Corrective Action Plans

CAP

Federal Award Finding: 2022-001 Material Weakness in Compliance and Internal Control over Compliance ? Procurement, Suspension and Debarment Standards Name and Contact Person: Sara Kinjo-Hischer, Tribal Administrator Corrective Action: Skagway Traditional Council will complete a checklist for procurement, based of Skagway Traditional Council?s procurement policies, to ensure that policies and procedures are followed including record retention to address procurement, suspension, and debarment standards of the Uniform Guidance. Proposed Completion Date: June 30, 2023

Finding 2022-001 Procurement, Suspension and Debarment (Repeat Finding 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: We agree with the auditor?s comments, and actions stated in the recommendation. The City of Evanston will: a. Implement structures to monitor external procurement service providers to ensure their procurement methods comply with applicable federal compliance requirements by: When using an external procurement services provider, Departments will review and retain procurement method and accompanying support, specifically: method of procurement (Bid, RFP, RFQ), history of procurement and accompanying support. b. Further expand Purchasing Manual to include policies and procedures for suspension and debarment searches and retaining support for suspension and debarment check by: The Purchasing Manual was revised during 2023 to incorporate procedures relating to suspension and debarment checks. The City will expand the Purchasing Manual to require suspension and debarment check support be retained in the vendor file. c. 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. d. Centralize the procurement process to ensure all departments are following applicable procedures in a uniform manner by: City staff will work with the City?s Purchasing Department to follow and adhere to applicable Procurement procedures. Contact Person: Hitesh Desai, Chief Financial Officer Anticipated Completion Date: December 31, 2023

Persons responsible for corrective action plan: Resty Rios, Staff Accountant Resty.rios@crihb.org Adrianna Davisson, Grants Manager Adrianna.davisson@crihb.org The Clinic will review the procurement standards set forth at 2 CFR part 200 and update our procurement and purchasing policies to include all required purchasing standards as required. All vendors will be required to submit and certify a statement regarding debarment and suspension prior to contract award. The anticipated completion date is 6/30/2023.

2022-003 Procurement, Suspension, and Debarment Recommendation: We recommend the program staff and ASD staff responsible for procuring contracts review federal compliance requirements to ensure appropriate language is included in all agreements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Although the Agency?s Certified Procurement Officer (CPO) later verified that all agreements did contain the required ?Suspension and Debarment? language, it was too late to test in time to submit the audit on time. The various departments of ECECD will use this finding to ensure that designated ASD and Program staff fully understand the importance of providing complete and accurate information to the auditors. In addition, ECECD ASD will work toward improving communication regarding potential audit findings to the appropriate program staff, allowing for enough time to address the potential finding and possibly avoid a finding altogether. Name(s) of the contact person(s) responsible for corrective action: Michelle Montoya, Chief Procurement Officer; ECECD Program Managers; Ron Lucero, ASD Director; Thomas Montoya, Deputy ASD Director; Carmel Pacheco-Aragon, Chief Financial Officer. Planned completion date for corrective action plan: June 30, 2023

Views of Responsible Officials: Management agrees with the finding and will implement any changes necessary.

Finding 2022-001 Description of Finding Procurement and Suspension and Debarment Statement of Concurrence or Nonconcurrence The Town Concurs Corrective Action The Town of Plainville has taken corrective action to remediate this finding by working on a draft of a new procurement policy for the Town that incorporates the essential elements as outlined in 2 CFR sections 2000.318 through 200.326. Due to the COVID-19 pandemic, the Town was not able to formally implement this policy prior to June 30, 2022. The Town has formally approved and implemented the updated procurement policy in January 2023. Name of Contact Person Robert Buden, Director of Finance Completion Date January 9, 2023

Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The College has updated verbiage in our general Terms & conditions to include compliance with the suspension and debarment regulation. Additionally, a Suspension and Debarment Self Certification statement will be included with all the college solicitations. Name of the contact person responsible for corrective action: Karina Jackson, Director for Finance Planned completion date for corrective action plan: April 30, 2022

