Corrective Action Plans

Corrective Action/Auditee Views ? Management acknowledges the comment; however, was not directly involved in the purchase of the equipment as it authorized the funds to be paid to one of the supporting non-profit volunteer fire companies for the procurement of hydraulic equipment used for extrication at the scene of a vehicular accident. The town recorded the asset as is the policy to record the capital assets purchased for the non-profit fire and rescue companies that serve our residents. Management will change the purchasing policy to include a policy that all outside agencies expecting funding from the town for any purchase must adhere to the town?s purchasing policy, allow the town to directly procure the items needed, or forfeit the right of reimbursement. Anticipated Completion Date ? June 30, 2023 Contact Person ? Kelli Russ, Finance Director

FINDINGS?FEDERAL AWARDS DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT 2022-002 Continuum of Care ? Assistance Listing No. 14.267 Recommendation: Procedures should be implemented to ensure an adequate review process is in place to monitor new and potential vendors to determine whether a conflict of interest exists. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: See attached Procurement and Conflict of Interest Policy. See Corrective Action Plan for chart/table Name of the contact person responsible for corrective action: Christine Simiriglia, President & CEO Planned completion date for corrective action plan: March 2023 If the U.S. Department of Housing and Urban Development has questions regarding this plan, please call Christine Simiriglia at 215-390-1500.

Finding 2022-002 Federal Agency Name: U.S. Department of Education Program Name: COVID-19 - Higher Education Emergency Relief Funds ? Student, COVID-19 ? Higher Education Emergency Relief Funds ? Institutional, and COVID-19 ? Strengthening Institutions Program Procurement, Suspension, and Debarment Significant Deficiency in Internal Control FAL #: 84.425E, 84.425F, and 84.425M Finding Summary: The University previously had not received federal awards, other than Student Financial Assistance monies. As a result, they did not have a written procurement policy in place. Management worked on creating a policy in the prior fiscal year, however the policy does not include all the required elements. Responsible Individuals: Spencer Conroy, Chief Financial Officer Corrective Action Plan: This finding was a repeat finding because by the time that the initial matter was discovered it was already too late to rework the policy. Management has since put in place a procurement policy which complies with compliance standards. The finding will not recur. Anticipated Completion Date: Immediately

Finding 2022-007: Procurement, Suspension, and Debarment Federal Agency Name: Department of Health and Human Services CFDA #93.087& 93.829 Program Name: Enhance Safety of Children Affected by Substance Abuse & Section 223 Demonstration Programs to Improve Community Mental Health Services Finding Summary: Testing identified one contract for each of the above programs where the required contract provisions in accordance with Uniform Guidance were not included within the contract over $25,000. In addition, no documentation was retained to support management?s rationale to select both of these contracted vendors. Responsible Individuals: Project Directors (Christina Eggink-Postma, Sarah Heinrichs, Rebecca McCrackin) and CEO (Dan Ries) Corrective Action Plan: CEO will review contracts to ensure proper contract provisions are included in accordance with Uniform Guidance and the Center?s procurement policy. The CEO will document what has been reviewed and whether or not the contract has all the necessary contract requirements before contracts are executed. Anticipated Completion Date: This process was implemented beginning January 2023.

DEPARTMENT OF TREASURY AND CENTERS FOR DISEASE CONTROL AND PREVENTION 2022-004 Coronavirus State and Local Fiscal Recovery Funds (CSLFRF) ? Assistance Listing No. 21.027 Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) ? Assistance Listing No. 93.323 Recommendation: We recommend the County design controls to ensure compliance with federal procurement and suspension and debarment regulation and its purchasing policy and suspension and debarment verification procedures. We recommend the County develop standard justification forms with approval of the noncompetitive procurement documented on the forms and the forms maintained in the procurement file. Also, we recommend the County update its purchasing policy to ensure clear, concise, and detailed suspension and debarment verification procedures. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: The County is currently in the process of implementing a county-wide contract clause that will be added to covered transaction contracts to comply with 2 CFR 180, to ensure covered transactions receive verification that the person or entity is not excluded or disqualified. Review and approval of this suspension and debarment verification will be performed during the contract approval process, which will include this standardized clause. The County?s purchasing policy and procedures manual will be updated to include this standard suspension and debarment verification process to ensure this procedure is communicated county-wide and followed. Additionally, the County will develop standard justification forms to document method of procurement to be maintained in the procurement file. The County will also update its contract templates to include applicable suspension and debarment attestation language which meets Federal requirements and update its purchasing policy and procedures manual to reflect these changes. Name(s) of the contact person(s) responsible for corrective action: Desiree Belding Planned completion date for corrective action plan: November 30, 2023

