Corrective Action Plans

In each of our districts we will practice oversight and due diligence over the documentation of Disaster Grant expenditures. We will review documents to ensure labor rates and equipment rates were those approved FEMA. We will acknowledge our review by signing the documents.

Finding No.: 2021-037 AL Program: 97.030 - Community Disaster Loans Area: Procurement and Suspension and Debarment Questioned Costs: $18,353,963 Contact Person(s): Ryan Camacho, Sr. Financial Analyst / Pam Marigmen, Sr. Financial Analyst, SOF Office / Brien Nicholas, Procurement Services Corrective Action Plan: Condition 1: The Department of Finance – Procurement Services agrees with this finding. For 709918-000 OP - Gov's Executive Order #2022-04 was issued renewing the declaration of State of Public Health Emergency establishing response, quarantine, and preventive containment measures concerning Corona Virus Disease 2019 (COVID-19) and renewing the order directing the CNMI Homeland Security & Management Office, through the CNMI COVID-19 Task Force, and in partnership with CHCC. The Emergency Contract does not require the PS Director’s signature. The Emergency Contract was created by HSEM and is a template being used when an Emergency Declaration is in effect. The person who prepared the Emergency Contract made an error in selecting the procurement method as it should have been selected as Emergency Procurement instead of Competitive Sealed Proposal. This PO was issued to exercise the option to extend performance provided for in COVID19-0163 and provide the Commonwealth with 40,800 square feet of warehouse space for staging and distribution of supplies, equipment, and other necessary support items including electricity (power) as well as other amenities in the initial contract. For 719000-000 OP / 723730-000 OP - Gov's Executive Order #2022-04 was issued renewing the declaration of State of Public Health Emergency establishing response, quarantine, and preventive containment measures concerning Corona Virus Disease 2019 (COVID-19) and renewing the order directing the CNMI Homeland Security & Management Office, through the CNMI COVID-19 Task Force, and in partnership with CHCC. The Emergency Contract does not require the PS Director's signature. The Emergency Contract was created by HSEM and is a template being used when an Emergency arises. The person who prepared this contract should have selected the Emergency Procurement instead of Competitive Sealed Proposal. For 714181-000 OP - Payment for Blocked rooms needed for Medical Referral Patients in San Diego, California. No justification was provided as it was approved by former Governor Torres. For 707002-000 OP - Gov's Executive Order #2022-04 was issued renewing the declaration of State of Public Health Emergency establishing response, quarantine, and preventive containment measures concerning Corona Virus Disease 2019 (COVID-19) and renewing the order directing the CNMI Homeland Security & Management Office, through the CNMI COVID-19 Task Force, and in partnership with CHCC. The Emergency Contract does not require the PS Director's signature. The person who prepared this contract failed to select any procurement method on the emergency contract. For 698865-000 OP - Gov's Executive Order #2022-04 was issued renewing the declaration of State of Public Health Emergency establishing response, quarantine, and preventive containment measures concerning Corona Virus Disease 2019 (COVID-19) and renewing the order directing the CNMI Homeland Security & Management Office, through the CNMI COVID-19 Task Force, and in partnership with CHCC. The Emergency Contract does not require the PS Director's signature. For 698605-000 OP / 698865-000 OP - Gov's Executive Order #2022-04 was issued renewing the declaration of State of Public Health Emergency establishing response, quarantine, and preventive containment measures concerning Corona Virus Disease 2019 (COVID-19) and renewing the order directing the CNMI Homeland Security & Management Office, through the CNMI COVID-19 Task Force, and in partnership with CHCC. The Emergency Contract does not require the PS Director's signature. Condition 2: The Department of Finance – Procurement Services disagrees with this finding. For 715112-000 OP / 727492-000 OP / 730942-000 OP. These three purchase orders were provided in the list for ALN 97.030 and were available for testing during auditor fieldwork. Auditors failed to perform the required testing. Proposed Completion Date: Ongoing

