Corrective Action Plans

2023-006 - Internal Control Over Compliance and Compliance – Procurement, Suspension and Debarment Contact: Jordan Kramer Title: Chief Financial Officer Phone Number: 202-624-7787 Anticipated Completion Date: July 2024 Management’s Corrective Action Plan NGA has always mandated that all vendors paid using federal funds be checked on SAM.gov for debarment or other issues. NGA believes this finding reflects a single isolated incident in which this check was completed, but records were not saved as a PDF within our vendor records. NGA has reiterated and retrained staff on the importance of documentation retention and ensuring that accounting staff consistently retrain these records. NGA expects this issue to have been fully addressed as of July 2024.

Introduction United Health Centers of the San Joaquin Valley (the "Organization") vigorously protests this finding. The Organization rigorously complies with not only federal and state procurement regulations, but also WIC regulations and the requirements found in the contract between the Organization and WIC. Additionally, numerous audits have been conducted by various entities (including audits by both WIC and the Health Resources and Services Administration (HRSA)) without any findings related to the Organization’s procurement. Finally, the Organization trains all individuals participating in the procurement process and provides guidance on procurement rules. Compliance with Regulations and WIC Program Contract The Organization’s compliance efforts are top tier. It uses many checks and balances to ensure compliance across the board with not only federal and state procurement regulations, but also WIC regulations and the requirements found in the contract between the Organization and WIC. It maintains written standards of conduct covering conflicts of interest and governing the actions of its employees engaged in the selection, award and administration of contracts, intentionally avoids acquisition of unnecessary or duplicative items and uses surplus items instead of purchasing items when feasible. It uses full and open competition and obtains prior written authorization from the appropriate CDPH Program Contract Manager as required. The Organization maintains a narrative description of the procurement system, guidelines, rules, or regulations that is used to make purchases, which is audited by WIC for compliance. The Organization’s contract with WIC even goes above and beyond the requirements of 2 CFR § 180.220 and §§ 200.318 through 200.327. For example, the contract requires the reporting, tagging and annual inventorying of all equipment and/or property that is furnished by CDPH or purchased/reimbursed with funds provided through the contract. Upon receipt of equipment and/or property, the Organization reports the receipt to the CDPH Program Contract Manager and receives property tags for the items, then tags and logs them. For all purchases, the Organization maintains copies of all paid vendor invoices, documents, bids and other information used in vendor selection, for inspection or audit. Justifications supporting the absence of bidding (i.e., sole source purchases) are also maintained on file by the Organization for inspection or audit. Finally, although training is not required under 2 CFR § 180.220 or §§ 200.318 through 200.327, the Organization trains all pertinent staff related to procurement, the Organization’s procurement policies and procedures, the WIC contract requirements, WIC’s regulations and Uniform Guidance. This is done to ensure compliance with the principles and requirements of each of these requirements. No Prior Audit Findings Most recently, in January 2024 the Organization’s procurement policies and procedures were comprehensively audited by the federal HRSA through an Operational Site Visit to verify the status of UHC’s compliance with the relevant statutory and regulatory requirements. The HRSA audit specifically reviewed the Organization’s procurement policies and procedures, as well as reviewed documentation related to procurements during the prior three years by evaluating ten elements. This assessment evaluated written procurement procedures to ensure compliance with federal procurement standards, including a process for ensuring that all procurement costs are allowable, consistent with federal cost principles found in 45 CFR 75 Subpart E: Cost Principles. Additionally, the audit reviewed records for procurement actions paid for in whole or in part under the federal award that include the rationale for method of procurement, selection of contract type, contractor selection or rejection, and the basis for the contract price. This review involved documentation related to noncompetitive procurements. The audit also included evaluating the Organization’s retention of final contracts and related procurement records, consistent with federal document maintenance requirements, for procurement actions paid for in whole or in part under the federal award. Another element of the audit was to ensure that all activities and reporting requirements are being carried out in accordance with the provisions and timelines of the related contract and UHC’s own policies and procedures. Following completion of the expansive audit, HRSA’s evaluation resulted in no findings related to procurement. UHC successfully met all six elements of the Operational Site Visit audit conducted by HRSA. Conclusion In conclusion, the Organization vehemently disputes the findings presented, underscoring its unwavering commitment to stringent compliance with federal and state procurement regulations, as well as the stipulations outlined in its contract with WIC. The Organization's robust compliance mechanisms, encompassing meticulous checks and balances, written standards of conduct, and adherence to full and open competition, exemplify its dedication to procurement integrity. Furthermore, the Organization's proactive measures, such as reporting, tagging, and inventorying equipment, surpass the mandated requirements, ensuring transparency and accountability. Notably, recent audits by both WIC and the Health Resources and Services Administration (HRSA) have yielded no findings pertaining to procurement, validating the efficacy of the Organization's practices. The Organization's unwavering commitment to compliance, coupled with its comprehensive procurement protocols and ongoing training efforts, unequivocally refute any assertions of impropriety. UHC will reevaluate the audit findings and may or may not adopt a Corrective Action Plan.

