Corrective Action Plans

Action Item Title 2022-003 – Procurement Policies and Covered Transactions Compliance Requirement Procurement, Suspension, and Debarment Status (Open: In-process) Condition: General Procurement Standards - Written Policies – The Corporation has an outdated institutional procurement manual approved in 2014 that lacks written policies to ascertain compliance with the provisions of federal statutes, regulations, or the terms and conditions of federal awards regarding procurement, suspension, and debarment requirements. Suspension and Debarment - Covered Transaction – From a population of nineteen disbursements, we selected nine disbursements to ascertain compliance with 2 CFR section 180.220 by examining the procurement documents provided by the Corporation. From that sample, we identified nine instances in which the SAM.gov registration verification process was not performed. Of the nine instances, we found eight suppliers properly registered, but one supplier appears as validated as unique and existing but not registered in SAM.gov. Identified root cause: Lack of understanding of procurement compliance requirements for federal awards. Fiscal year 2023 was the first year for the Corporation to be subjected to a single audit compliance requirement for receiving and expending COVID-19 public health emergency programs Grantee resolution plan: General Procurement Standards - Written Policies – With the implementation of Law No. 73 of 2019, previous processes established by regulation are repealed and rendered ineffective. In addition, the Corporation will adopt procurement policies in compliance with the federal regulations. Suspension and Debarment - Covered Transaction - Currently, the Corporation is verifying and requesting all suppliers with contracts of $25,000 and over with evidence of being active at SAM.gov. Also, the Corporation is verifying if the supplier is suspended or debarred to do business with the Federal government. Completion Date: General Procurement Standards - Written Policies – By June 30, 2025 Suspension and Debarment - Covered Transaction – Corrected in FY2023. Name and Title of contact: Linnette Dávila Alemán- Financial and Budget Assistant Manager Phone: 787-724-4747 ext. 2105 Email: ldavila@cba.pr.gov Jetppeht Pérez de Corcho Morgado – General Manager Phone: 787-724-4747 ext. 2102 Email: jperez@cba.pr.gov

Finding 2022-003 Finding Summary: In testing of procurement, suspension, and debarment, the auditors noted that the City’s procurement policy followed state law which is some cases is less restrictive than federal law. They also noted that the policy does not include the required contract provisions that are needed in contracts with federal grants. Responsible Individuals: Douglas Heinrich, Finance Officer Corrective Action Plan: We will assess if we need to adopt a policy for procurement if we receive federal grants in the future. We will be aware of the contract requirements to ensure they are included in contracts which involve federal money. Anticipated Completion Date: December 31, 2024

CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE Stevens County January 1, 2022, through December 31, 2022 This schedule presents the corrective action the District is planning to take for findings included in this report in accordance with Title 2 US. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance). Finding ref number: 2022-001 Finding caption: The County's internal controls were inadequate for ensuring compliance with federal procurement, suspension and debarment requirements. Name, address, and telephone of County contact person: Jill Jacobs, Chief Deputy Auditor 215 S. Oak St, Colville, WA 99114 509 684-7549 Corrective action the auditee plans to take in response to the finding: 1) The County has drafted and adopted Resolution 85-2023 on July 17, 2023, addressing the federal procurement standards recommendation. 2) A staff member took training on federal procurement standards and processes related to FEMA recovery efforts after a disaster and has shared the documents and training aids with staff that do federal procurement. Further, review with several staff was done related to this training to beef up internal knowledge and controls. 3) The County has trained staff on proper documentation and retention of documentation on suspension and disbarment. Further, the County is currently working on an internal policy on this subject. We expect to have this policy complete and adopted by May 31, 2024. Anticipated date to complete the corrective action: May 31, 2024

Finding 2022-002 – Special Education Cluster – AL No.’s 84.027 & 84.173 Department of Education Massachusetts Department of Elementary and Secondary Education and the Massachusetts Department of Early Education and Care Noncompliance and Significant Deficiency Related to Internal Control over Compliance of the Major Programs 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 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. 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 2022, the Town did not comply with the required procurement policies and procedures process for procurements that exceeded both State and Federal thresholds. Questioned Costs: Unknown Cause: Weaknesses in the design and operation of controls. Effect or Potential Effect: Due to the weaknesses in internal controls noted above, there is a risk that amounts charged to federal awards may not be in accordance with procurement, suspension, and debarment principles. No known questioned costs are reported, as it is not quantifiable. Identification as a Repeat Finding: Yes, finding number 2021-002 Recommendation: The Town should address the weaknesses in internal controls noted above in order to ensure that procurements are conducted in accordance with federal and state requirements. Managements Response: The Town and Schools have Acushnet’s Federal Grant Procedures Manual (February 2023) to ensure that procurements are conducted in accordance with Federal and State requirements – in particular, the procurement standards set out at 2 CFR sections 200.318 through 200.326 Responsible for Corrective Plan: Patrick McIntyre, School Business Manager Estimated Completion Date: Fiscal Year 2024 Action Taken: Procurements are conducted in accordance with Acushnet’s Federal Grant Procedures Manual which abide by Federal and State requirements – in particular, the procurement standards set out at 2 CFR sections 200.318 through 200.326