Finding ref number: 2022-001 Finding caption: The County did not have adequate internal controls for ensuring compliance with federal procurement requirements. Name, address, and telephone of County contact person: Susanne Yost, Financial Manager Office of the Kitsap County Auditor Financial Services Division 614 Division Street, MS-31 Port Orchard, WA 98366 (360) 337-4672 Corrective action the auditee plans to take in response to the finding: We thank the State Auditor?s Office for their comments and recommendations. The director responsible for authorizing purchases for the Emergency Management Department during the review period is no longer with the County. The function of Emergency Management is being restructured to provide for direct County oversight and supervision. Rather than reporting to a board of officials across multiple government agencies, the Department will be solely a County function with services provided to other agencies through interlocal agreements. A new director will be required to follow the forthcoming structure, including compliance and monitoring with County internal controls. The declaration of emergency resolution for Covid response under which the previous director made purchases has been repealed, and any subsequent emergency declarations will be closely managed regarding procurement. Additionally, employee training will be enhanced during emergency responses going forward regarding County purchasing and internal controls. Anticipated date to complete the corrective action: December 31, 2023

Description of Finding: During the Auditor?s control and compliance test work the following was noted: o In testing three of the consultants used, all three had contracts that exceeded $25,000 but were not tested for suspension and debarment. o In testing three of the consultants, used, all three had contracts that exceed the Simplified Acquisition Threshold (SAT) of $250,000, but no sealed bids, proposals, or documentation of sole source was performed. o Through further inquiry, the written ?micropurchase? policy of $50,000 was not self-certified. o Through further inquiry, small purchases that exceed micropurchase policy but are less than SAT did not obtain quotations. As a result, FHI is not in compliance with federal requirements when entering into procurement contracts as well as not meeting suspension and debarment requirements by potentially contracting with a suspended or debarred vendor. Statement of Concurrence or Nonconcurrence: A resume of every contractor and their budgeted compensation was provided to the Department of Agriculture with our competitive application as well as with the service agreement contract signed by both representatives of USDA and FHI. Because of timing on the grantor?s end, FHI has less than 10 business days to review and ratify contract and no one at USDA questioned use of consultants, consultants by name/resume or compensation amounts. However, we acknowledge Federal regulations cited by the Auditor. Questioned Costs: None Corrective Action: ? FHI will search SAM.gov for suspension and debarment of contractors and keep those records on file. FHI will perform this search annually as the contractors registration expires and is renewed. ? FHI will perform an annual self-certification that includes a justification, clear identification of the threshold, and supporting documentation to allow for $50,000 as the micropurchase limit. Name of Contact Person: Person responsible for completing the corrective action plan is Nicole Mast, Director of Operations, nmast@flowerhill.institute. Projected Completion Date: December 31, 2023 Oversight: Contractor documentation will monitored annually to ensure compliance through the end of the current contract (currently March 2026).

Suggested Action (s)- Send out communication to reinforce understanding and responsibilities of the verification process as required by CRS policy. Responsible Official- Global Controller Senior Director Finance Systems & Operations Regional Finance Officers Country Program SMT. Completion Date- September 30th, 2023.

2022-002?Procurement Corrective Action: Current Management is not able to confirm nor deny that appropriate documentation was not collected prior to payment, but highly doubts that it was not collected based on the reliability of the previous Grants Manager. Management notes that the vendor was specifically mentioned in the Grant submission. Management will ensure that purchasing SOP are implemented and selection of vendors is adequately documented. Management has secured project management software that will retain project documentation. This should ensure appropriate documentation is collected and available to all Management for the life of the project, until date of destruction. Person Responsible: Jennifer Hogan, Executive Director Completion Date: September 30, 2023

FINDING: 2022-004 Name of contact person: Bruce Peterson, Supervisor Corrective Action Plan: We have drafted a procurement policy that meets all the requirements of 2 CFR section 200.318 through 200.326 that has been approved by the Township board on June 12, 2023. The policy has been submitted to the Township attorney for review, and will be finalized pending any modifications or recommendations by our attorney. Proposed Completion Date: Immediately.