Going forward, the board will vet any grant offers that require a specific vendor with our legal counsel before accepting funds.

Finding 2023-002 Issue: For the procurement samples tested, Management did not provide adequate supporting documentation for the procurement including ensuring proper suspension and debarment checks were performed. Recommendation: We recommend that the Organization establish written procurement policies and procedures to ensure that Organization is in compliance with the Uniform Guidance and that all staff are trained on this policy to ensure compliance and related internal controls over compliance are operating effectively. Action Taken: Current MGHPCC policy states that criteria for approval of Purchase Orders above $25,000 include a check to ensure that the vendors are not suspended disbarred, or otherwise excluded from participating in a covered transaction as defined in 2CFR 180.220 and 2CFR 180.300. Policy has been updated to require that the check be documented by capturing a copy of the entity information database entry at www.sam.gov as part of the Purchase Order approval process for vendors who exceed the threshold defined in 2CFR 180.220 and 2CFR 180.300. The entity information database report includes a time stamp, which serves as an indication of when the database entry was checked. Completion date: The MGHPCC Controls for Federal program document was updated on March 15, 2024, and documentation has been retained for all relevant Purchase Orders subsequent to that date. If the National Science Foundation has questions regarding this plan, please contact John Goodhue by telephone at 413-552-4900 or by email at jtgoodhue@mghpcc.org.

The Organization plans to use their procurement policy to ensure they are in compliance with the procurement standards.

U.S. Department of Health and Human Services National Indigenous Women's Resource Center respectfully submits the following corrective action plan for the year ended September 30, 2023: Audit Period: October 1, 2022 to September 30, 2023 The finding from the Schedule of Findings and Questioned Costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. FINDING-MAJOR FEDERAL PROGRAMS SIGNIFICANT DEFICIENCY 2023-001 Suspension & Debarment Recommendation: We recommend the Organization increase training for those individuals involved in procurement and contract approval to ensure suspension and debarment checks are performed on all covered transactions. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: We have informed all individuals involved in procurement and contract approval of the requirement to perform suspension and debarment checks on hotel venues. Additionally, we will provide additional training to provide a better understanding of the procurement and contracting requirements. Name of the contact person responsible for corrective action: Lora Helman Planned completion date for corrective action plan: September 30, 2024 If the U.S. Department of Health and Human Services has questions regarding this plan, please contact Lora Helman at lhelman@niwrc.org.

Finding # 2023-002 Assistance Listing: 10.937 Partnerships for Climate-Smart Commodities Immaterial noncompliance over procurement The Organization’s fiscal policies and procedures does not meet the required federal standards for procurement. Corrective Action: The Organization agrees with and independently identified this issue and proactively procured services of a national non-profit focused CPA firm and has begun methodically rewriting all financial policies to ensure compliance with the Uniform Guidance. The procurement policy was updated and compliant with all Uniform Guidance requirements as of January 2024, all other policies will be updated by the end of 2024. Anticipated Completion Date: January 2024

The Organization is in the process of developing a procurement policy and suspension and debarment policies that aligns with Uniform Guidance.