CONDITION: During my review of the District’s compliance with the requirements for noncompetitive procurement, I noted the District did not document its rationale for purchases made from four (4) vendors - CJAWS, Inc., Edmentum, Inc., Savvas Learning Company, and Technology Resource Advisors, Inc. This is a repeat finding (2021-007) from the previous fiscal year for CJAWS, Inc. CRITERIA: In accordance with Section 2 CFR 200.318(i) of the Uniform Guidance, the District must maintain records sufficient to detail the history of procurement. These records 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. Furthermore, Section 2 CFR 200.320(c’) of the Uniform Guidance details five (5) circumstances in which noncompetitive procurement can be used. RECOMMENDATION: I recommend that the School District update their policies to include those most recent related to ‘federal fiscal compliance’ in accordance with the Uniform Guidance, in particular, procurement policies to address the requirements of Section 2 CFR 200.318(i) and 320(c). In addition, I would recommend that District personnel responsible for expenditures related to federal funding receive updated training related to ‘procurement’ policies and procedures as they relate to federal funding. MANAGEMENT’S PLANNED CORRECTIVE ACTION: Management of the School District will review and update as necessary its ‘federal fiscal compliance policies’ to comply with the requirements of the Uniform Guidance. Particularly as it relates to procurement procedures, for acquisitions of property or services in which the aggregate dollar amount is greater than the micro-purchase threshold but does not exceed the simplified acquisition threshold, the District will obtain and document price or rate quotations from at least three qualified sources. In addition, management of the District will obtain training where available and applicable to enhance their internal controls over the management of federal program funds. The District’s timeframe for implementation is effective immediately.

Corrective Action Planned: The City Clerk and Mayor, with help from the Treasurer, will develop and implement documented procurement procedures that conform to the procurement standards relating to Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) 200.317 through 200.327 Name(s) of Contact Person(s) Responsible for Corrective Action: City Clerk, Kami Hoerning. City Treasurer, Karen Kipp. City Mayor, John McGinley. Anticipated Completion Date: Summer 2024

The Wilmington Land Bank is working to rectify the deficiency identified in the procurement policy and procurement action documentation finding. The Land Bank has committed to adopting a written procurement policy that will comply with federal requirements in 2 CFR Part 200 Subpart D as well as any local and state requirements. Becky Vogel, the Land Bank’s Director of Finance will create the policy, the Land Bank’s Finance Committee will review the policy, and the Land Bank’s Board of Directors will adopt the policy no later than the August 1, 2024 Board of Directors meeting.

FINDING 2022-005Contact Person Responsible for Corrective Action: Kristin CharlesContact Phone Number: 765-866-0203Views of the Responsible Official: The School Corporation is in agreement with the Finding.Description of Corrective Action Plan: We will provide additional training to our Food Service team about the processes with suspension and debarment. We had assumed we had done enough due diligence since we passed our IDOE Child Nutrition audit; on the same token that audit may not have encompassed the sample that was randomly selected by CLA. We will also add suspension and debarment language into any other contract we anyone that we enter where there is a chance that Federal Dollars could be used for the purchase.Anticipated Completion Date: ASAP

REFERENCE: 2022-018 ? Procurement and Suspension and DebarmentResearch and Development Cluster (12.420, 93.103 and 93.853)Federal Grantor: U.S. Department of Defense and U.S. Department of Health and Human ServicesFacility: St. Joseph?s Hospital and Medical CenterFinding: St. Joseph?s Hospital and Medical Center did not prepare and retain documentation of sole source justification for three procurements over the micro-purchase threshold made without competition.Corrective Action Plan: Training was provided to program and operations managers to add additional documentation to requisitions. An updated work instruction will be developed by the research administration department outlining the necessary documentation for non-competitive purchases.Person Responsible: Sheri Sanders, Division Director Research AdministrationExpected Completion: April 2023

