Corrective Action Plans

Finding No. 2022-001: Procurement and Suspension and Debarment ? Significant Deficiency (Program Level) Finding: During testing the Federation?s controls on compliance over procurement and suspension and debarment, the Federation could not provide a procurement policy that is in compliance with prescribed standards in the Uniform Guidance. Corrective Actions Taken or Planned: Management will update its procurement policy to ensure it is in compliance with Uniform Guidance requirements and will take the additional steps of updating the policy as changes in the Uniform Guidance requirements occur. Review and monitoring is effective immediately and will be on-going beginning January 2023 and is expected to be completed by February 2023

Recommendation: We recommend the County management establish internal controls to ensure compliance with federal procurement requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The finance department has met with the IT department to discuss federal procurement requirements and possible checklists. Name of the contact person responsible for corrective action: Lisa Malinski, Finance Director

The Fremont County Clerk is responsible for paying the bills for the county and was not aware that we should be verifying the vendors that they were not debarred, suspended, or otherwise excluded per 2 CRF 200.318(h) and 2 CFR 180. We will set a policy to use going forward, that will be attached to the voucher for these vendors showing that we have done our due diligence in these matters. The proposed policy is to work with the Commissioners (who approve contracts), accounts payable department and Treasurer on steps to verify the companies upon the receipt of their contract. Contracts are approved by the County Attorney, and once they are approved, I will add a step to have a member of our staff do the verification and attach a form stating the date and outcome of the verification prior to accepting the contract by the vendor.

Finding No. 2022-004: Procurement Policy ? Material Weakness in Internal Control Over Financial Reporting; U.S. Department of Health and Human Services, Rare Disorders: Research, Surveillance, Health Promotion, and Education; Assistance Listing Number 93.315 Condition There is no evidence of a documented formal procurement policy with regards to federal grant awards and expenditures, no documented support that a competitive price analysis for vendors and organizations funded with federal grant funds were performed and no evidence that suspension and debarment verifications were performed for certain vendors and organizations, as required by the general procurement standards of the Uniform Guidance. Recommendation It was recommended that the Association establish a written procurement policy governing contracts with vendors that will be reimbursed by federal grants to incorporate all of the provisions included in the general procurement standards of the Uniform Guidance Section 200.318 and the debarment and suspension regulations of Uniform Guidance Section 200.214. It was also recommended that a review of all existing vendor or sub-awardee contract files be performed to ensure that the documentation as required under the Uniform Guidance is maintained in the files. Action Taken The Spina Bifida Association will take action to ensure an up-to-date Procurement Policy is approved by the Board of Directors. Anticipated Completion Date December 2023

The responsible officials within the Foundation acknowledge the findings from the 2022 audit related to our procurement practices under 2 CFR section 200.320. We understand the gravity of the situation, particularly considering that the Foundation did not have a formal procurement policy in place. To address the deficiencies identified in the audit, our planned corrective actions are foundational. Firstly, we will develop and implement a comprehensive procurement policy that adheres to the federal regulations specified in 2 CFR sections 200.318 through 200.326. This policy will provide clear and specific guidance on both competitive and noncompetitive procurement methods, establishing a framework for future procurement activities. Secondly, we recognize the paramount importance of robust documentation. Therefore, we will institute rigorous documentation procedures that mandate the thorough recording of the historical context and rationale for procurement decisions at the time of contract execution. This documentation will be meticulously maintained, adhering to the stringent requirements mandated by the federal regulations. Additionally, we will prioritize staff training to ensure that all personnel involved in the procurement process are well-informed about the new policy and are capable of consistently adhering to the documentation standards. These measures, including the creation of a procurement policy from the ground up, will enable us to rectify the audit findings promptly, establish compliance with federal regulations, and uphold the integrity of our federal award programs.