The Agency will implement internal controls to ensure that supporting documentation is maintained for the procurement of goods and services in accordance with 200.320. The Agency will update our written policies and procedures to ensure that documentation is included regarding the avoidance of the acquisition of unnecessary or duplicative items. Documentation and policies will include procedures for the competitive bidding of bus parts on a quarterly basis and evidence that purchases are from these bid responses and from the lowest qualified vendor. Procurement will perform an annual review of SAM.gov for all vendors. CFO, Eddriene Sylvester. Timeline 180 days.

District Response: A. What corrective action will be taken: District will follow all the requirements of 2 CFR 200 with respect to federal procurement requirements. B. Who is responsible (name and position): Dr. Stephen Gregory, Federal Program Director C. When will the plan be implemented? Corrective action started May 5, 2023, and will continue.

FA 2022-001 Improve Controls over Federal Expenditures Compliance Requirement: Activities Allowed or Unallowed Allowable Costs/Cost Principles Procurement and Suspension and Debarment Internal Control Impact: Significant Deficiency Compliance Impact: Nonmaterial Noncompliance Federal Awarding Agency: U.S. Department of Education Pass-Through Entity: Georgia Department of Education Assistance Listing Number and Title: COVID-19 - 84.4250 - Elementary and Secondary School Emergency Relief Fund COVID-19 - 84.425U - American Rescue Plan Elementary And Secondary School Emergency Relief Fund Federal Award Number: S425D200012 (Year: 2020), S425D210012 (Year: 2021) S45U210012 (Year: 2021) Questioned Costs: $221,797 Repeat of Prior Year Finding: None Description: The policies and procedures of the School District were insufficient to provide adequate internal controls over expenditures as it relates to the Elementary and Secondary School Emergency Relief Fund program. Corrective Action Plans: The School District will review all contracts to ensure all payments to contractors are not in excess of the contracted amount. In addition, the policies and procedures for haling all funds, including ESSER, will be reviewed to ensure internal controls are in place and all compliance requirements are met. The Finance Director will participate in processional development to better understand how to calculate and report indirect cost. Estimated Completion Date: June 30, 2023 Contact Person: Mary Beth Gordon Telephone: 912-545-2367 Email: bgordon@longcountyschools.org

The Fiscal Officer and management company have reviewed the description of the issues and are taking steps to put stronger documentation procedures in place that will support the evaluation and selection of vendors paid from Federal programs. With respect to these specific purchases in FY22, we are confident that if the process had been appropriately documented, we would have reached similar conclusions about who was ultimately selected as the vendor for these projects. We believe the corrective actions we are taking will put us in full compliance with 2 CFR part 200 and the School?s Federal Procurement Policy in future periods.

FINDING 2022-002 Contact Person Responsible for Corrective Action: Bryce Welsh Contact Phone Number:765-345-5101 Views of Responsible Official: We concur with the finding. While we believe that we had controls in place for this finding we failed to produce the proper documentation to prove that we did so. Description of Corrective Action Plan: Going forward we will make sure that all suspension and debarment documents are provided to the Business Manager and kept at central office. These documents will be reviewed and signed by the Business Manger showing internal controls are in place. We will also ensure that we have a contract with the vendors for purchases between $50,000 and $100,000. Anticipated Completion Date: 3/14/2023

FINDING 2022-002 Contact Person Responsible for Corrective Action: Jami Parks Contact Phone Number: 812-794-8750 Views of Responsible Official: We concur with the finding Description of Corrective Action Plan: The School Corporation will sign agreements with Food2School for all Food Service contracts to obtain quotes, these quotes will meet Procurement, Micro purchases and simplified acquisition requirements. Food2Schools will also obtain and share documentation with the school showing vendors meet suspension and disbarment requirements. Anticipated Completion Date: August 01, 2023 (Beginning of the 23/24 school years)

2022-006 Special Education Cluster (IDEA) Recommendation: The School Corporation should design procedures and controls to ensure compliance with suspension and debarment provisions. Before entering into a contract, a check should be performed and retained to support the contractor status. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: The school corporation will check vendors on the SAMS site to verify the contractors are not suspended. Documentation of the verification will be retained. Name of the contact person responsible for corrective action: Cheryl Harvey, Business Manager Planned completion date for corrective action plan: Begin immediately

