Corrective Action Plans

Corrective action the auditee plans to take in response to the finding: (If the auditee does not concur with the finding, the auditee must list the reasons for disagreement). Procurement The City of Grandview will update our procurement policies to comply with federal procurement requirements. The procurement policy update will include other required procedures for procuring transactions, such as contracting with small and minority business owners, women’s business enterprise and labor surplus area firms, domestic preferences, recovered materials, contract cost or price analysis and more. Going forward, the City will establish internal administrative controls to ensure that city staff receive the proper training and are aware of all procurement policies and guidelines. Suspension and Debarment The City of Grandview will establish internal controls on contract proposals exceeding $25,000, must be reviewed to ensure that contractors are not suspended or debarred. The City will verify this by adding a clause or condition into the contract that states the contractor is not suspended or debarred. The City will verify this before entering into a contract or purchasing goods and services, and it will maintain documentation demonstrating compliance with federal requirements.

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.

Type of Finding: Material Weakness in Compliance and Internal Control over Compliance Federal Agency: U.S. Department of Defense Federal Program Name: Conservation and Rehabilitation of Natural Resources on Military Installations Assistance Listing Number: 12.005 Federal Award Identification Number and Year: H79TI083313 - 2020 Award Period: September 28, 2020, through September 27, 2025 Criteria or specific requirement: 2 CFR 200.320 requires non-federal entities to have and use documented procurement procedures. 2 CFR 200.318(i) states that "the non-Federal entity must maintain record 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". In addition, 2 CFR 200.320(a)(2)(i) states that "... If small purchase procedures are used, price or rate quotations must be obtained from an adequate number of qualified sources as determined appropriate by the non-Federal entity". Furthermore, 2 CFR 200.320(b) states that "When the value of the procurement for property or services under a Federal financial assistance award exceeds the SAT, or a lower threshold established by a non-Federal entity, formal procurement methods are required. Formal procurement methods require following documented procedures. Formal procurement methods also require public advertising unless a non-competitive procurement can be used in accordance with § 200.319 or paragraph (c) of this section.". Condition: During our testing, it was noted that the Organization was not performing suspension and debarment checks prior to entering into vendor contracts to ensure the vendor was not listed in the suspended or debarred database maintained by the General Services Administration. In addition, the Organization does not have an established procurement policy nor procedures in place at the time of the audit in compliance with Uniform Guidance. Questioned costs: None. Context: For procurement, a sample of 8 was made from a population of 30 procurement transactions charged to the major program that exceeded $3,000 (the Organization's procurement policy after 2023 and below the minimum micropurchase threshold before it was increased by the FAR to $10,000 for those with a written established policy). Of the 8 sampled procurement selections, three did not retain an adequate number of price comparisons prior to exercising the procurement, four did not follow the formal procurement methods for proposals when required, and all lacked evidence of controls over procurement considerations. For suspension and debarment, a sample of 3 was made from a population of 3 (entire population) suspension and debarment transactions charged to the major program. Of the 3 sampled, all were not checked for suspension or debarment prior to entering into the transaction. Cause: Prior to completing the prior year’s audit, staff were not aware of the specific compliance requirements and procedures for procurement, suspension, and debarment status. Effect: Purchases may occur that do not follow the procurement, suspension and debarment standards as required by Uniform Guidance, and contracts to vendors that had been suspended or debarred could be awarded and not detected. Repeat Finding: The finding is a repeat of a finding in the immediately prior year. Prior year finding number was 2022-002. Recommendation: We recommend the Organization ensure its current process to review potential contractors for suspension and debarment is taking place prior to entering into transactions with such entities. The Organization has already taken steps to address considerations around procurement by implementing a Procurement Approval form. CLA recommends the use of this form, including signature, and emphasizes the importance of retaining adequate price rate quotations, RFP documentation, sole-source evidence, and price analyses in accordance with their established thresholds. Views of responsible officials: There is no disagreement with the audit finding. Action taken in response to finding: Previous corrective actions were completed in April 2024 upon receipt of our FY 2022 Audit from CLA. We believe these corrective actions would have captured most, if not all, of the findings if they were in place for the entire FY23 period. That said we have further reviewed and expanded our internal controls around procurement, suspension, and debarment, including the process for reviewing potential contractors for suspension and debarment. Specifically, we have added language in all agreement templates to ensure we are in accordance with Uniform Guidance. As noted, we have also added a procurement approval form and a standardized process for approval signature, quotes, sole source evidence and price analyses. As part of that effort, we have also updated threshold amounts for micro-purchase, small purchase, and procurement standards to be consistent with FAR and we are providing additional training to staff. Name(s) of the contact person(s) responsible for corrective action: Gary Slater Planned completion date for corrective action plan: 10/1/2024

2023-002 Coronavirus State and Local Fiscal Recovery Funds — Assistance Listing No. 21.027 Recommendation: Procurements should follow the required methods per Uniform Guidance and document the full procurement history. Procurement procedures should be designed, implemented, and written consistent with Uniform Guidance. Personnel responsible for procurement should be trained on Uniform Guidance requirements and Centro Hispano's written procurement procedures. Action Taken: Centro Hispano drafted and approved an Accounting Policies and Procedures manual in September 2024 which conforms with Uniform Guidance requirements.