Significant Deficiency in Internal Controls ? Procurement, Suspension and Debarment Funding Agency: Department of Treasury Program: Emergency Rental Assistance Program Assistance Listing Number: 21.027 Criteria or Specific Requirement: Criteria or specific requirement: 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". Per the Organization's written procurement policy, the adequate number of sources is determined to be three. Condition: For the entire population (two disbursements from one procurement), documentation was not retained for the adequate number of price comparisons prior to exercising the procurement, as required and stated in the Organization's written procurement policy. Context: A sample of two disbursements from a population of one procurement transaction charged to the major program that exceeded the Organization's established micropurchase threshold of $10,000. The transaction was found to be out of compliance with the Procurement requirements, as documentation was not retained for the adequate number of price comparisons. Questioned Costs: Undeterminable Cause/Effect:. An employee charged with the procurement process for these transactions misinterpreted the aggregation rules between capitalization and procurement thresholds, and therefore did not obtain nor retain three contemporaneous quotes. Without adequate records retained, the Organization is at risk of noncompliance with the standards of Procurement. Recommendation: Opportunity Council has already taken steps to communicate the error with the applicable employee and is currently implementing an additional level of fiscal review earlier in the procurement process to ensure that documentation exists prior to procurement and that it is retained with the accounting record. We recommend moving forward with the additional layer of review and emphasizing the importance of the procurement standards and established policy to all authorized purchasers within the Organization. View of Responsible Official and Corrective Action Management accepts the finding and is taking the following corrective action to prevent recurrence: ? Updating Organizational Policies to clearly permit a higher small purchases threshold, combined with annual certification of eligibility, to sharply decrease the likelihood of recurrence of the underlying cause of the finding. ? Implementing accounting system-level controls that will require an additional approval from assigned fiscal staff to transactions exceeding the small purchase threshold prior to payment, ensuring accountability for monitoring of required documentation for procurements in excess of the threshold. ? Procurement training planned throughout the agency to ensure that personnel authorized to initiate procurement transactions are aware of organizational policies and have the guidance necessary to comply with procurement rules.

SINGLE AUDIT FINDINGS: Finding 2022-002: Procurement and Suspension and Debarment Description of Finding: The Town?s procurement standards included an incorrect threshold for small purchases as outlined in 2 CFR sections 200.318 through 200.326 ($25,000 versus $10,000). Statement of Concurrence or Nonconcurrence: There is no disagreement with the audit finding. Corrective Action: The Town will review its formal procurement policies and make necessary changes to comply with the criteria as set out in 2 CFR sections 200.318 and 200.326. Name of Contact Person: Susan E. Hale, Municipal Finance Officer Projected Completion Date: June 30, 2023

Finding Number: 2022-005 Condition: The Corporation's procurement procedures does not fully conform to the procurement standards identified in ?? 200.317 through 200.327. Planned Corrective Action: The procurement policies will be revised and additional education will be conducted for those individuals responsible for the procurement process. Contact person responsible for corrective action: Kristen St. Peter Anticipated Completion Date: June 2023 Management Response: Management concurs with the finding and will be conducting a thorough review of the current policies to ensure compliance with Uniform Guidance, as well as providing additional training and education to those responsible for procurement.

Higher Education Emergency Relief Fund ? Assistance Listing No.: 84.425F Recommendation: We recommend that the University establish a process where when the SAM.gov check is performed, evidence is retained to show that this was completed. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The procurement policy for Federal Grants will be revised to include the process of how to have a SAM.gov check performed and documented for evidence, as well as include procedures for the procurement of goods over $250,000. At this time, with the HEERF grant completely spent, there are no other Federal grants in place where the SAM.gov check would be required. However, the revised policy will be communicated to department managers for future federal grant awards. Name of the contact person responsible for corrective action: Michelle Hegarty, CFO Planned completion date for corrective action plan: June 1, 2023

U.S. DEPARTMENT OF TREASURY 2022-001 Coronavirus State and Local Fiscal Recovery Funds- ALN No. 21.027 Recommendation: We recommend the Town design and document a procurement policy in accordance with the compliance requirements outlined in Title 2 of the U.S. Code of Federal Regulations part 200.318. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We agree with the auditor?s findings. Management will design a formal procurement policy. Name(s) of the contact person(s) responsible for corrective action: Sue Nickerson, Town Accountant. Planned completion date for corrective action plan: Immediately.