2022-003 FINDING Contact Person ? CJ Holl, County Administrator Corrective Action Plan ? The County will implement procedures to ensure that federal procurement standards are followed for federal grant purchases. Completion Date ? Ongoing

Management has updated their procurement policy to align with the requirements of 2 CFR 200.318

CORRECTIVE ACTION PLAN For the Year Ended September 30, 2022 Southwest Kansas Area Agency on Aging, Inc. respectfully submits the following corrective action plan for the fiscal year ended September 30, 2022. Name and address of independent public accounting firm: Kennedy McKee and Company LLP P.O. Box 1477 Dodge City, Kansas 67801 Audit period: October 01, 2021 through September 30, 2022 The findings from the September 30, 2022 Schedule of Findings and Questioned Costs are discussed below. The findings are numbered consistently with the numbers assigned in the Schedule. FINDINGS AND QUESTIONED COSTS - Major Federal Award Programs Audit U.S. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT 2022-001 Title III Aging Cluster Title III B Supportive Services CFDA 93.044 Title III C Nutrition Services CFDA 93.045 Title III C Nutrition Services Incentive CFDA 93.053 Grant Period: Year ended September 30, 2022 Condition: The Organization did not have a written procurement policy to properly implement all the requirements of 2 CFR Section 200.318 through 200.326 of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance). Criteria: In accordance with 2 CFR Section 200.319(c), non-federal entities must have written procedures for procurement transactions. Such policy should incorporate all requirements within 2 CFR 200.318 through 200.326 of the Uniform Guidance. Cause: The Organization?s procurement policy does not incorporate all the requirements of 2 CFR Section 200.318 through 200.326 of the Uniform Guidance. Effect: An important component of internal controls is the existence of operating policies and procedures and that they are clearly understood and communicated. Without clear written policies and procedures, there is a higher risk of noncompliance with program compliance requirements. Southwest Kansas Area Agency on Aging, Inc. Corrective Action Plan February 9, 2023 Recommendation: Management should continue to develop comprehensive written policies and procedures to administer all federal programs. Current written policies should be evaluated for inclusion of and compliance with Uniform Guidance requirements. Grantee Response: Management agrees with the finding and will adopt written policies to comply with Uniform Guidance requirements. If the Oversight Agency has questions regarding this plan, please call Rick Schaffer at (620) 225-8230. Sincerely yours, Rick Schaffer Executive Director 236 San Jose Drive Dodge City, KS 67801

Finding 2022-005 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Testing and Mitigation for Rural Health Clinics FFAL #93.697 Compliance Requirements: Procurement, Suspension, and Debarment Finding Summary: The Facility did not obtain quotes from multiple vendors as it relates to the procurement and purchasing of flooring which was over the micro-purchase threshold. In addition, the vendor was not verified against the central contractor registry prior to transaction inception or on a periodic basis to ensure the vendor was not suspended or debarred. Responsible Individuals: Phillip Husher, CFO, Freeman Regional Health Services Corrective Action Plan: Going forward Freeman Regional Health Services will obtain and retain quotes from multiple vendors based on our procurement policies. Documentation will be retained to support the decision of the vendor selected. Also, we will review the Central Contractor Registry to ensure vendors are not suspended or debarred before entering into covered transactions. Anticipated Completion Date: September 30th, 2023

Finding 2022-002 Lack of Internal Control Over Procurement Name of Contact Person: Stella Krumrey, Tribal Council President Corrective Action Plan: The Alutiiq Tribe of Old Harbor has purchasing policies and procedures in place and takes them very seriously. The Tribe believes it followed the proper procedures for the transactions that took place during FYE 09-2022. Unfortunately, due to Tribal Administrator transition during the fiscal year, the documentation of proper purchasing procedures for a major transaction was misplaced and after a thorough search could not be located. The Tribe believes this error was a single mistake and not a pattern. Proposed Completion Date: September 30th, 2022

ARPA Business Support Program ? Assistance Listing No. 21.027 Recommendation: We recommend the Chamber adopt a procurement and suspension and department policy that is in accordance with requirements established by the Uniform Guidance. Furthermore, we recommend these policies are approved by the board of directors. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Chamber is not expecting to receive federal funds exceeding the $750,000 single audit threshold in the future. However, the Chamber will review 2 CFR ? 200.318 and 200.213 while preparing the procurement and suspension and debarment policies to ensure Uniform Guidance standards are followed. Name of the contact person responsible for corrective action: Colin Hastings, Executive Director Planned completion date for corrective action plan: May 2023