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.

In responding to the findings of the audit regarding the absence of a documented procurement policy that aligns with federal statutes and procurement requirements as outlined in 2 CFR Part 200, Sigma Beta Xi, Inc. acknowledges the criticality of this oversight. We understand the importance of having formal, documented policies in place to guide our procurement processes, ensuring they are transparent, equitable, and in full compliance with federal regulations. The absence of such documentation represents a missed opportunity for our organization to institutionalize best practices and safeguard the integrity of our procurement activities. Corrective Actions and Commitments: Please let it be known prior to completion of our 2023 audit we were still in the process of finalizing our 2022 audit. Therefore, it was not a matter of willful intention in not being compliant with the Federal mandated guidance policy for Procurement and Suspension and Debarment, but a matter of timing. Research of our vendors was in the process for 2023, but documentation of the research was not being recorded. To address this finding and prevent future occurrences, Sigma Beta Xi, Inc. has taken the following steps: 1. Policy Development: We are in the process of developing a comprehensive procurement policy that will be fully documented and accessible. This policy will outline the procedures for all procurement activities, ensuring they are consistent with the requirements set forth in 2 CFR sections 200.318 through 200.326. It will reflect applicable state and local laws and regulations, as well as conform to applicable federal statutes and procurement requirements. 2. Stakeholder Engagement: Recognizing the importance of stakeholder buy-in, we will involve key personnel from various departments in the development of the procurement policy. This collaborative approach ensures the policy is comprehensive, practical, and adheres to the diverse needs of our organization while maintaining compliance with federal regulations. 3. Training and Implementation: Upon completion and approval of the procurement policy, we will conduct training sessions for all relevant staff. These sessions will cover the details of the policy, emphasizing the importance of compliance with federal statutes and the procurement requirements identified in 2 CFR Part 200. This will ensure that all team members are knowledgeable about the policy and understand their roles and responsibilities within the procurement process. 4. Monitoring and Compliance: We will establish mechanisms for monitoring compliance with the new procurement policy. This includes regular audits of procurement activities and ongoing reviews of the policy to ensure it remains current with federal regulations and best practices. 5. Documentation and Transparency: All procurement activities, especially those exceeding the simplified acquisition threshold, will be thoroughly documented, including the rationale for the procurement method used, selection of contract type, contractor selection or rejection, and the basis for the contract price. This documentation will ensure transparency and accountability in our procurement processes. Sigma Beta Xi, Inc. is committed to rectifying this deficiency by not only developing and implementing a documented procurement policy but also by fostering a culture of compliance and continuous improvement. We view the audit findings as an opportunity to enhance our operational effectiveness and ensure that our procurement practices fully support our mission to break the cycle of poverty and violence through mentoring, education, and community organizing. Our dedication to upholding the highest standards of integrity and transparency in all our operations is unwavering, as we continue to empower future professional leaders in every community we serve.

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

The Organization will document a procurement policy to ensure it fully complies with the Uniform Guidance requirements.

Management agrees with the assessment and will work to develop a procurement policy.

The Distilled Spirits Council of the U.S. recognizes the importance of implementing a procurement process in accordance with 2 CFR 200.318(a). The International Team (with feedback from the Finance Team), will adopt an updated procurement process with procedures to address various methods of procurement and ensure all vendors entered a covered transaction are not debarred, suspended,or otherwise excluded. The procurement policy was updated; however, it did not take effect until the 2024 fiscal year due to the finalization of the 2022 audit, which occurred near the end of the 2023

Written procurement procedures have been written for the Nevada Test Site Historical Foundation to ensure that procurements will be processed in conformity with 2 CFR 200.317 to 327. These procedures will be followed for procurements related to grants awarded to the entity. The dollar amount of the grant will determine the process to follow to be in compliance. Implementation of these procedures will begin as of the date of this writing.