Finding No.: 2021-032 AL Program: 21.027 - Coronavirus State and Local Fiscal Recovery Funds Area: Procurement and Suspension and Debarment Questioned Costs: $2,775,965 Contact Person(s): Ryan Camacho, Sr. Financial Analyst / Pam Marigmen, Sr. Financial Analyst, SOF Office / Brien Nicholas, Procurement Services Corrective Action Plan: Condition 1: The Department of Finance – Procurement Services disagrees with this finding. No procurement documents were provided because these thirty-four transactions were for payments made out for Travel, Medical Referral Patients, etc. Condition 2: The Department of Finance – Procurement Services agrees with this finding. The supporting documents were subsequently located. PO #725713-OP - FUJI Pacific - Office Space Rental. Copy of purchase order is available for inspection. Condition 3: The Department of Finance – Procurement Services disagrees with these findings. For 732176-000 OP $13,440 - No other quotes provided as it was the PS Acting Director's (FC Aguon) discretion, and the purchase requisition was approved by the former SOF (D. Atalig). For 724870-000 OP $8,789 - No other quotes provided as it was the PS Acting Director's (FC Aguon) discretion, and the purchase requisition was approved by the former SOF (D. Atalig). The Emergency Declaration suspended the procurement regulations and authorized the Expenditure Authority to procure any items/procure services exceeding the threshold without obtaining any price quotes. For PO #732176 & 728470, these are not part of the Gov’s Executive Order #2022-04. The Division of Procurement Services will accept the findings as noncompliance with the CNMI Procurement Regulations. Condition 4: The Department of Finance – Procurement Services agrees with these findings. For 726353-000 OP - No quotes were obtained. (FCA) former Acting Director of PS was off island. No DOA given for PS. The former SOF, David Atalig signed the requisition and M. Torres signed the P.O. We weren’t given ample time to seek legal advice from the Attorney General because we were instructed to process this request ASAP. However, moving forward we will advise the Agency to follow the Procurement Regulations regardless of Authority. We will send an LSR to the Attorney General and place the request on hold until we receive legal advice to proceed forward. For 727542-000 OP - No quotes were obtained. (FCA) former Acting Director of PS was off island. No DOA given for PS. M. Torres signed the requisition and the former SOF, David Atalig signed the P.O. For 727113-OC - FCA, the former Acting Director of PS was off-island, and no DOA was given to PS. Both D. Atalig and M. Torres signed the contract. Condition 5: The Department of Finance – Procurement Services agrees with these findings. This transaction doesn't relate to Procurement Services and is not a procurement matter. Donation/Gov's Office - September 2021 Heritage Month. Proposed Completion Date: Ongoing

Finding No.: 2021-020 AL Program: 15.875 - Economic, Social, and Political Development of the Territories Area: Procurement and Suspension and Debarment Questioned Costs: $1,240,465 Contact Person(s): Nerissa Benavente Karakaya, CIP COTR Corrective Action Plan: Condition 1: The Office of Grants Management (with the assistance of Procurement Services) agrees with the finding. The procurement processes are currently being revamped and with the implementation of the Tyler Munis system, procurement related documentation will be uploaded to the system and available for the Auditors to review. Condition 2: The CIP Office disagrees with this finding. The Capital Improvement Program provided information regarding these question costs. Please see the attached bid documents, bid submissions, and advertisement. For 703-OS/32200344 - RFQ20-GOV-084 was provided to the Auditor for their review. Three (3) proposers submitted - SP Dancoe & Associates; Marianas GeoTech Services; TRL Architecture & Pacific Engineering Group & Services. For 702-OS/32200912 - The procurement method for this was processed through a Sole Source. For CUC-WW-18-C032 - Lower Base Sewer Phase 1 - Lift Station and Focemain - This contract was executed by the Commonwealth Utilities Corporation on July 12, 2018. Procurement Services was able to obtain a copy of the contract from CUC to satisfy the audit testing. For 712727-OC (ITB20-DLNR/DOA-098) - Purchase of One (1) 13" Chipper Machine. Two bidders responded to this ITB; Boyer Trading Company & J. & J Company. Boyer Trading was selected as the lowest and responsive bidder. Condition 3: Document #1561570 ($2,500) and Document # 1573947 ($2,500): The Office of Grants Management disagrees with these findings because these are Open Accounts, and this would mean that no price quotations were required during the purchase requisition process in order to obtain the purchase orders. As confirmed by Financial Services and Procurement Services, quotations were not required on an open account. Open accounts were allowed during the JD Edwards period and were discontinued after September 30, 2021. MUNIS was implemented in October 2021. Condition 4: Document #333922 ($1,194,578): The Office of Grants Management (assisting DHSEM) disagrees with the finding because assigned personnel were not made aware of the documents needed; however, OGM is more than happy to provide the following documents to substantiate the purchase of a mobile Covid-19 Biological Safety Lab for the Commonwealth Healthcare Center and for the Alternate Care Site at Kanoa Resort. Per the documentation, the Public Assistance Office and DHSEM followed competitive procurement processing and invoked the Public Health Emergency Executive Order#2020-04 and to which the CNMI Attorney General’s Office approved the purchase. Purchase Order # 708019 was used by the Department of Homeland Security and Emergency Management and the Covid-19 Task Force. Contract number Covid19-0-0626 is attached for your reference. Expenses were later transferred to Department of the Interior CARES Act Funds under D20AP00049 per OGM Memo Number 2021-013. Proposed Completion Date: Ongoing

