Corrective Action Plans

CONDITION: The Moniteau School District contracted with a third-party vendor (Smart Solutions Technologies) for technology equipment (Smart Boards and Mobile Carts) for the District which 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. 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. 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. RECOMMENDATION: I am recommending that the management of the School District review and update as necessary its procurement policies to ensure retention of the appropriate procurement documentation, in all instances, so as to comply with all applicable sections of the Uniform Guidance, in specifically, Section 2 CFR 200.318(i) of the Uniform Guidance. In addition, I am recommending that management contact the PA Department of Education, and explain the circumstances and oversight, and seek direction as to the allowability of this program cost in writing for their permanent files. 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 be finalized during the District’s 2024-2025 fiscal year and will be revised on an ongoing basis as required by new policy directives from oversight agencies.

Management has already been working with legal counsel and the board to develop a formal policy to put in place, with a planned implementation date of July 25, 2024.

Finding 2023-003 - Procurement, Suspension and Debarment (COVID-19 American Rescue Plan Act Local Fiscal Recovery) Significant Deficiency – Internal Control over Compliance Other Matters (Noncompliance) Description of Finding - The City’s procurement standards do not include the essential elements as outlined in 2 CFR sections 200.318 through 200.326. Statement of Concurrence or NonConcurrence - Management agrees with this finding. Corrective Action - The City has implemented a revised procurement policy which addresses the essential elements of uniform guidance, including suspension and debarment. However, the policy was not in place for all of the current year. Name of Contact Person - John Monks, Comptroller Projected Completion Date - June 30, 2024

1) Management will review procurement policies with staff 2) Timely action will be taken to solicit bids for contracts that exceed District thresholds. 3) To ensure full and open competition takes place, management will routinely review current contracts and spending reports to identify expenditures that exceed the dollar amount threshold to individual vendors. Anticipated completion date: June 30, 2024 Responsible contact person: Emily Johnson

2023-005 – Procurement Material Weakness in Internal Control over Compliance; Other Matters Procurement documentation has been developed and shared with all Department Heads along with directives of utilizing documentation to properly vet in procurement practices for any expenses over the $25,000.00 threshold. Person responsible for correction action plan: County Board Administrator Date corrective action plan is being implemented: Tuesday, June 25, 2024

Corrective Action Plan: Testing of procurement, suspension, and debarment was accomplished timely in most cases and leadership will continue to engage and teach agency staff to follow existing procurement policies to assure compliance. No further policy is necessary. Staff training will be strengthened. Responsible Individuals: Dr. Kenneth D. Varble – Vice President of Accounting Anticipated Completion Date: December 2024

Management agrees with the finding. Our current federal project is substantially completed, however, should the Township receive additional federal construction grants, the Township will implement controls to ensure verification of debarment, suspension, or exclusion takes place before entering into a covered transaction and that documentation is maintained. The anticipated date of completion is prior to receiving another federal construction grant award.

Management agrees with the finding. Our current federal project is substantially completed, however, should the Township receive additional federal grants, the Township will adopt the required written procedures. The anticipated completion date is prior to receiving another federal award.

Management thought the bidding for the Township engineer a number of years ago, met the bidding requirements. In the future, if the Township obtains any federal grant that requires engineering services, the Township will make sure that we bid engineering services. The anticpated completion date is prior to receiving another federal grant award requiring engineering services.

Finding 2023-002 U.S. Department of Education Condition: Two vendors were awarded a contract through a sole source procurement without a written determination that only one practicable source existed and the reasoning for such a determination. Corrective Action Planned: The School will implement procedures to include in its procurement files a written determination for all sole source procurements. Anticipated Completion Date: Immediately Contact: Gilbert Lefort III, Director of Finance, North Attleborough Public Schools

Views of Responsible Officials:This instance was largely due to staff turnover. ASCB will train all grant-related and all finance staff in proper processes and procedures based on contract price thresholds. This will create awareness throughout both departments which will result in everyone taking ownership of the process and not being reliant on any one staff member.