Recommendation: The Auditor recommended developing a system of internal controls which provides adequate documentation surrounding procurement and suspension and debarment transactions. Planned Corrective Action: Management agrees with the recommendation and has implemented the following steps. A procurement policy, compliant with the Procurement Standards codified in 2 C.F.R. ? 200.317 through? 200.327 has been approved by the Board of Directors. This policy states the procedures required for documentation for procurement of goods and services related to all Federal awards. As well, the procedure includes a step for accessing Sam.gov to review all vendors annually to ensure they have not been identified as suspended or debarred.

Recommendation: CLA recommends the County follow their internal procurement policy procedures and keep documentation of such procedures to ensure compliance with the federal procurement requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will implement new policies and procedures to ensure that all expenditures of American Rescue Plan (APRA) funds will follow the procurement guidelines outlined in the US Treasury rules and regulations as well as County procurement policies. Name(s) of the contact person(s) responsible for corrective action: Sherri Crow, Interim Director of Budget and Finance Planned completion date for corrective action plan: January 1, 2024

2022-004 Special Education Cluster ? Assistance Listing No. 84.027 & 84.173 Recommendation: We recommend the District reviews its procedures and controls over procurement to ensure that all procurements are documented such that a third party can clearly see and understand the detailed history of the procurement. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The District will work with their departments utilizing federal dollars to ensure the proper procurement method is utilized for all procurements and that documentation of that process is retained so its clear what considerations were made in the procurement decision. Name of the contact person responsible for corrective action: Shari Thompson Planned completion date for corrective action plan: June 30, 2023.

Finding 2022-001 Program: Highway Planning and Construction Cluster CFDA Number: 20.205 Federal Agency: U.S. Department of Transportation Pass-through: California Department of Transportation Award Year: 2021-2022 Compliance Requirement(s): Procurement, Suspension, and Department Finding Summary: The City?s written policy and procedures for purchasing were not updated to incorporate the applicable Uniform Guidance requirements of sections 200.318 through 200.327 that apply to the procurement action based on the method of procurement. Responsible Individuals: Kelly Sessions, Director of Administrative Services Corrective Action Plan: The City is working to update its written procurement policies and procedures to incorporate the applicable requirements identified in sections 200.318 through 200.327 of the Uniform Guidance that apply based on the procurement action and the method of procurement as required by section 200.318(a). Anticipated Completion Date: September 30, 2023

2022-001 Procurement, Suspension and Debarment Contact: Joseph Wilson Title: SVP, Procurement Phone Number: 202-760-4193 Estimated completion date: September 2023 Corrective Action: Management agrees with the finding and recommendations set forth within and is nearing completion of its revised procurement policies and procedures to conform with Uniform Guidance procurement requirements. The updated procurement policy is scheduled to be released during the third quarter of the fiscal year 2023. Training on the Uniform Guidance procurement requirements has been developed and will be required for all staff with procurement responsibilities to ensure (1) adherence to Uniform Guidance and (2) that appropriate justifications for noncompetitive contracts are used and properly documented. Last, during the first quarter of the fiscal year 2023, NeighborWorks implemented a new contracts management system that will be used to manage all aspects of vendor contracts from planning to closeout, including the contract expiration date. Full transition to the new system is targeted for the end of the fiscal year 2023.

Finding 2022-002 ? Child Nutrition Cluster ? Procurement and Suspension and Debarment Contact Person Responsible for Corrective Action: Serena Francis, Business Manager Contact Phone Number: (765) 226-0603 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: We have joined the Food 2 School consortium beginning with 2022-2023 school year. Both our Food Service Director and our Business Manager receive all emails and communication. This will allow internal control and oversight to ensure that the consortium is compliment with all state and federal procedures. We also have moved all of our small purchases into this purchasing consortium system. Anticipated Completion Date: August 1, 2023