Finding No.: 2021-013 AL Program: 10.539 - CNMI Nutrition Assistance Area: Procurement and Suspension and Debarment Questioned Costs: $97,850 Contact Person(s): Margaret Aldan, NAP Administrator Corrective Action Plan: Condition 1: The CNMI-NAP disagrees with the finding. This transaction was supposed to be process in FY 2020 but because of the delay and completion date was done in FY 2021, a Change Order Contract No. 01 was processed, and the funds was carried over to FY 2021 (see attached copies of original contract and the change order. The Account number A1551L is a carryover account number from FY 2020 to FY 2021. Copy of the bid is also attached. The bid summary was not necessary because a change order was processed changing the account from A0551E to A1551L per NAP email dated 1/11/21 (Pending Change Order Contract) - CNC 01/13/21 Change Order #1 to charge $35,989.60 (Contract #707410-OC) to A1551L.64560 to extend the delivery period from thirty (30) days to ninety (90) days. (Researched in JDE and found the remarks made by Ms. Cozy N. Camacho - Financial Management) Condition 2: The CNMI-NAP disagrees with the finding. The Nutrition Assistance Program did follow the proper procurement method by processing Invitation to Bid and obtained the lowest bidder and processed the contract with a notice to proceed, please see attached copy of the Contract and the Summary of the bidders to prove that it went through the proper procurement process. Condition 3: The CNMI-NAP disagrees with the finding. The Nutrition Assistance Program tried to obtain quotations to purchase perforator machines on island and there was none. However, ARMATECH company submitted their price quotation stating that they are able to from off-island and NAP can purchase from them. Proposed Completion Date: Ongoing

CONDITION: The Cambria Heights School District contracted with a third-party vendor (Trafera) for the purchase of technology equipment. The contract with Trafera was procured through a cooperative purchasing group (COSTARS). The District did not obtain an adequate number of price or rate quotations for the technology equipment as required by the Uniform Guidance and 24 PS 8.807.1. CRITERIA: As specified in Section 2 CFR 200. 318(i) of the Uniform Guidance, the District must maintain records 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, small purchase procedures per Section 2 CFR 200.320(a)(2)(i) for acquisitions between the micro-purchase threshold (currently $10,000) and the simplified acquisition threshold (current $250,000), price or rate quotations must be obtained from an adequate number of qualified sources as determined appropriate. Per 24 PS 8.807.1, there should be three quotes that are either written or well documented. The use of COSTARS only constitutes one quotation. 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 2 CFR.320(a)(2)(i). 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 to address the requirements of Section 2 CFR 200.318(i) and 2 CFR.320(a)(2)(i). 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.

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 ‘CJAWS, Inc.’ totaling $140,389. 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.

While BREC currently does not have any federal expenses identified as unallowable costs applicable to this finding, a written SOP will be developed for determining allowable costs and procurement requirements in accordance with the applicable CFR to guide key finance staff with responsibility for federally eligible expenditures. o Anticipated Completion Date: July 31, 2024 o Responsable Contact Person: Rhonda Williams

The County will establish policies and procedures to create better communication between the Emergency Manager and the County Officers.

2021-005 Procurement Standards set out at 2 CFR sections 200.318 through 200.326 Management Response: The Tribe will update fiscal, payroll, HR, and procurement policies by the end of the year. Anticipated Completion Date: 12/31/2024 Responsible Party: Treasurer, Comptroller, Accounting Manager and Federal Programs Accounting Manager

2021-003 Summary of Finding (optional) Missing Documentation for procurement, suspension and debarment: Per Uniform Guidance 2 CFR 200.318, any contracts procured with federal funds for over $10,000 should be obtained via a bidding process or documentation is required to show that the contractor is the sole source for the services. In addition, the Organization should keep documentation to show that they have verified that contractors are not suspended or debarred. Bid or sole source documentation was missing for one contract and in addition, for that contract, there was no documentation of the verification that the contractor was not suspended or debarred. We consider this to be an instance of non-compliance and a significant deficiency in internal control over compliance for the reporting requirement. Statement of Concurrence or Nonconcurrence The Maryland Network Against Domestic Violence concurs with this finding. Corrective Action The contract highlighted as part of this audit was a contract that predated FY21 and both the current Executive Director and Finance Manager. As this was not a new contract, no bid or verification that the contractor was not suspended or debarred was conducted during FY21. g However, it is understood that this should have been completed in prior years and the fact that there was no documentation to support the completion of this activity is problematic. In order to ensure that proper sole source documentation is in place, MNADV will review all sole source contracts over $10,000 and verify that a bid process is in place and all vendors are properly vetted for suspension or debarment. This will be completed by May 31, 2024.