FINDING 2022-002 Contact Person Responsible for Corrective Action: Shane Hacker, CFO; Tracy Boss, Deputy Treasurer; Jordan Ryan, Coordinator for Nutrition Services Contact Phone Number: 317-852-5726 Views of Responsible Official: We concur with the audit finding. Description of Corrective Action Plan: Moving forward, the Nutrition Services Coordinator will ensure that a certification of suspension and debarment is completed prior to approving contracts over the $150,000 threshold, per the district?s Child Nutrition Procurement Plan. Anticipated Completion Date: July 1, 2023

Recommendation: We recommend that when the District decides to utilize cooperative purchasing programs and use federal funds for those purchases that a review of compliance with the procurement policy occurs. The District should then document its process and how it complies with the procurement standards. View of Responsible Officials: The District has reviewed the applicable Uniform Guidance from the Federal Office of Management and Budget and has developed administrative procedures to aid with ensuring that all procurements financed with federal funding fully comply with Uniform Grant Guidance Federal acquisition thresholds and requirements. Effective the 22-23 fiscal year forward the District will fully deploy the referenced administrative procedures to all applicable District stakeholders and monitor all such procurements for compliance purposes.

2022-006 Higher Education Emergency Relief Funds (HEERF) Procurement, Suspension and Debarment Award Period: July 1, 2021 to June 30, 2022 Type of Finding: Significant Deficiency in Internal Control over Compliance; Other Matters Recommendation: We recommend that the College review their Procurement and Suspension and debarment policies and ensure that any missing federal requirements are included in their written policies. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Tabor College will ensure that appropriate procedures and policies are followed for procurement, including suspension and debarment. Name(s) of the contact person(s) responsible for corrective action: Cathy Castle, Vice President for Business and Finance Planned completion date for corrective action plan: Immediately.

FA 2022-001 Improve/Strengthen Controls over Expenditures Compliance Requirement: Activities Allowed or Unallowed Allowable Costs/Cost Principle Procurement and Suspension and Debarment Internal Control Impact: Significant Deficiency Federal Awarding Agency: U.S. Department of Education Pass-Through Entity: Georgia Department of Education Assistance Listing Number and Title: COVID-19 - 84.425D - Elementary and Secondary School Emergency Relief Fund COVID-19 - 84.425U - American Rescue Plan Elementary and Secondary School Emergency Relief Fund COVID-19 - 84.425W - American Rescue Plan Elementary and Secondary School Emergency Relief Fund - Homless Children and Youth Federal Award Number: S425D200012 (Year: 2020), S425U2120012 (Year: 2021) S425W210011 (Year: 2021) Questioner Costs: $30,180 Prior Year Finding: None Description: The polices and procedures of the School District were insufficient to provide and adequate internal controls over expenditures as it relates to the Elementary and Secondary School Emergency Relief Fund program. Corrective Action Plans: Revise Federal Programs Handbook to enhance internal controls in the area of contracts. Provide addendums to contracted services to provide for retention bonuses to contracted staff. Estimated Completion Date: June 30, 2023 Contact Person: Seth Taylor, Chief Financial Officer Telephone: 229-723-4337 Email: staylor@early.k12.ga.us

FINDING 2022-002 Contact Person Responsible for Corrective Action: LaGrange County Auditor Contact Phone Number: (260) 499-6310 Views of Responsible Official: We concur with the findings from SBOA The County will establish a internal control system of checking Excluded Parties List System, collecting a certification from that person or adding a clause or condition to the covered transaction with that person for all vendors equal to or in excess of $25,000 for SLFRF award funds to ensure such contractors and subrecipients are not suspended, debarred or otherwise excluded. Copies of supporting documents to be retained. Anticipated Completion Date: Implementation will begin immediately.

Audit Finding Reference Number: 2022-003 Recommendation - South Shore should develop a documented procurement policy in accordance with the uniform guidance. Corrective Action Plan - We will develop a policy as part of our overall Policy & Procedure Manual that matches all uniform guidance regulations related to procurement.

Finding Summary: The Town did not have written policies, procedures, and standards of conduct relative to federal awards as required by the Uniform Guidance. Responsible Individual: Jake Roger, Town Administrator. Corrective Action Plan: The Town will produce policies, procedures, and standards of conduct relative to federal awards as required by the Uniform Guidance. Completion Date: December 31, 2023.