COVID-19 State and Local Fiscal Recovery Funds – Assistance Listing No. 21.027 Recommendation: We recommend the City reviews its procedures and controls over procurement to ensure that all procurements are documented such that a third party can clearly see and understand the detailed history of the procurement. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The City will work with their departments utilizing federal dollars to ensure the proper procurement method is utilized for all procurements and that documentation of that process is retained so it’s clear what considerations were made in the procurement decision. Name of the contact person responsible for corrective action: Pa Thao Planned completion date for corrective action plan: December 31, 2024.

Views of Responsible Officials: New audit procedures were established for the FY 2023 audit related to federal procurement testing that generated these findings. Management is aligned with the findings from the audit firm. We have the following takeaways. Vendor Screenings: Vendor screening procedures are part of our current procedures, but we will make process improvements:  In accordance with the Suspension and Debarment compliance requirements (section M-12 & M-14) of the USAID Cooperative Agreement, JGI-USA and JGI-Tanzania will process and retain vendor screenings before payment to vendors.  The following sources will be used for screenings:  SAM.gov  OFAC sanctions list  UN List  We will retain the evidence of the screenings, including the dates of the screenings, within our files and these will be available for subsequent audit procedures.  Our Procurement Policy in Tanzania and the USA will be updated to include these required procedures. Procurement Documentation: JGI-USA and JGI-Tanzania have procurement procedures and policies in place, but our procedures need to be updated to include some specific considerations:  When a partner or vendor is included in a proposal by name, we must prepare documentation that supports sole source procurement or a bid analysis to justify the selection of this partner. Alternatively, we may work with the donor to obtain written approval to proceed with the vendor used in proposal.  We will update our procurement manuals to include templates for sole source justifications and bid analysis to justify vendor selection and fully comply with §200.320.  Our Procurement Policies will be updated to fully comply with §200.320 and §200.213

Finding 2023-004 – Procurement Policy Criteria: In accordance with Uniform Guidance 2 CFR, Part §200.318 "General Procurement Standards", the non-federal entity must have and use documented procedures, consistent with State, local, and tribal laws and regulations and the standards of this section, for the acquisition of property or services required under a federal award or subaward. The non-federal entity's document procedures must conform to the procurement standards identified in 2 CFR, Part §200.317 - §200.327. Condition: During our review of the Coalition's Policies and Procedures, we determined that the Coalition's Procurement policy does not comply with 2 CFR, Part §200.317 - §200.327 Questioned Costs: None Cause: The Coalition was unaware of the changes in General Procurement Standards within Uniform Guidance and therefore does not have sufficiently established control policies and procedures to comply with 2 CFR, Part §200.317 - §200.327. Effect: The Coalition does not have the ability to determine if disbursements, projects, and bids comply with 2 CFR, Part §200.317 - §200.327. Recommendation: We recommend the Coalition becomes familiar with requirements of 2 CFR, Part §200.317 - §200.327. and establishes appropriate internal control policies and procedures related to procurement and that all staff be trained in those policies and procedures, so they are familiar with the requirements. We further recommend no contract or agreement be awarded by the Coalition in which appropriate procurement policies have not been followed Corrective Action: In response to the finding regarding non-compliance with procurement policies as outlined in 2 CFR, Part §200.317 - §200.327, the Coalition will take the following corrective actions: 1. Review and Update Procurement Policies: o The Coalition will conduct a comprehensive review of its current procurement policies and procedures. We will update these policies to ensure full compliance with Uniform Guidance 2 CFR, Part §200.317 - §200.327, as well as any relevant state, local, and tribal laws and regulations. o We will review and update detailed procedures. These procedures will be clearly aligned with the standards identified in 2 CFR, Part §200.317 - §200.327. 2. Training and Education: o All staff involved in the procurement process will receive training on the updated procurement policies and procedures. This training will ensure that all relevant personnel are familiar with the requirements of Uniform Guidance 2 CFR, Part §200.317 - §200.327, and understand their responsibilities in adhering to these standards. 3. Implementation of Internal Controls: o The Coalition will implement internal controls to ensure compliance with the updated procurement policies and procedures. This will include establishing a review and approval process for all procurements to verify adherence to the new standards. 4. Monitoring and Compliance Checks: o We will establish a system for ongoing monitoring and compliance checks to ensure that all disbursements, projects, and bids comply with 2 CFR, Part §200.317 - §200.327. Quarterly audits will be conducted to identify and address any deviations from the established policies and procedures. Timeline for Implementation: The corrective actions outlined above will be implemented within the next 30 days. The review and update of procurement policies and procedures will be completed within this period, and training sessions for relevant staff will be conducted immediately following the implementation of these changes. Internal controls and monitoring systems will be established concurrently. Contact Information: For further information or questions regarding this corrective action plan, please contact: Carlett Gregory, CFO, Email: cgregory@nuihc.com, 402-346-0902 x 204. Carlett Gregory Carlett Gregory CFO