2021-006 - Compliance with Uniform Guidance - Procurement; During the 23-24 fiscal year, the Controller (Jarri Melton) audited the vendors more than the $25,000 threshold to determine if they are debarred, suspended, or otherwise excluded from participation in federal award programs. None were noted to be ineligible for participation. The Agency developed and implemented a purchasing policy which encompasses the requirements of the Uniform Guidance, including the requirement to review and document the verification that vendors are not debarred, suspended, or otherwise excluded from participation in federal award programs. During the 21/22 fiscal year the Payables Accountant (Jarri Melton) completed a review of the Agency’s vendor list to ensure that the Agency followed 2 CFR Sections 200.212, 200.318(h), and 180.300 and 48 CFR Section 52.209-6. A hard copy of this review was signed by the Controller (Jarri Melton), then filed. The Payables Accountant (TBD) and the Controller (Jarri Melton) will perform this review going forward for any new vendors. Additionally, the Agency’s purchasing policy was updated in fiscal year 21-22, with purchase orders, a purchase order numbering system and tracking. here are monthly closings / reconciling of outstanding purchase orders from the prior month done by the Payables Accountant (TBD). The Revenue Accountant (Deena Iaccarino) and Purchasing Clerk (Marissa Anderson) assign purchase order numbers to the purchase orders and the originals are kept in a folder for the Payables Accountant (TBD) to retrieve when closing out the month. The Controller (Jarri Melton) will ensure this occurs by conducting monthly reviews. The CEO (Marianne Gribbon) will monitor the process, quarterly.

Description of Finding: Lack of documentation on sole source contracts and verification of vendors Statement of Concurrence or Nonconcurrence: The California Asian Pacific Chamber of Commerce (CalAsian) agrees with the finding. Corrective Action: CalAsian understands the serious nature of this finding and the compliance required with 2 CFR sections 200.318 through 200.327, as well as Part 1326 for vendor exclusions. The Interim Controller and Director of Finance will be revising procedures to document requirements for all procurement activities, regardless of type. Staff will attend training to ensure all procurement activities adhere to the CFR requirements and company policies. Periodic reviews of the procurement activities will be performed to ensure compliance with these procedures to mitigate the risk of continued deficiencies. Name of Contact Person: Ryan Fong, Director of Finance, 916-446-7883, rfong@calasiancc.org Pat Fong Kushida, President & CEO, 916-446-7883, patfongkushida@calasiancc.org Projected Completion Date: March 2024

Child and Adult Care Food Program - Assistance Listing No. 10.558 Recommendation Auditor recommends the Organization familiarize itself with the procurement regulations prior to entering into any future federal grants and review state and federal guidance. Explanation of disagreement with audit finding The Child and Adult Care Food Program was created as an emergency response during the COVID-19 pandemic. In such an emergent situation, management believes the federal government acted in good faith to meet the needs of the country by contracting with regional sponsoring organizations. New Vision Foundation was selected by the sponsoring organization to be a community-based food provider to culturally-specific populations. All activities related to the program were expressly approved by the sponsoring organization. The finding of material noncompliance is overstated. Management followed all guidelines and fulfilled all obligations outlined by Feeding Our Future. Procurement procedures and contracting processes used by management were approved by the sponsor organization. Action taken in response to finding The program noted was discontinued at the end of 2021. If the Organization enters into any other federal funding, we will consult with experts on compliance requirements from the start of the grant. Name of the contact person responsible for corrective action Hussein Farah, Executive Director Planned completion date for corrective action plan N/A

Management of the Organization has stated the process of creating new and updating policies, procedures related to financial reporting, activities, including written procurement standards and written conflicts of interest.

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.