FINDING 2023-003 Finding Subject: COVID-19 CORONAVIRUS STATE AND LOCAL FISCAL RECOVERY - PROCUREMENT AND SUSPENSION AND DEBARMENT. Summary of Finding: There were deficiencies in the internal control system of the City resulting in noncompliance with the grant’s procurement and suspension and debarment requirements. Contact Person Responsible for Corrective Action: Ashley Huffman Contact Phone Number and Email Address: 765-521-6803 nccityclerk@gmail.com Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The City did not follow its policy for Federal Grant Disbursements. The Clerk Treasurer's office will ensure compliance with the Procurement requirement. The City has implemented maintaining contract files with the Deputy Clerk Treasurer reviewing to ensure they contain documentation of the history of the procurement, including the rationale for the method of procurement and selection of the vendor. Anticipated completion date: September 1, 2024

FINDING 2023-005 Finding Subject: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds – Procurement and Suspension and Debarment Summary of Finding: Procurement - Policy The County had not established a purchasing policy that would reflect applicable state laws and regulations including procedures to avoid acquisition of unnecessary or duplicative items, procedures to ensure that all solicitations incorporate a clear and accurate description of the technical requirements for the material, product, or service to be procured and did not maintain written standards of conduct covering conflicts of interest and governing actions of its employees engaged in the selection, award, and administration of contracts. Procurement – Small Purchases The County had one vendor that was identified as being less than the simplified acquisition threshold of $150,000 but exceeding the $50,000 micro-purchase threshold. The one vendor was selected for testing. For the one vendor, the County did not obtain price or rate quotes nor was there documentation detailing the history of procurement, which must include the reason for the procurement method used. Suspension and Debarment One covered transaction paid with SLFRF grant funds was identified during the audit period. The covered transaction totaled $66,000 with $46,752 paid in the audit period. Upon review, the County had not performed procedures to ensure the vendor was not suspended or debarred, or otherwise excluded or disqualified, from participation in federal assistance programs or activities at any time during the audit period Contact Person Responsible for Corrective Action: Bryan Lewis Contact Phone Number and Email Address: 574-223-4764 and blewis@co.fulton.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The County will work on establishing a purchasing policy which will address federal procurement requirements. Before entering into contracts we will ensure the procurement procedures in the policy are followed and obtain quotes for vendors that meet the small purchase threshold as well as verify the suspension and debarment status. The Commissioners and Auditor’s office will work together to ensure requirements are met before payment is processed. Anticipated Completion Date: No later than December 31, 2024

Finding 2023-001 Procurement, Suspension and Debarment (Repeat Finding 2022-001 and 2021-001) Federal Agency: U.S. Department of the Treasury Federal Program: 21.027 Coronavirus State and Local Fiscal Recovery Funds (CSLFRF) Questioned Cost: N/A Corrective Action: a. The Purchasing Manual was revised in 2023 to incorporate procedures relating to suspension and debarment checks. Purchasing will communicate and reinforce its procurement policies and procedures to ensure compliance with applicable requirements by: Provide revised Purchasing Manual to staff with yearly reminder from Purchasing and Community Development Federal Grants Manager. b. City staff will work with the City’s Purchasing Department to follow and adhere to applicable Procurement procedures. c. Ensure all departments are following applicable procedure in a uniform manner. Contact Person: Hitesh Desai, Chief Financial Officer Anticipated Completion Date: December 31, 2024

FINDING 2023-004 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds – Procurement and Suspension and Debarment Summary of Finding: The County entered into an interlocal agreement with the City of Sullivan to procure services for a Sewer Lift Station Improvement/Line Extension to the New County Jail project. The County could not provide any documentation required to verify compliance with the procurement and Suspension and Debarment requirements for the SWIF funds spent on the project. Contact Person Responsible for Corrective Action: Amy Scarbrough Contact Phone Number and Email Address: (812)268-4491 ascarbrough@sullivancounty.in.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The County will adopt a procurement policy. In addition, the County will work with the City of Sullivan to obtain the necessary documentation related to the interlocal agreement and maintain the documentation for future audit periods. Anticipated Completion Date: October, 2024

FINDING 2023-002 Finding Subject: COVID-19 Coronavirus State and Local Fiscal Recovery Funds – Procurement and Suspension and Debarment Summary of Finding: The County had not implemented procurement policy or procedures for procuring goods and services paid with Federal funds. The County did not have policies or procedures in place to verify that the entities which they entered into covered transactions were not suspended, debarred, or otherwise excluded. Four out of seven covered transactions were selected for testing, and none of the contractors’ suspension or debarment statuses were checked prior to payment. Contact Person Responsible for Corrective Action: Pia O’Connor Contact Phone Number and Email Address: 812-379-1510 and pia.oconnor@bartholomew.in.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The Auditor’s Office will continue to work with the Commissioner’s Office and other county departments to improve upon the process of administering the COVID-19 Coronavirus State and Local Fiscal Recovery Fund. The County implemented a Procurement, Suspension and Debarment Policy; however it did not specifically reference federal funds. The County will amend the current policy to include the necessary verbiage and information related to the federal funds. By establishing this system of Internal Controls and developing the proper policies and procedures, this should help ensure contractors and sub recipients, as appropriate are not suspended, debarred or otherwise excluded prior to entering any contacts or sub awards. Anticipated Completion Date: December 31, 2024