Criteria: According to 2 CFR section 200.318(c) and 48 CFR sections 52.203-13 and 52.303-16, an entity should have written standards of conduct to cover conflicts of interest and govern the performance of its employees engaged in the selection, award, and administration of contracts. According to 2 CFR section 200.214, an entity is subject to the non-procurement debarment and suspension regulations. Condition: During our testing of federal award expenditures, it was noted that there were no formal written policies in place for standards of conducts covering conflict of interests for employees engaged in the selection, award, and administration of contracts nor to determine if a vendor is suspended or disbarred. Recommendation: The City should create policies and procedures for applicable requirements in order to comply with Federal regulations including procedures that cover conflicts of interest and govern the performance of its employees engaged in the selection, award, and administration of contracts and for procedures to determine whether vendors have been suspended or debarred prior to entering into contracts or purchase orders for all transactions and maintain documentation supporting this verification View of Responsible Officials and Planned Corrective Action: 1. Develop Comprehensive Policies and Procedures:  Policy Development: Create policies that align with federal, state, and municipal regulations governing conflicts of interest and employee conduct in contract selection, award, and administration.  Conflicts of Interest Policy: Define clear guidelines and procedures for identifying, disclosing, managing, and mitigating conflicts of interest among employees involved in contracting activities.  Contract Administration Procedures: Establish detailed procedures that encompass the entire contract lifecycle, ensuring compliance with federal, state, and municipal requirements at every stage.  Training and Awareness: Conduct training sessions for employees involved in contracting to ensure understanding and adherence to the newly developed policies, procedures and current bid law regulations set forth by the State of Alabama. 2. Implement Procedures for Vendor Evaluation and Debarment Checks:  Vendor Evaluation Process: Develop standardized procedures for evaluating vendors before entering into contracts, including criteria for assessing qualifications, capabilities, and compliance with regulatory requirements.  Debarment Check Procedure: Establish a systematic procedure to verify whether potential vendors have been suspended or debarred by federal, state, or municipal authorities prior to initiating contract negotiations.  Documentation Requirements: Specify the documentation that must be collected and maintained to demonstrate compliance with vendor evaluation and debarment check procedures. 3. Maintain Comprehensive Documentation:  Document Retention Policy: Create a policy outlining requirements for retaining all documentation related to contracts, including vendor evaluations, debarment checks, contract awards, modifications, and performance records.  Centralized Documentation Management: Implement a centralized system or repository for storing and managing contract-related documentation, ensuring accessibility, security, and compliance with retention policies.  Audit Trail: Maintain a clear audit trail for all contract-related activities, documenting decisionmaking processes and actions taken to ensure accountability and compliance. 4. Monitoring and Compliance Oversight:  Monitoring Mechanisms: Establish mechanisms for ongoing monitoring of compliance with federal, state, and municipal regulations, as well as internal policies related to conflicts of interest, contract administration, and vendor debarment checks.  Regular Audits: Conduct regular audits of contract management practices and documentation to identify any deviations from established procedures and regulatory requirements.  Reporting and Accountability: Implement a reporting structure that provides regular updates to management and stakeholders on compliance status, audit findings, and corrective actions taken to address deficiencies. 5. Continuous Improvement and Adaptation:  Feedback and Review: Encourage feedback from employees involved in contract management to identify opportunities for improving policies, procedures, and compliance practices.  Benchmarking: Benchmark contract management practices against industry standards, best practices, and regulatory changes to continuously enhance processes and ensure alignment with evolving requirements.  Adaptation to Changes: Stay informed about updates and changes in federal, state, and municipal regulations impacting conflicts of interest, contract administration, and vendor management, and update policies and procedures accordingly.