Finding 2023-007: Procurement Finding: The District did not maintain adequate records for procurement transactions in the IDEA and Child Nutrition Clusters. Corrective Actions Planned: The District will train its employees on the documentation trail needed for procurement actions and review its policies and procedures for any needed updates. Expected Implementation Date: June 30, 2024 Contact Person: Dr. Frank Williams

Views of Responsible Officials: The Organization will complete and implement a formal, written procurement policy.

FA 2023-002 Improve Controls over Procurement Compliance Requirement: Procurement and Suspension and Debarment Internal Control Impact: Material Weakness Compliance Impact: Material Noncompliance Federal Awarding Agency: U.S. Department of Education Pass-Through Entity: Georgia Department of Education Assistance Listing Number and Title: 84.027 - Special Education Grants to States COVID-19-84.027 - Special Education Grants to States 84.173 - Special Education Preschool Grants COVID-19-84.173 - Special Education Preschool Grants Federal Award Number: H027A210073 (Year: 2022), H027A220073 (Year: 2023), H027X220073 (Year: 2023), H173A210081 (Year: 2022), H173A220081 (Year: 2022), H173X220081 (Year: 2023) Questioned Costs: $88,074 Prior Year Finding: FA 2022-001 Description: A review of expenditures charged to the Special Education Cluster (Assistance Listing Numbers 84.027 and 84.173) revealed that the School District's internal control procedures were not operating appropriately to ensure that the School District's procurement procedures were followed. Corrective Action Plans: We concur with this finding and as noted it is a repeat finding from the previous year (2022). We have updated our federal purchasing policy with the following verbiage to address micro purchases. "For purchases less that $10,000, no competitive quotations will be required (micro purchase procedures). As defined by FAR 2.101, as in acquisition of supplies or services, the aggregate amount of which does not exceed the micro-purchase threshold ($10,000). For purchases between $10,000 and $250,000, price quotes from at least three qualified." Internal Controls procedures have been reviewed and will be followed to ensure that required procurement methods are being applied to each transaction and that proper documentation is maintained in the expenditure field. Transactions will be reviewed by the Program Directors to ensure that the internal control procedures are operating appropriately and in accordance with Federal Programs Uniform Guidance. Estimated Completion Date: Fiscal Year 2024 Contact Person: Trey Wood, Finance Director Telephone: 706-795-2191 ext. 1023 Email: trey.wood@madison.k12.ga.us

Finding 2023-001: Procurement United States Department of Agriculture – Child Nutrition Cluster United States Department of Agriculture – Child and Adult Care Food Program Criteria: The non-federal entity must maintain records sufficient to detail the history of procurement. These records will include, but are not necessarily limited to, the following: Rational 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)). The non-federal entity must also establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States or the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO) (2 CFR section 200.303(a)). Condition: Records detailing which vendors were contacted, when they were contacted, and support for the rationale in choosing the vendor, is not documented. Questioned Costs: None Cause: Management did not maintain a detailed history of procurement and did not document a review process. Effect: There is no reasonable assurance that the Organization managed the federal awards in compliance with federal statutes, regulations, and the terms and conditions of the federal award Recommendation: Purchasers should record, and keep on file, backup detailing which vendors were contacted, when they were contacted, support for the rationale in choosing the vendor. Management should implement a system of internal controls for this process. Planned Corrective Action: Shloma Weiss, Administrative Director, will establish and implement a process for documenting the procurement history and establishing a system of internal controls.

MANAGEMENT’S PLANNED CORRECTIVE ACTION: For noncompetitive procurement, the District will maintain records sufficient to detail the history of procurement. These records will include but are not limited to the rationale for the method of procurement, selection of contract type, contractor selection or rejection, and the basis for the contract price. The District’s timeframe for implementation is effective immediately. Currently, the District has contracted with J. Martin & Associates, LLC (JMA) to provide business office accounting services. Representatives from JMA and the rest of the business office staff will monitor the implementation of noncompetitive procurement procedures to ensure that they are followed appropriately.