Program 66.958 Water Infrastructure Finance and Innovation Award No: WIFIA-N18147WI Award Year: 2023 Finding 2023-001: Procurement policy and related contract Repeat finding of 2022-001Waukesha Water utility management has worked closely with WIFIA to craft contracts that include all necessary language prior to releasing RFPs for construction contracts. WIFIA was presented all service contracts to review prior to reimbursements received in fiscal year 2023. The finance department is working to update the procurement policy to ensure necessary federal language is included. The finance department will also work with service contractors to execute contract addendums

All County departments utilizing Federal dollars will be required to complete the Federally mandated procurement procedures. The County previously passed resolution #2018-868 pertaining to this requirement and will ensure all departments are following this policy moving forward.

FINDING 2023-004 Finding Subject: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds – Procurement and Suspension and Debarment Summary of Finding: Suspension and Debarment – Allen County did not have documentation that vendors’ suspension and debarment status were verified through either a) checking the Excluded Parties List System (EPLS), b) collecting a certification, or c) adding a clause or condition to the covered transaction agreement. Procurement – Allen County did not ensure purchases between $10,000 and $150,000 had received the adequate number of quotes or documented why an adequate number of quotes was not received. Contact Person Responsible for Corrective Action: Chris Cloud, Chief of Staff Contact Phone Number and Email Address: 260-449-4752 / chris.cloud@allencounty.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: To correct Finding 2023-004 for Suspension and Debarment, the Chief of Staff to the Board of Commissioners will check the EPLS on SAM.gov every time a contract is placed before the Board of Commissioners for signature not containing the appropriate suspension and debarment language or a county department starts a project with a vendor using State and Local Fiscal Recovery Funds (SLFRF). If a vendor is not found in EPLS, a certification will be solicited from the vendor prior to contract signing or purchase of goods or services verifying that they have not been suspended or disbarred. A new verification must be sought for every contract or purchase. Documentation will be kept on file by the Controller to the Board of Commissioners who is responsible for reviewing claims submitted for payment utilizing SLFRF. To correct Finding 2023-004 for Procurement, the Chief of Staff to the Board of Commissioners will instruct departments who may be spending between $10,000-$150,000 of SLFRF that price or rate quotations must be obtained from an adequate number of qualified sources. When departments submit a claim to the Controller of the Board of Commissioners for payment, they must also provide a cover sheet outlining a) rationale for the method of procurement, b) copies of quotes received, and c) a justification for the selected vendor. This information will be reviewed and if everything is in order, the cover sheet will be uploaded, along with the accompanying invoices, in the Workflow payment system as part of the record. Anticipated Completion Date: This CAP will be completed by December 31, 2024

Finding 2023-001 Internal Control over Procurement Name of Contact Person: Francis Norman Corrective Action: Procurement Policy will be updated and followed Proposed Completion Date: 7/18/2024

Corrective Action Plan: The Corporation has reviewed the current procurement standards and has identified gaps in compliance with the federal requirements. To address this, the Corporation will adopt a Procurement Policy Addendum, based on the attached draft, which includes compliance measures for: ● Small and minority business engagement ● Domestic preferences for procurements ● Recovered materials procurement ● Cost analysis for contracts over the Simplified Acquisition Threshold ● Bonding requirements for construction contracts ● Contract provisions regarding Equal Employment Opportunity, Davis-Bacon Act, and other federal mandates The attached model policy will be presented to the Board for formal adoption and will be incorporated into the Corporation's procurement procedures to ensure full compliance with 2 CFR § 200.318-326. Responsible Individual: Joseph Ninomiya - Chief Executive Officer Planned Date of Implementation: October 23, 2024

Corrective Action Plan: A new Procurement policy is currently being drafted and will be approved prior to October 31, 2024. This will include update to policies to align with Shiloh’s general purchasing policy and updated to include requirements identifies in 2 CFR 200.318 through 200.326. Individual responsible for corrective action plan: Steven Ramirez

93.493 Congressional Directives Complete documentation of vendor suspension and disbarment verification was not maintained. While outside vendor verification services were performed monthly, adequate documentation for all vendors is not provided, only vendors with suspension or disbarment issues are identified and communicated to management. Management will coordinate with appropriate departments to review federal provisions for grant procurement and adjust policies and procedures to comply. Management will work with appropriate departments and the outside vendor to identify all grant related vendors and request positive verification monthly. All grant project directors will be educated on the procurement requirements for all federal awards. Contact Person: Jane Hardy – VP Corporate Accounting jane.hardy@childrens.com Expected Completion Date: December 31, 2024