Finding Reference Number; 2022-002 Federal Agency:Department of Agriculture (USDA) Description of Findi ng: Criteria: : 2 CFR Section 200.318 stipulates that a non-Federal entity must use its own documented procurement procedures which reflect applicable state, local, and tribal Jaws and regulations, provided that the procurements conform to applicable Federal law and the standards identified in Part 200 Subpart D. Additional ly, 2 CFR Section 200.213 stipulates that no awards, subawards, or contracts be awarded to parties that are debarred, suspended, or otherwise excluded from or inel igible for partici pation in Federal assistance programs or activities. Condition: During audit testing performed by Mengel, Metzger, Barr & Co, LLP, they noted the following: - The contractors util ized by the Food Bank in 2022 were not properly checked for compl iance requirements regarding debarment. They did not have a control in place to ensure the contractors used for their covered transactions were not made with a debarred or suspended party . Statement of Concurrence or Nonconcurrence: The Food Bank agrees with this findi ng. Corrective Action : The Food Bank has implemented procedures to ensure all contracted vendors are vetted to ensure they are not on the federal exclusion list. All contractors used in 2022 have been checked and are not on the list. Name of Contact Person: Renee Law, Chief Financial Officer; phone number 518-786-3691 ext 226; email ReneeL@Regionalfoodbank.net. Projected Completion Date: May 31, 2023

FINDING 2022-001 Contact Person Responsible for Corrective Action: Christy Nale Contact Phone Number: 765-492-5411 View of Responsible Official: Procurement request for milk and dairy was requested from the West Central Educational Service Center. After not receiving the bid request in a timely manner, the procurement bid was received from the Wilson Education Center. The North Vermillion Community School Corporation was unaware that the Wilson Education Center was not IDOE approved in 2021. The IDOE approved cooperative list was not made available to our corporation, and not easily accessible on the IDOE School Nutrition link. Description of Corrective Action Plan: The corrective action has been made as the Wilson Education Center was approved as a Cooperative Procurement site in 2022 by the IDOE. Anticipated Completion Date: No anticipated date, the Corrective Action has already been completed.

Finding 2022-003 Contact Person Responsible for Corrective Action: Rhonda Morgan, FSD Contact Phone Number: 765-240-2386 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Procurement: Frontier School Corporation will have the Food Service Director prepare contacts to all possible food & drink vendors asking for Vendor Bids for the following school year. Any email correspondence will be CC?d to the Corporation Treasurer and Superintendent when contacting the Vendors. A phone call log will also be kept by the Food Service Director. After receiving Vendor Bids, all Vendor Bids or Vendor Declining to Bid will be presented to the School Board for their approval. The Food Service Director will also give a recommendation at that time on who they would like to award the Vendor Bid to. After the School Board vote on Vendor Bid Awards, e-mail correspondence will be sent to all vendors with Corporation Secretary and Superintendent CC?d. All email data, phone logs, and School Board notes will be filed in the Food Service Director?s office. This internal control system will ensure compliance with the state Procurement agreements and requirements. Anticipated Completion Date: The CAP will be in place by March 24, 2023 in preparation for the Vendor Bids for the School Year 2023-2024 to be prepared and sent out in April 2023. Suspension and Debarment: Frontier School Corporation Food Service Director will check SAM Exclusions, collect a certification from that vendor, or adding a clause or condition to the covered transaction with that vendor. This information would then be kept in the Vendor?s file. Anticipated Completion Date: The CAP will be in place by March 17, 2023 in preparation for the Vendor Bids for the School Year 2023-2024 to be prepared and sent out in April 2023. The Food Service Director will have current vendors checked on SAM Exclusion or have a certification from that vendor, or adding a clause or condition to the covered transactions with the current vendors by March, 17, 2023.