Procurement Policy Action taken in response to finding: In response to the above finding related to procurement the staff team at the organization has already researched the procurement requirements and developed a policy to comply with Uniform Guidance. The policy was reviewed by all our department leaders and feedback was collected from our finance committee and implemented into the policy. The new procurement policy was presented to our Board of Directors at the same meeting as our 2023 Financial Statement Audit (May 30, 2024) and was reviewed and approved. Following approval of the policy by the Board of Directors the CFO will hold one or multiple meetings with NeighborWorks Green Bay’s leadership team to present the changes in the policy and plan any process adjustments needed to comply with the updated policy. The new policy and process changes will then be presented to all staff and specific changes will be shared then and worked through during individual team meetings for all departments to ensure the new policy is understood and will be complied with. The approved vendor list will also be developed and finalized. We expect that the new policy will be in effect and followed for all purchases within 90 days of our Board’s acceptance of the 2023 Financial Statement Audit and this corrective action plan. Since this policy will be new to our organization, the CFO will review procurement documentation in detail for all purchases over the micro-purchase threshold of $10,000 for the first three months following the implementation of the policy and then conduct a review on a sample of transactions thereafter through the end of 2024. Any deviation from the policy will result in additional training with the entire staff or specific department as applicable.

Finding Summary: During the testing performed, it was determined that documentation to support quotes, estimates, or closed bids were not maintained prior to entering into contracts. Additionally, documentation was not maintained to support that the vendors were not suspended or debarred. Responsible Individuals: Andre Stringfellow, CFO Corrective Action Plan: Procedures will be developed and staff will be trained to ensure future procurement, suspension and debarment transactions are identified and documentation is maintained to support the evaluation. Anticipated Completion Date: August 2024

Management concurs with this finding. Management is reviewing and revising its procurement policies to comply with state and local laws, the standards of the CFR, as well as reflect current operating procedures.

Management agrees with this finding. The City will update the purchasing policy to include the CFR requirements. The City has initiated to hire an adequate amount of staffing which will allow the Purchasing Department to enforce the suspension and debarment process during the procurement process; which will include checking sam.gov and other appropriate federal resources to check for vendor suspension and debarment.

1. The District will obtain more information from the Ohio Purchasing Council going forward on future projects. 2. On the purchase of a used van, the transportation supervisor searched for a van that would suit the needs for our school district. 3. Our maintenance supervisor received 2 quotes for the floor scrubbers that we purchased. The district split the order between the two vendors.

Condition: During testing we noted the Organization did not retain support showing they had searched if an entity was debarred, suspended or otherwise excluded. Planned corrective action: KYD Network and the American Rescue Plan Act (ARPA) Compliance Contractor will conduct a search to ensure all ARPA funded organizations have not been debarred, suspended, or otherwise excluded from receiving federal funds prior to receiving ARPA summer program funds. The results of the search will be included in the ARPA spreadsheet. Responsible Person: Viridiana Carvajal, Co-Executive Director, and American Rescue Plan Act (ARPA) Compliance Contractor Anticipated completion date: May 10, 2024. This action already has been implemented for the 2024 ARPA summer program.

Program Name/Assistance Listing Title: COVID‐19 Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number: 21.027 Contact Person: Melissa M. Tomlinson, CPA, CGFM, Director of Finance Anticipated Completion Date: May 2024 Planned Corrective Action: The YWCA will develop and implement formal procurement procedures aligned with federal regulations, including thresholds for prior‐purchase authorization and vendor checks for suspension and debarment. Staff training will be conducted to ensure competency, and oversight mechanisms will be strengthened through regular monitoring and integration of SAM verification processes. Comprehensive documentation and record‐keeping practices will be established, with periodic reviews to facilitate continuous improvement. Through these actions, the YWCA aims to enhance compliance with federal procurement standards and ensure transparent and accountable procurement practices.

Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: 1) A formal procurement policy will be developed and implemented at the agency’s earliest convenience, but no later than July 31, 2024. 2) Provide training to procurement personnel on the new policy and procedures. Name of the contact person responsible for corrective action: Talana Lay, Board Treasurer Planned completion date for corrective action plan: July 31, 2024 If the U.S. Environmental Protection Agency has questions regarding this plan, please call Talana Lay at 509-322-5973.

Finding Number: 2023-002 Condition: The Society did not have documentation to support that two covered transactions were checked for potential suspension or debarment before entering into the transaction. There was one covered transaction where the Society did not have documentation to support the procurement process followed or that more than one vendor was reviewed for pricing before selecting the vendor chosen. Planned Corrective Action: Staff turnover in early 2023 resulted in limited capacity for dedicated staff to check for potential suspension or debarment before adding vendors to the system. We have dedicated staff who will be managing this process going forward. The Society has written procurement policies and procedures. Key leadership stakeholders have been apprised of our policies and procedures. The Society will be implementing a training series for government funded procurement stakeholders within the Society to ensure compliance. Contact person responsible for corrective action: Dharshni Sabapathy, Senior Director of Accounting Anticipated Completion Date: April 25, 2024

Recommendation: The organization should develop and document procurement procedures that meet state, local, and Uniform Guidance requirements. The conflict-of-interest policy should be updated to include standards of conduct for those involved in procuring and to include organizational conflicts of interest. Internal controls should be designed, implemented, and documented within the procurement procedures to ensure compliance with 2 CFR sections 200.317 through 200.327. At a minimum, the procurement history including rationale for the method, procurement method support, contract selections and rejections, suspension and debarment, and bases for contract prices should be documented. Ac􀆟on Taken: BGCDC has already established a Uniform Guidance worthy procurement policy and is currently working on an update to the Conflict-of-Interest policy. These will go to our Finance Committee and Board soon for full approval as well as implementation. Leadership has been informed of this change and is already starting on the implementation as far as seeking out bids, documenting rationale, and making informed decisions. The contact person responsible for the corrective action is Wendi Speed, CFO. The anticipated completion date is June 30, 2025.

Sufficient Documentation for Noncompetitive Proposals for Pacific Fisheries Data Program, 11.437 Recommendation: CLA recommends increased internal monitoring to ensure that noncompetitive procurements are sufficiently justified and that internal Sole Source Justification Forms are completed correctly and retained for all vendors procured under noncompetitive methods. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Commission will modify its subcontractor request form and PO form to require competitive supporting documents or non-competitive justification documents to be attached with the subcontractor request or PO form. Contract Specialist and Purchasing Specialist will review request package to ensure all required paperwork completed properly before moving forward with the process. In the pipe line, Requisition Module in Navision Software will be designed to put a hard stop if a purchase order of $10,000 or greater is missing supporting document for competitive/non-competitive procurements. Name(s) of the contact person(s) responsible for corrective action: Kathy Ameral and Michael Arredondo. Planned completion date for corrective action plan: October 15, 2023

Federal Agency Name: U.S. Department of Transportation; U.S. Treasury Department; Assistance Listing Number(s): 21.027; 20.507; Program Name(s): Federal Transit Cluster - FTA 5307 CARES Act 2020; COVID-19 Coronavirus State and Local Fiscal Recovery Funds Material Weakness in Internal Control Over Compliance – Compliance Requirement – Procurement, Suspension, and Debarment Finding Summary: The City’s purchasing policy is missing elements required by Uniform Guidance, the City did not verify vendors were not suspended or debarred before entering into contracts with vendors, and elements required to be included in contracts with vendors paid using federal monies were missing from contracts. Corrective Action Planned: The City concurs with the auditors’ findings. The City is working to develop an updated purchasing policy, improve processes, and continue training staff around purchasing and contracting to ensure Uniform Guidance requirements are met, and specifically, that vendor contracts include elements required when using federal monies, and the vendors are checked against the suspended and debarred listing. Responsible Individual(s): Mark Hagedorn, Finance Manager/Treasurer; Brooks Slyter, Assistant Finance Manager Anticipated Completion Date: March 2025