Management Response to Audit Comment # 2021-005 INTERNAL CONTROLS OVER DISBURSEMENTS OF FEDERAL FUNDS MUST BE IMPROVED HEAD START AND EARLY HEAD START PROGRAMS Federal Assistance listing # 93.600 Responsible Person: G. Keith Williams/ CCCSA Management Anticipated Completion Date: December 31, 2023 Corrective Action: The management of Clayton County Community Services Authority, Inc. has reviewed the above referenced finding and takes exception to several of the items listed. For example, some of the transactions listed that were missing check requests (both Head Start/Early Head Start and Indirect Cost Pool) were for monthly expenditures like utility bills, insurance, rent and other contractual obligations. Management has not in the past issued a check request each month for these transactions as they are a part of the ongoing operation of the programs listed. Transactions listed with only one signature occurred as an oversight as the banking authority only requires one signature while our policy may indicate two signatures. Management feels the purchase of the truck was procured in agreement with approvals from the funding agency and board as required. Proper documentation was provided and is currently available for further review. Management continues to follow the proper guidelines regarding procurement and purchases related to the policies and procedures of the agency as well as micro purchase guidelines set forth by the Federal awarding agency. The Board of Directors also approved a revision to the policies and procedures requiring two “live” signatures on all checks issued by the agency. There is also an ongoing review of the current policies and procedures and recommendations for changes and updates are forthcoming. Management reserves the right for further review of these findings with the audit firm for additional documentation and resolution.

FINDING 2021-003 Contact Person Responsible for Corrective Action: Porter County Auditor Contact Phone Number: 219-465-3445 Views of Responsible Official: County concurs with audit finding Description of Corrective Action Plan: County will keep records of all procurement items for Federally-funded projects in accordance with 2 CFR 200.318(i) requirements in project files as they are approved by the relevant department. Anticipated Completion Date: 12/1/2023

Title 97.036 – Disaster Grants – Public Assistance (Presidentially Declared Disasters), Responsible personnel will attend training classes by OSAI, OEM, and Muskogee Creek Nation to stay updated on allowable expenditures and record keeping techniques to allow for more accurate reporting. I will work with the County Emergency Management Coordinator to ensure quarterly reports are filed on time., Responsible Contact Person Board of County Commission Chairman - James Yandell

Finding ref number: 2020-002 Finding caption: The Town did not have adequate internal controls for ensuring compliance with federal procurement requirements. Name, address, and telephone of Town contact person: Randy Kilmer, Clerk Treasurer PO Box 278 Twisp, WA 98856 (509) 997-4081 Corrective action the auditee plans to take in response to the finding: The Town of Twisp agrees with the findings as presented and has committed to adopting policy as recommended by the State Auditor’s office in accordance with the BARS manual, implementing internal controls for federal expenditures and annual reporting. As this audit occurred in the 2023/24 fiscal year, it will not be possible to have these changes in place at the time of this audit. Anticipated date to complete the corrective action: No later than 12/31/24

Finding No.: 2019-016 Federal Agency: U.S. Department of Health and Human Services CFDA Program: 93.870 Maternal, Infant and Early Childhood Home Visiting Grant Program Award Number: 1X10MC31162-01-00 Area: Procurement and Suspension and Debarment Questioned Costs: $60,104 Contact Persons: Perlie Santos, Chief Financial Officer; Yuline Cruz, MIECHV Program Manager; Vincent Camacho, Grants Administrator; Cora Ada, Procurement Director. Corrective Action: CHCC concurs with the findings but not the questioned costs. Although not timely scanned and sent electronically to the Auditors, the Procurement Documents are available for testing. In fiscal year 2020, CHCC implemented the document routing repository for the procurement process using Laserfiche Forms. This will enable CHCC to warehouse all supporting documentation related to procurement activities and document the approval process. With the implementation of the Munis Financial Information System in January 2023, CHCC is now able to electronically attach scanned supporting documents to the vouchers through the Tyler Content Manager (TCM). This will allow for audit testing to be done by providing auditors view only access to CHCC Financial Information System. Proposed Completion Date: On-Going

Finding No.: 2019-011 Federal Agency: U.S. Department of Health and Human Services CFDA Program: 93.243 Substance Abuse and Mental Health Services Projects of Regional and National Significance Award Number: 5U79SP020710-04 and 5H795M062879-02 Area: Procurement and Suspension and Debarment Questioned Costs: $183,926 Contact Persons: Perlie Santos, Chief Financial Officer; Reyna Saures, CGC Director; Vincent Camacho, Grants Administrator; Cora Ada, Procurement Director; Chellah Sablan, Comptroller. Corrective Action: CHCC concurs with the findings but not the questioned costs. Although not timely scanned and sent electronically to the Auditors, the Procurement Documents are available for testing. In Fiscal Year 2020, CHCC implemented the document routing repository for the procurement process using Laserfiche Forms. This will enable CHCC to warehouse all supporting documentation related to procurement activities and document the approval process. With the implementation of the Munis Financial Information System in January 2023, CHCC is now able to electronically attach scanned supporting documents to the vouchers through the Tyler Content Manager (TCM). This will allow for audit testing to be done by providing auditors view only access to CHCC Financial Information System. Proposed Completion Date: On-Going