The PrimeCare Controller and the PrimeCare Grants Manager will attend Uniform Guidance training related to procurement to a.) ensure that all Uniform Guidance procurement rules and regulation are appropriately understood and appropriately reflected in PrimeCare?s procurement policies; and b.) implement procurement processes and workflows that are reflective of compliance with Uniform Guidance procurement rules and regulations.

U.S. Department of Housing and Urban Development Lake Wales Housing Authority respectfully submits the following corrective action plan for the year ended June 30, 2022. Audit period: July 1, 2021 to June 30, 2022 The finding from the schedule of findings and questioned costs are discussed below. The finding is numbered consistently with the numbers assigned in the schedule. FINDINGS?FEDERAL AWARD PROGRAMS AUDITS U.S. Department of Housing and Urban Development 2022-001 Public and Indian Housing ? Assistance Listing No. 14.850 Recommendation: We recommend the Authority update it Procurement Policy from 2009, which was done on September 30, 2022, putting in place the procurements listed in the Uniform Guidance (UG) and clarifying procurement methods. As well as, including in the policy that all vendors? eligibility needs to be verified prior to signing contracts, either through the SAM website or by collecting a certification form from the vendor. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The new procurement policy was approved September 20, 2022 Name of the contact person responsible for corrective action: Al Kirkland, Executive Director Planned completion date for corrective action plan: Completed September 20, 2022 If the U.S. Department of Housing and Urban Development has questions regarding this plan, please call Al Kirkland, Executive Director at (863)676-7414 ext. 12.

Finding 2022-004 United States Department of Health and Human Services Pass-through from North Carolina Department of Health and Human Services Program Name: Block Grants for Prevention and Treatment of Substance Abuse Federal Assistance Listing Number - 93.959 Significant Deficiency in Internal Control over Compliance and Noncompliance - Procurement Responsible Individuals: Thom Elmore, Executive Director Finding Summary: Recipients of federal awards are required to comply with the procurement guidelines established by 2 CFR 200.318-.327. The Organization has developed a basic purchasing policy; however, the written policy does not include complete procurement procedures that align with the requirements of 2 CFR 200.318-.327. Corrective Action Plan: The Organization will develop a formal procurement policy that considers the required elements of 2 CFR 200.318-.327 and obtain approval of such policy from the governing board. Anticipated Completion Date: Ongoing

Finding: 2022-001 Federal Agency Name: Department of Energy, passed through Colorado Governor?s Energy Office Program Name: Weatherization Assistance for Low-Income Persons CFDA #81.042 Finding Summary: The Organization has a written procurement policy for the year ended June 30, 2022 which established 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), including 2 CFR section 200.320(c), Noncompetitive Procurement; however, documentation of compliance with the policy was not retained on one instance of single-source vendor for services provided. Responsible Individuals: Emilee Powell, Executive Director and Marcy Child, Weatherization Program Director Corrective Action Plan: Housing Resources of Western Colorado will utilize a procurement checklist to ensure that all required procurement actions are undertaken and all required documentation is obtained for procuring contracts over the micro-purchase threshold under federal awards, in order to comply with Housing Resources? procurement policy and federal compliance requirements and will conduct additional training to ensure that all staff understand which actions are considered procurement actions. Implementation date: November 1st, 2022.