2CFR 320, Methods of Procurement Standards are to be followed by each department requesting federal award. The County Auditor has instructed our employees and admin people of the changes made to our system to be followed for methods of procurements. County Auditors have provided an easy sheet to be followed and dated to be turned into the auditor's office to be approved prior to purchases as to see all steps have been completed of the procurement policy prior of purchasing items on any federal award. All items by County Auditor will be processed and looked at again prior to a check written.

Action Plan: Upon learning of this finding during the FY2022 audit, we worked with our external consultant, our Council auditors and our external auditor to reperform and review the base year and subsequent year calculations of revenue, using financial information in our final audit reports. These corrected calculations of lost revenue have been clearly documented and will be reported going forward. We will continue to work to ensure that all controls for grants be documented with written procedures. The procedures will include the title of the positions responsible for each control (preparation, review, reconciliation, etc.) and will require that the performance of the controls be documented in a clear, reperformable manner including the name of each responsible individual, the specific control they performed over compliance for the grant and the date(s) the controls were performed. Contact Names responsible for the plan – Marcia Saulo Anticipated completion date of the plan – September 30, 2024

Finding 2023-001 – I. Procurement, Suspension and Debarment Information on the federal program: Grantor: Department of Treasury Program Name: COVID-19 – Coronavirus State and Local Recovery Funds Assistance Listing No.: 21.027 Views of responsible officials and planned corrective actions: Management concurs with this finding and is currently drafting a procurement policy to incorporate the provisions required by the Uniform Guidance for purchasing goods and/or services with federal funds. Name of responsible official: Devin Murphy AVP, Accounting & Strategic Projects Email: Devin.Murphy@nuvancehealth.org Projected completion date: March 31, 2025

Corrective Action Plan: Management has implemented controls to support the requirement to receive multiple number of price quotes for any purchases over the required threshold. Anticipated Corrective Action Plan Completion Date: Ongoing. Contact Information: For additional information regarding this finding please contact Jodi Bauer, Chief Financial Officer, at 414-316-5028.

National Health Foundation and Subsidiary Corrective Action Plan For the Fiscal Year Ended December 31, 2023 U.S. Department of Housing and Urban Development Federal Awards Finding Item 2023-001 – Procurement and Suspension and Debarment – Significant Deficiency over Internal Controls over Compliance Conditions – The auditors selected two out of a universe of three vendors that had covered transactions over the covered transactions threshold. National Health Foundation and Subsidiary was unable to provide supporting evidence documenting that it had verified either entity was not excluded or disqualified before National Health Foundation and Subsidiary went under contract with those vendors. However, a subsequent review did show both vendors were not on the excluded or disqualified listing. The written policies at National Health Foundation and Subsidiary include the requirement to attach evidence of the debarment verification when submitting an invoice for payment. The procurement policy effective during the audit period did not include the required written ethics and conflicts of interest standard to avoid actual or apparent conflict of interest involving expenditures of federal grant awards. National Health Foundation and Subsidiary has a conflict-of-interest policy for employees to adhere to however, the specific consideration for anyone who participates in the selection, awarding, or administration of a contract with federal funding was not included. Corrective Action Plan: National Health Foundation will update the existing procurement policy and conflict-of-interest policy to strengthen compliance with federal funding guidelines. A checklist will be created and kept on file for vendors over $25,000. Checklist to include the following: 1) list of vendors and their proposal/quotes, 2) list of employees involved in the decision process and verified that no conflict of interest between employees and vendors under consideration, 3) document vendor selected, and 4) check federal site that the selected vendor is not suspended or debarred from federal contract. Name of Contact Person: Dr. Felita Jones, CEO/President (FJones@nhfca.org) Kristina Tran, CFO/Sr. Vice President Finance (ktran@hasc.org) Projected Completion Date: June 30, 2024