Finding No.: 2019-007 Federal Agency: U.S. Department of Health and Human Services CFDA Program: 93.104 Comprehensive Community Mental Health Services for Children with Serious Emotional Disturbances (SED) Award Number: 5U79SM062447-04 Area: Procurement and Suspension and Debarment Questioned Costs: $23,500 Contact Persons: Perlie Santos, Chief Financial Officer; Reyna Saures, CGC Director; Vincent Camacho, Grants Administrator; Cora Ada, Procurement Director. Corrective Action: Condition 1 CHCC does not concur with the findings and the questioned costs. RFP19-CHCC/CHC-SOC-019 was published for Contract 686641, that supports Document 1475823 for $9,800. Document 1430779 was encumbered using 672067OM. This is a bridge obligation through an approved request for payment memorandum, while the contract was in progress. ITB 16-CHCC/CGC-002 was published for Contract 621100, that supports documents 1456419 for $850 and 1440996 for $850. Condition 2 and 3 CHCC does not concur with the findings and the questioned costs. The requested documentation was provided, however, CHCC acknowledges that the file sent referenced the Purchase Order numbers and the Document number (Payment Voucher Number). This may have resulted in auditors not properly associating the provided Purchase Orders to the selected payment vouchers. 2019-007 Finding No.: 2019-007, Continued With the implementation of the Munis Financial Information System in January 2023, CHCC is now able to electronically attach Purchase Orders to the Invoices and supporting documents are also electronically linked to the Purchase Order and invoices. This will allow for audit testing to be done by providing auditors view only access to CHCC Financial Information System. Condition 4 CHCC does not concur with the findings and the questioned costs. Although solicitations were not obtained for the car rental for the 4th year of the grant, CHCC believes that the vehicle rental agreement was competitively procured during the initial years of the rental. The agreement was rolled over annually to avoid disruption of service and program activity. To illustrate that, although no solicitation was obtained on the subsequent rental renewal, CHCC still ensures reasonableness of cost. For this agreement, the rental was even reduced from $950 per month to $900 per month on the 5th year of the agreement. Proposed Completion Date: Not applicable as CHCC does not concur with the findings.

We are creating a position and job description for a project manager who will work closely with the Controller and Executive Director. The project manager will be responsible for creating the bid packages, the contractor selection, managing the construction project, and documenting finaI resuIts of the project. The anticipated completion date for this corrective action is July 31, 2024.

Action Plan to Address Policy Updates and Implementation (Finding 2018-001): a. Review and Update Policies: Begin by conducting a comprehensive review of existing policies, particularly those related to procurement, suspension, and debarment. Ensure these policies align with the latest HRSA requirements and federal regulations. b. Engage a Policy Consultant: Seek the expertise of a policy consultant or legal counsel well-versed in healthcare compliance and HRSA regulations to assist in policy revision. c. Policy Training: Develop a training program to educate staff, especially key personnel like the CEO and CFO, on the updated policies. This training should emphasize the significance of compliance and the potential consequences of non-compliance. d. Implementation Oversight: Appoint a Compliance Officer responsible for overseeing the implementation of updated policies and procedures. This officer should regularly audit and monitor adherence to these policies. e. Documentation and Reporting: Implement a robust documentation system to track policy adherence and any deviations. Ensure that timely and accurate reports are generated for review by internal committees and the board. f. Board and Committee Involvement: Enhance board and committee involvement in the oversight of policy compliance. Provide regular updates and reports to these entities to keep them informed and engaged in the compliance process. g. Continuous Monitoring: Establish a continuous monitoring process to identify any policy-related deficiencies promptly. Regularly assess the effectiveness of policies and make necessary adjustments. h. External Audit: Schedule an external audit ahead of time by an independent auditor or agency to ensure objectivity and compliance with HRSA standards. i. Communication: Promote a culture of compliance through effective communication channels. Encourage employees at all levels to report potential violations or concerns without fear of retaliation. j. Periodic Review: Commit to a periodic review of policies, at least annually, to ensure they remain current and aligned with any evolving HRSA regulations or federal mandates.