Respectfully, the school corporation does not agree with several of the findings in regards to segregation of duties and purchases. First, the SBOA auditors' told the school corporation during the 2019 audit that operating the school lunch program through the extracurricular account was not legal. The school corporation was informed that this account must be transferred to Central Office and a Corrective Action Plan must be in place. This directive was incorrect and pointed out in the official response from November 5, 2019 under IC 20-26-5-4(a)(l l). Second, segregation of duties, oversight, and approval of functions existed in 2019 and are presently occurring daily, weekly, and monthly within the cafeteria program under the corporation accounts and supervision of Central Office. Cafeteria workers record and submit timesheets of duties performed during each payroll period. The Cafeteria Director verifies and signs timesheets to be submitted to the Treasurer and Deputy Treasurer for review and payment from the Cafeteria account. A payroll docket report is sent to the Superintendent prior to payment from the bank. Prior to the 2019 audit, the High School Treasurer spent approximately two hours per day counting cash received each day from school lunches purchased. She also receipted those funds it into the software system, made deposits to the bank, paid invoices for food expenses, and processed part of payroll. Tasks conducted by the High School Treasurer were segregated by a timesheet and supervised by the High School Principal. All those tasks were shifted to Central Office in 2020 and are now segregated to the Treasurer and Deputy Treasurer. The Treasurer documents hours spent on Cafeteria accounts on a timesheet for review and signature by the Superintendent. Financial reports of expenditures and revenues are provided for review and oversight to the Superintendent and School Board at monthly board meetings. Third, RSSC has a small Central Office consisting of a Superintendent, Treasurer, Deputy Treasurer, and Secretary. It has no Assistant Superintendents, Human Resources Director, or Business Manager. Each person in Central Office wears multiple hats and performs multiple duties each day. It was noted in the Audit Report filed from July 1, 2008 to June 30, 2010 that " ...Randolph Southern School Corporation is unable, due to financial limitations, to employ additional personnel to segregate duties in our receipts and cash and investment balances. This statement would apply to all of our internal controls. " The circumstances for RSSC have not changed in the audit periods from July 1, 2010 through June 30, 2022. Corrective Action Plan: The School Board had chosen not to add additional staffing due to costs. RSSC is still unable to segregate duties for financial transactions and reporting. Fourth, the Cafeteria Program only has one full-time staff member, the Cafeteria Director. Eight part-time cafeteria workers prepare and feed up to 300 students each day. This food service program is one of the best run programs in the State oflndiana. It has not had one food preparation or sanitation violation from IDOE or Department of Health in the last 12 years. Fifth, the Cafeteria Program is economically efficient and fiscally responsible. The account carries at least a 3-month cash balance at all times. This success is a direct result of oversight by the combination of the Superintendent, Treasurer, and Cafeteria Director. RSSC adopted board policy 6114 Cost Principles-Spending Federal Funds on May 9, 2016. RSSC has had an Indirect Cost Rate in place since 2013. The adopted policy allows the school corporation to apply Indirect Costs to all federal funds including the Cafeteria account. On December 5, 2019, email communications between the Dr. Donnie Bowsman, Superintendent and Tina Herzog, IDOE Assistant Director of Operations and Food Distributions clearly state the school corporation can apply the Indirect Cost Rate to the Cafeteria account. The email communication clearly states that the high cash balance was a result of not applying the Indirect Cost Rate to the Cafeteria account (See Exhibit 1 Emails). The Indirect Rate was approved by the IDOE Office of School Finance and existed prior to the audit years being referenced in the finding. Technically, the prospective portion (going forward for the next school year) as referenced on pages 24-25 of USDA Indirect Cost Guidance Manual pertains to the 2013 Fiscal Year. Moreover, the fact was reiterated by the IDOE School Nutrition Office with email communications on December 5, 2019, not 2021 or 2022 as referenced in the finding. RSSC has not charged or recouped the Cafeteria Account the Indirect Cost rate for many years and has subsidized this account which should be independent and self-sufficient. The School Corporation did not apply the Indirect Cost Rate in 2020 or 2021 because we were not sure how many students would be eating and how fiscally sound the account would be due to students not attending school because of COVID. Corrective Action Plan: The Indirect Cost Rate will be applied and collected in the future prior to June 30 of each current fiscal year. It should also be noted that in 2021, RSSC purchased a new cafeteria dishwasher utilizing ESSER II funds. This unit was 20+ years old and needed to be replaced in order to continue feeding children and to run the food service program. This expense could have been and should have been a direct cost of $58,189 to the Cafeteria account. However, due to the unknown circumstances of COVID, the RSSC could not take a chance. The ESSER II grant is still open and we are now questioning whether this expense could be charged directly to the Cafeteria account. Those ESSER II fund could be utilized for staffing to support student learning loss and remediation. Sixth, COVID caused this financial account to increase exponentially from 2020 to 2021. ESSER funds were provided by the federal government to provide free lunches to every child which paid the food operations expenses for two school years. Student participation of eating school lunches increased during these time periods. Additionally, staff members were receiving hazard pay incentives on top of their regular hourly rate. Further, the School Corporation and Cafeteria Program took on the enormous task of feeding children over the summers of 2020 and 2021 when COVID cases were at its peak. The cafeteria personnel fed 5286 and 5740 students respectfully during those summers. The number of meals served during the summer almost equaled the total amount of meals served during the entire school year for each respective academic year. These additional meals created additional unexpected revenues for the fiscal year. The school corporation did not charge mileage for satellite lunches being delivered or indirect costs.

Views of Responsible Officials: The Organization is in the process of updated its procurement policy, so it aligns with the requirements set by the UG.