FINDING NO 2023-001 Significant deficiency in Internal Control Over Compliance – Improve Control and Documentation over Procurement Detail of Finding and Planned Corrective Action Plan During the single audit it was discovered that a summary of bid quotes for one of the items selected for procurement testing was not available. The project selected had initially begun in FY2017 before the Town implemented its procurement tracking system. The individual in charge of the project had resigned and although the Technology Department tried to do a search of the employee’s email, the documentation was not found. The Town maintains an online procurement folder (by fiscal year) available to all departments to store all procurement information by project. The Town views this particular finding as an unfortunate exception to the procedures and policies that it has put into place to procure everything properly during FY2020. The Town will continue to follow all procurement guidelines and store all procurement documentation in a centralized location so that this finding does not happen again. Contact Dan O’Donnell – Finance Director Jesse Beyer – Town Accountant Completion Date (expected) These procedures and policies mentioned above related to procurement are expected to be implemented before the completion of June 30, 2024.

Failure to Follow Procurement Policy Finding 2023-003 Auditor Description of Condition and Effect: The Authority did not comply with the current procurement policy as procedures were not fully followed and required forms were not completed. The following forms required by either 2 CFR 200 and/or the Authority’s own procurement policy were not completed for the current year capital asset purchases: Written Record of Procurement Checklist Form, Method of Procurement Decision Matrix, Advertisement and Solicitation Form, Bid Quotations, Fewer Than 3 Offers Received Evaluation if applicable, Proposal Tabulation, Certification of Compliance with Federal Clauses for the assets less than $25,000, Responsibility Determination (sam.gov debarred verification), and Cost/Price Analysis. Also, as stated in the prior finding, the procurement policy needs to be updated. As a result, the Authority is noncompliant with 2 CFR 200 and its own procurement policy. Auditor Recommendation: We direct the Authority to implement procedures to ensure that the fiscal year 2022 is certified within the required nine-month deadline. Corrective Action Plan: The Authority will review and update its procurement policy to comply with federal requirements. The Authority’s management, consultant, and finance director will review the procedures in the policy to ensure they are being acted upon accordingly going forward. Responsible Official: Contact person is Rufus Adams, Executive Director,275 East Wall Street, P.O. Box 837, Benton Harbor, Michigan 49023. Telephone (269) 927-2268. Due Date: September 30, 2024

Federal Aid Policies Finding 2023-002 Auditor Description of Condition and Effect: The Authority’s management has completely turned over and been restructured. However, the Authority’s policies for federal aid approved in 2021 have not been revised to update for the current management structure. The policies have also not been updated for changes in the 2 CFR 200 that have occurred. As a result, the Authority is noncompliant with 2 CFR 200. Auditor Recommendation: We direct the Authority review and update all federal aid policies and implement procedures to ensure that they are being reviewed at least once a year for changes in the Authority’s management structure or changes that occur in the 2 CFR 200. Corrective Action Plan: The Authority will update their federal policies to comply with 2 CFR 200 and will review all policies on an annual basis going forward. Responsible Official: Contact person is Rufus Adams, Executive Director,275 East Wall Street, P.O. Box 837, Benton Harbor, Michigan 49023. Telephone (269) 927-2268. Due Date: September 30, 2024

American Diabetes Association (ADA) is committed to ensuring the appropriate documentation is in place to adhere to federal regulations regarding procurement, suspension, and debarment. In response to the audit finding, ADA is taking the following corrective actions to address the audit recommendations: 1) Financial Services will communicate annual reminders of the existing policy relating to procurement policies including the requirement to evaluate a firms status relating to federal suspension and debarment. 2) Federal grant program management will develop and utilize a checklist to ensure that all procurement steps are completed prior to forming a relationship with a potential vendor.

Views of Responsible Officials: NFHA will review and update its current Procurement Policies to ensure that they meet all current Federal and Uniform Guidance requirements. This will include documentation of contractor selection and single source vendor criteria. NFHA will provide additional training to all staff on the revised policies and procedures.