Finding: 2022-001 Department of Education Federal Program(s): Education Stabilization Fund- AL No. 84.425F and 84.425M Type: Significant deficiency in controls over compliance Compliance Requirement: Procurement Recommendation: We recommend the College implement a procurement policy with the requirements identified in 2 CFR Section 200.318 through 200.327. Explanation of any disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The College is in the process of formalizing the procurement standards noted above within its purchasing policies. Planned completion date for corrective action plan: April 30, 2023 Name(s) of the contact person(s) responsible for corrective action: Holly Higgins, Director for Business Services

U.S. Department of Health and Human Services 2022-002 Health Centers Cluster ? Assistance Listing No. 93.224/93.527 Recommendation: We recommend the Health Center update the procurement and conflict of interest policies to meet Uniform Guidance requirements, and ensure proper documentation is retained for transactions, particularly in cases where single source procurement is utilized over the micro purchase threshold. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Procurement and Conflict of Interest Policies were recently revised in Oct 2022 and Dec 2022 ahead of HRSA operational site visit to meet Uniform Guidance requirements. Staff have been trained on requirements related to the procurement thresholds and documentation standards. Documentation and discussion of procurement standards will be captured per that policy, with board action and discussion. Name(s) of the contact person(s) responsible for corrective action: Lori Zook, CFO Planned completion date for corrective action plan: 12/20/2022

Finding Number: 2022-03 Anticipated Completion Date: 10/31/2022 Responsible Contact Person: Laurence Emrie Planned Corrective Action: In response to PwC?s prior audit finding, the Company completely revised its Vendor Selection Form (for Projects Expending Federal Funds Only), effective as of October 2022, to provide explicit directions on the process to be followed when requests for bids from multiple vendors result in only one responsive bid being received. As such, this issue was remediated in October 2022. In such cases, the procurement must be documented as a noncompetitive procurement in Section 3 of the Vendor Selection Form. As a result, enhanced documentation must be attached to the Vendor Selection Form to justify the use of noncompetitive procurement as a purchase mechanism before the purchase will be approved. Moreover, management oversight of the procurement process has been enhanced by having both the Legal Office and the Accounting/Finance Office review and sign-off on the Vendor Selection Form and supporting documentation prior to purchase authorization for goods or services above the micro-purchase threshold being approved.

2022-002 ? COVID-19 ? Education Stabilization Fund ? Institutional Portion Recommendation: The School should revise its policies and procedures to comply with the requirements of the Uniform Guidance and ensure that they are followed to verify that a vendor with which its plans to enter into a covered transaction is not debarred, suspended, or otherwise excluded. Additionally, all employees involved in procurement should be trained on the School?s procurement policies and procedures to avoid a break down of internal controls designed to reduce the risk of improper expenditures. Planned Action Management agrees with the finding and is committed to strengthening its procedures to avoid similar issues in the future. Members of the College did not appropriately follow federal procurement guidelines related to costs that were included in the institutional reimbursement portion of HEERF funding. This was an oversight and occurred as a result of the timing of when the purchases were made, or the contracts were entered into, and when the HEERF funding and applicable guidance was communicated by the Department of Education. At the time the contracts were entered into, members of the College did appropriately review all contracts and the related costs for reasonableness to ensure that the College was being prudent with its financial resources, whether from the federal government or not. Members of the College have also reviewed SAM to ensure that these vendors were not suspended or debarred. The College?s federal procurement policies and procedures will be updated to ensure that all items from the Uniform Guidance are included and followed for all federal grants. Proposed Completion Date: The School will review processes to ensure we are in compliance by March 15, 2023.

Price or rate quotes will be obtained from three different sources when required by the Uniform Guidance. Doris Guzman will monitor budget projections to determine which expenses will require implementation of the appropriate level of procurement procedures that must be followed. Additionally, Hispanic Federation?s program managers will be trained on how to execute the Hispanic Federation Procurement Policy. Finally, Hispanic Federation?s new Compliance Department will review contracts to determine compliance needs.

Federal Procurement Requirements for Higher Education Stabilization Fund Planned Corrective Action: A policy addressing procurement standards has been created and will be implemented for future expenditures Person Responsible for Corrective Action Plan: Cindy L Weaver, Interim CFO/Director of Finance Anticipated Date of Completion: July 25, 2023