FINDING 2022-005Subject: Child Nutrition Cluster - Procurement and Suspension and DebarmentFederal Agency: Department of AgricultureFederal Programs: School Breakfast Program, COVID-19 ? School Breakfast Program, National SchoolLunch Program, COVID-19 ? National School Lunch Program, Summer Food Service Program, COVID-19 ?Summer Food Service ProgramALN Numbers: 10.553, 10.555, 10.559Federal Award Numbers and Years (or Other Identifying Numbers): FY21, FY22Pass-Through Entity: Indiana Department of EducationCompliance Requirements: Procurement and Suspension and DebarmentAudit Findings: Material Weakness, Other MattersContact Person Responsible for Corrective Action: Chad Yencer - SuperintendentContact Phone Number: 765-348-7550Views of Responsible Official: We concur with this findingDescription of Corrective Action Plan:BCS has established the following internal controls to ensure compliance:1. Internal Control: When a purchase is made at $10,000 or more using Federal Funds, thesuperintendent will require that any vendors selected are in compliance with theProcurement and Suspension and Debarment compliance requirement by completing one ofthe following quality checks with each vendor prior to purchase:a. Checking the federal System for Award Management (SAM) database athttps://sam.gov/content/exclusions and maintain a screenshot of the search results.b. Collect a certification from the vendor directlyc. Add a clause or condition to the covered transaction with the vendorAnticipated Completion Date:This corrective action will be implemented and completed immediately with any purchase made that meets theabove threshold.

Finding Number: 2022-002Prior Year Finding: NoFederal Agency: U.S. Department of TreasuryFederal Program: Special Education ClusterAssistance Listing: 84.027, 84.173Pass-Through Entity: Maryland State Department of EducationPass-Through AwardNumber and Period:211021-03 (10/1/20 ? 9/30/22)220391-02 (7/1/21 ? 9/30/23)221324-01 (7/1/21 ? 9/30/23)Compliance Requirement: ProcurementType of Finding Significant Deficiency in Internal Control over Compliance,Other MattersRecommendation:We recommend that the Board ensures that documentation of Procurement's decisions on anypurchases that are excluded from the requirements noted in the Procurement Policy are retainedfor audit purposes.Explanation of disagreement with audit finding: There is no disagreement with the auditfinding.Action taken in response to finding This finding was a result of only one vendor being availableat the time. The Office of Purchasing and Grants staff will comply with the requirement forobtaining quotes and document any exceptions if two quotes cannot obtained.Name(s) of the contact person(s) responsible for corrective action: BCPS Office ofPurchasing staff, grant accountants/fiscal staff.Planned completion date for corrective action plan: For immediate implementation andongoing.

Finding 2022-002 - Procurement, Suspension and DebarmentMaterial Weakness in Internal Control over ComplianceFinding Summary: As part of the audit, Eide Bailly LLP identified that the formally documented policy didnot include many of the necessary procurement provisions. Provisions include a consistent control in placeto check applicable vendors for potential suspension and/or debarment for covered transactions. Inaddition, current controls are to be documented to provide for a proper audit trail.Responsible lndividual(s): Chief Financial OfficerCorrective Action Plan: The policy has been updated to include all federal requirements regardingprocurement controls and suspension and debarment controls as proposed by the auditors. Managementwill retain documentation to support that the control process was followed.Anticipated Completion Date: Ongoing

Recommendation: We recommend that the College ensure its policies and procedures over procurement are being enforced to ensure reasonable prices and rates. Specifically, the College should consider training employees that regulations do apply when a single vendor is being used for a good or service, yet the charges are split amongst various funding sources.Explanation of disagreement with audit finding: There is no disagreement with the audit finding.Action in Response to Finding: The College will implement training and procedural changes during the grant budgeting process and in the post-award process to ensure documentation of reasonable prices and rates to include training related to handling vendors who may be used across multiple funding sources.Name of the contact person responsible for corrective action: Tess Powers, Director of Faculty Research Support (719) 389-6318Planned completion date for corrective action plan: May 1, 2023

Recommendation: The auditors recommend the University implement controls to ensure all employees making federal purchases on behalf of the University are aware of the University?s documented procurement policy that is in accordance with 2 CFR Part 200. In addition, they recommend the University document its standard of conduct that covers conflicts of interest and governs the performance of its employees engaged in the selection, award, and administration of contracts.Planned Corrective Action: Heritage University agrees to put procedures in place to make certain that every employee making federal purchases on the University's behalf is aware of the University's written procurement policy, which complies with 2 CFR Part 200. Additionally, the University is to formalize its code of conduct, which addresses conflicts of interest and establishes expectations for staff members involved in contract administration, selection, and award.Name of Responsible Party:1. Dr. Andrew Sund, President2. Thomas Richter, VP of Administration/CFO3. Melissa Hill, Interim Provost4. Corey Hodge, Interim VP of Academic AffairsAnticipated Completion Date: June 30, 2023

