-001. In addition, the District did not conduct a cost or price analysis for this procurement, which was in excess of the Simplified Acquisition Threshold of $250,000. CRITERIA: 24 Pa. Statutes 751 of the Public School Code and Section 2 CFR 200.318(i) of the Uniform Guidance prescribes the bidding requirements for equipment, supplies, and work of any nature made by a school district whereby the cost exceeds certain dollar thresholds as adjusted annually for an inflation index. The construction project exceeded the simplified acquisition threshold of $250,000. As specified in 2 CFR 200. 318(i) of the Uniform Guidance, the District must maintain records sufficient to detail the history of procurement. These records will include, but are not necessarily limited to, the following: rationale for the method of procurement, selection of contract type, contractor selection or rejection, and the basis for the contract price.CRITERIA (Continued): In addition, Section 2 CFR 200.324(a) of the Uniform Guidance requires the performance of a cost or price analysis in connection with every procurement in excess of the Simplified Acquisition Threshold. MANAGEMENT’S CORRECTIVE ACTION PLAN: Management will review and update as necessary, it’s current procurement policies and procedures to ensure compliance with all applicable sections of the Uniform Guidance, in specifically, Section 2 CFR 200.318(i) of the Uniform Guidance. The timeframe for completion of this process will commence immediately with an anticipated completion date during the 2024-2025 fiscal year and will continue on an ongoing basis as required by new policy directives from oversight agencies. All future procurements will involve a collaboration between the District’s business office and federal programs department to ensure compliance with the District’s updated procurement policies.

Finding: 2023-005 • Condition: There are no written policies and procedures for allowable costs/cost principles, cash management, procurement and suspension and debarment requirements. • Planned Corrective Action: Financial policies and procedures will be created and implemented. Contact Person: Katherine Jaeger Anticipated Date of Completion: 6/30/2025

A detailed Procurement process currently exists; however, due to staff turnover we were unable locate all the procurement documentation requested. We will continue to reinforce our Procurement policy (detailed below as it relates to documentation) and now require all documentation be stored in a Central location for all applicable Finance staff. (1) Mary's Center will establish and maintain procurement records and files. The physical records will be kept in the office of the Chief Executive Officer and/or Finance office and virtual copies will be stored on the Finance shared folder. (2) Mary's Center will document in the procurement files some form of cost or price analysis made in connection with every procurement action. (3) For any contracted service (other than equipment-specific technical support), Mary's Center procurement file will include: Basis for selection of the contractor, Justification for lack of competition when competitive bids or prices are not obtained, and Basis for award cost or price. (4) These records and files will be kept in accordance with Mary's Center's Record Retention and Document Destruction Policy. Anticipated Completion Date: 3/31/2025 Responsible Contact Person: Tony Ricciardella, Interim Chief Financial Officer and Alison Roca, Controller

2023-003 Assistance Listing Number:21.027Program:COVID-19 – Coronavirus State and Local Fiscal Recovery FundsFederal Agency:U.S. Department of TreasuryPass-Through Agency:Arizona State Office of the Governor; Maricopa CountyCompliance Requirement:Procurement, suspension and debarmentCriteria or Specific Requirement:In accordance with 2 CFR § 200.318 – Procurement Standards, the Association is required to maintain records to sufficiently detail the history of each procurement transaction, including the rationale for the procurement method, contract type selection, contractor selection or rejection, and the basis for the contract price.Condition:The Association did not retain documentation regarding the procurement procedures performed over one of the vendors tested. Name of Contact Person:Debbie Hann, Interim CEOPhone Number:(602) 306-4000Anticipated Completion Date:February 2025 Views of Responsible Officials and Corrective Actions:Management agrees with the finding. To address the auditor’s recommendation, ASBA will update its policies and procedures to ensure compliance with 2 CFR § 200.318. This will include implementing a formal procurement process with clear guidelines for competitive bidding, documentation, and approvals. Management will also establish a system to monitor procurement activities regularly, ensuring ongoing adherence to the updated policies and regulations.

Views of Responsible Officials and Planned Corrective Actions: Following ICMEC's internal procurement policy and based on the Federal program’s technical specifications, ICMEC contracted an independent third party to select the recommended equipment and services using Florida Department of Law Enforcement protocols for procuring equipment.

Department of Health and Human Services, Passed Through Substance Abuse and Mental Health Services Administration, Section 223 Demonstration Programs to Improve Community Mental Health Services Listing 93.829, H79SM085287, 8/31/2022 - 8/30/2023 Procurement, Suspension and Debarment Material Weakness in Internal Control over Compliance Finding Summary: As part of the audit, Eide Bailly LLP identified that the formally documented policy did not include many of the necessary procurement provisions prior to its revision in February 2024. Provisions include a consistent control in place to check applicable vendors for potential suspension and/or debarment for covered transactions. In addition, current controls are to be documented to provide for a proper audit trail. Responsible Individual: Chief Financial Officer Corrective Action Plan: The policy was updated in February 2024 to include all federal requirements regarding procurement controls and suspension and debarment controls as proposed by the auditors. Completion Date: February 2024

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

Coronavirus State and Local Fiscal Recovery Funds -Assistance Listing No. 21.027 Recommendation: We recommend the Agency's procurement policy is updated to reflect the current federal guidelines and that policies and procedures are implemented to ensure that the history of the procurement, including the rationale for the method of procurement, selection of contract type, basis for contractor selection, and the basis for the contract price is documented as applicable (2 CFR section 200.318(i) and 48 CFR Part 44 and section 52.244-2). Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to the finding: Ventures is in the process of evaluating and updating our procurement policy and expects it to be complete by year end. We have already started making sure necessary documents needed for RFQs and RFPs are kept in a restricted access folder along with the methodologies and tabulations for the final decisions. The Executive Director will approve all final decisions on RFPs and RFQs. Name(s) of the contact person(s) responsible for corrective action: Theo Everheart and Monique Valenzuela Planned completion date for corrective action plan: 12/31/2024

Vendors will be reviewed and documented that they are not debarred, suspended, or otherwise excluded from participation in federal award programs by use of the System for Award Management (SAM), the Official U.S. Government system. Based on the timeline of the 2022 audit, many of the corrective actions were made in late Oct/November 2023.

Finding 2023-005 - Procurement Repeat Finding- See Finding 2022-007 Recommendation: We recommend that the City establish procedures to ensure that their purchasing policy follows Uniform Guidance procurement standards. Action Taken: The City does follow Uniform Guidance procurement standards. In this instance, a vendor was selected under an emergency contract basis utilizing our waiver of bids policy. The entire country was awarded ARPA funds with water and sewer lining replacement being an allowable use of these funds. Due to the fact that there are a very limited number of vendors who provide this service, and the fact that there would be a significant number of municipalities seeking this service with the influx of ARPA dollars, as well as the fact that due to supply and demand, the cost for these services were escalating rapidly, the City wanted to be one of the first to engage with a contractor in order to secure a vendor in a timely manner before we would be unable to do so since the projects are long term projects and there was a time limit on when this money would need to be spent. Therefore, we knew it would not be possible to conduct our own bid. We chose a vendor off the COSTARS contract. I have attached a copy of the ordinance where we explained to Council our concern for our securing a vendor and our need to act quickly, which is why we originally initiated the purchase from City funds, before ARPA funds were distributed, and then replaced the City funds with ARPA funds once they were received.