CORRECTIVE ACTION PLAN July 21, 2023 We have prepared the following corrective action plan as required by the standards applicable to financial audits contained in Government Auditing Standards and by the audit requirements of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance). Specifically, for each finding we are providing you with the names of the contact people responsible for corrective action, the corrective action planned, and the anticipated completion date. 2022-101: Procurement and Record Retention Recommendation: The Organization should maintain proper documentation to help ensure that all the required documentation is retained in order to confirm its compliance with federal procurement requirements. Action Taken: Early in 2023, the organization revised our grant process to ensure proper documentation and retention during the grant award period. A new grant closeout process and grant closeout checklist was developed to ensure compliance with all documentation and retention requirements. Contact Person: Laura Rood, Sr. Procurement Manager Completion Date: June 2023

Finding: 2022-01 The College, under the direction of the Vice President of Business and Finance, is in the process of revising the existing Procurement Policy to include the required federal procurement standards set out in 2 CFR sections 200.318 through 200.326. It is anticipated that the new policy will be in place by June 30, 2023. While the requirements have not been stated in the current policy, the College believes that it is following the prescribed requirements in practice. The College understands the importance of following the guidelines and providing clear expectations in the policy. Person responsible: Lynn Miskus, Vice President for Business and Finance. Contact Information: LMISKUS@CCSJ.EDU; 1-219-473-4310

FINDING 2022-001 Contact Person Responsible for Corrective Action: Kelli Keith Contact Phone Number: (812) 438-2655 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: We will maintain communication with the Wilson Education Center to ensure that they comply with requirements related to the grant agreement and the Procurement and Suspension and Debarment compliance requirement. In the event that the Wilson Education Center does not comply with the above requirement, the school corporation will look at the federal website to ensure that all vendors are on the approved list. If the Wilson Education Center fails to meet the above criteria, the school corporation would advertise to solicit bids for milk and bread. Anticipated Completion Date: January 13, 2023

Finding # 2022-002 Immaterial noncompliance over procurement U.S. Department of Agriculture ? Rural Development 10.755 Rural Innovation Stronger Economy U.S. Department of the Treasury 21.027 Coronavirus State and Local Fiscal Recovery Funds Finding: The Organization should follow the procurement standards set out at 2 CFR sections 200.318 through 200.326 including documentation to justify when a competitive process was not used. The Organization?s procurement policies also should be expanded to incorporate the provisions of the standards referenced. Recommendation: The Organization's procurement policy must have documented procurement procedures, consistent with state, local, and tribal laws and regulations for the acquisition of property or services required under a federal award or subaward. The Organization should maintain records sufficient to detail the history of procurement. Corrective Action: Spruce Root will review the federal procurement guidelines and update its policies and procedures to be consistent with federal requirements. Anticipated Completion Date December 31, 2023

FINDING 2022-006 Contact Person Responsible for Corrective Action: Judy Brooks, Food Service Coordinator Contact Phone Number: 812-274-8001 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The Food Service Coordinator will follow our procurement procedures for all purchases. Food Service Coordinator will document that vendors for the BID are not suspended or debarred from participation in federal programs before purchasing also vendors used through the Wilson Center. The Deputy Treasurer will verify procurement and suspension and debarment documentation is on file before payment is made. When we are checking the vendors on the sams.gov website and there are no results founds then we will also request the vendor to submit a suspended and debarred form. Anticipated Completion Date: 2/13/2023

FINDING 2022-002 Contact Person Responsible for Corrective Action: Tammy Breedlove, Food Service Director Contact Phone Number: 765-569-4308 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The following internal control process has been added to the Business Office Handbook Effective February 1, 2023. It is the responsibility of the Food Service Director to ensure compliance and comply with the grant agreement and the Procurement and Debarment compliance requirements. Each School year, the Food Service Director & Superintendent will present the West Central IN ESC Food Service Bids & any Food Service Small Purchase quotes to the School Board for review and approval. Audit Evidence will be the Board packets and Board Minutes. Food Service Small Purchases- The Food Service Director will obtain quotes directly from the vendors or use the vendor?s website/catalog to compare products and prices. The Food Service Director attends WCIESC procurement meetings to get the most up-to-date pricing information. It is the responsibility of the Food Service Director to keep all documentation. The Food Service Director will present the documentation to the Business Manager for review. Small Purchase Vendors will be approved by the School board each School Year. Audit Evidence will be the quote documentation as well as the Board packets and Board Minutes. Anticipated Completion Date: March 15, 2023