Federal Agency Name: Department of State ? Bureau of Population, Refugees, and MigrationProgram Name: Oversees Refugee Assistance Programs for AfricaCFDA #19.517Federal Agency Name: Agency for International DevelopmentDepartment of StateProgram Name: USAID Foreign Assistance for Programs OverseasCFDA #98.001Finding Summary: CVT has documented procurement procedures that conform to applicable federal standards; however, the procedures were not followed regarding maintaining documentation of obtaining quotes for simplified acquisition small purchases and the conclusion as to which item was selected. In addition, CVT was not testing vendors for suspension and debarment.Responsible Individuals: James Behnke, CFO and Mary Kinder, ControllerCorrective Action Plan: Management will maintain adequate supporting documentation and records to document history, methods of procurement, and documentation to support check for suspension and debarment. This will be maintained for all formal written vendor contracts.Anticipated Completion Date: July 2023

FINDING 2022-001Contact Person Responsible for Corrective Action: Mayor Terry AmickContact Phone Number: 812-752-3169Views of Responsible Official: I concur with the findings.Description of Corrective Action Plan: The City plans to review existing policies and procedures andmake any needed changes to endure that they are in compliance with the federal compliancerequirements for procurement as well as suspension and debarment. Furthermore, controls will beestablished to ensure that the City?s policies related to compliance with the federal compliancerequirements for procurement as well as suspension and debarment are followed.Anticipated Completion Date: December 31, 2023

Contact Person Responsible for Corrective Action: Brenda Grider, Clerk TreasurerContact Phone Number: 765-521-6803Views of Responsible Official: We Concur with this findingDescription of Corrective Action Plan:Internal controls have been put into place and the segregation of duties has been implemented.A policy has been approved on moving forward for the procurement, suspension and disbarment.Anticipated Completion Date: Immediately

Policies will be placed and adopted by the agency that meet the UG code. These policies will be placed in the fiscal manual. The fiscal manual will be created by using federal guidelines and by using the DDAP fiscal manual as guidance.

Finding Number: 2022-006 Finding Title: Procurement and Suspension and Debarment Programs: Highway Planning and Construction 20.205 COVID-19 — Coronavirus State and Local Fiscal Recovery Funds 21.027 Name of Contact Person Responsible for Corrective Action: Colleen Robeck, Finance Director Corrective Action Planned: McLeod County recognizes the importance of internal controls over Federal funding to be compliant with the Title 2 U.S. Code of Federal Regulations and is working on a procurement policy to address these issues. There are no misuse of funds, issues with allocation, nor concerns with any handling of funds; however, internal controls assist to assure compliance and will be implemented once complete. Anticipated Completion Date: McLeod County is finishing up the procurement policy and will have the State Auditor’s Office review it for compliance before it is taken to the County Board for approval in 2024.

The District concurs with the recommendation to adopt a written procurement policy and is in the process of writing the policy.

The District concurs with the recommendation to adopt a written conflict of interest policy and is in the process of adopting a policy.

Corrective Action Plan: We have taken proactive measures within the Purchasing Department to enhance training and awareness among our staff. Additionally, the Grant division has been reinforcing the importance of adhering to Federal grant guidelines regarding procurement. We will continue to monitor and improve our processes to ensure compliance with established guidelines. Anticipated Completion Date: December 2024

Plan of Action: Provide policy F2.0 Materials Management, F2.01 Vendor Selection & Discount, 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 but needs to be signed by the organizational board on May 24, 2024. The organization acknowledges that the procurement policy was not followed for one vendor procurement in 2022 due to an administrative error. Going forward this policy will be strictly followed. Date of implementation: F2 policies was implemented on 6/1/21 and updated on 6/1/2024

Views of Responsible Officials and Planned Corrective Actions: Astraea created a best practice procurement policy in December 2021 that was implemented in February 2022 (i.e. Q3 of FY2022). Prior to December 2021, procurement practices were not standardized across the organization. Since implementation of the current procurement policy, all staff members have been trained on the procurement policy, and the Finance and Operation teams have developed internal processes to ensure that all procurement flows through the organization are documented and in compliance with 2 CFR 200. With the policy in place, we recognize that implementation across teams is critical and are actively training people managers to improve oversight and improve implementation. Anticipated Completion Date: January 31, 2024 Responsible Official: Associate Director, Grants Management and Compliance; Director of Program Operations

US Department of the Treasury - COVID-19 - Coronavirus State and Local Fiscal Recovery Funds (ARPA) (ALN 21.027) 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 choose 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.