Corrective Action Plans

Suspension and Debarment ? Assistance Listing No. 93.224/93.527 Recommendation: We recommend that Legacy retain documentation that Sam.gov was used to verify that a vendor was not suspended, debarred, or otherwise excluded from participating in the transaction prior to contract. The organization can keep screenshots that Sam.gov was checked or a PDF print out of the web page. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: ? LMC staff will review the OIG exclusions list prior to onboarding or signing contracts with vendors. ? LMC staff will print and retain proof of each review for reporting purposes. Name(s) of the contact person(s) responsible for corrective action: Melissa D?Onorio, CEO, and Emily Faricy, CFO. Planned completion date for corrective action plan: January 15, 2023

FINDING 2022-004 Contact Person Responsible for Corrective Action: Christopher Dixon, Director of Nutrition and Sheryl Graves, Purchasing Specialist Contact Phone Number: 574-533-8631 Views of Responsible Official: We concur with the finding. Micro-Purchases The School Corporation will document the review/oversight of disbursements from program funds prior to payment. Claims will be prepared and reviewed by Christopher Dixon, Director of Nutrition, or designee, and submitted to the Accounts Payable Specialist for payment. Claims will be initialed or signed demonstrating approval of disbursements. Accounts Payable Specialist will enter claims into the financial software and pays claims after approval by the Chief Financial Officer and School Board. Documentation for claims will be kept in the business office. Small Purchases For Small Purchases, the School Corporation will obtain 3 quotes. Documentation of the 3 quotes are kept within the financial software system or electronically. For purchases about $50,000, GCS will enter into a contract with the vendor, after verifying that the vendor is not suspended or disbarred on SAM.gov. The contract will be electronically maintained by the Purchasing Specialist and uploaded to Gateway. Exceeds Simplified Acquisitions Signed and approved contracts will be maintained and filed electronically by the Purchasing Specialist. Suspension and Debarment All contracts will include documentation from SAM.gov that the vendor has not been suspended or disbarred. Anticipated Completion Date: April 2023

Finding Number: 2022-001 Condition: The City was found to have inadequate controls over procurement during our testing. The lack of controls led to noncompliance over federal procurement standards because the City was unable to provide documentation demonstrating their rationale for contractor selection, selection of the contract type, basis for the contract price, or how full and open competition was achieved. Planned Corrective Action: The City adopted an updated procurement policy after the conclusion of the fiscal year, on October 17, 2022. This procurement policy has been followed since, and it complies with both federal procurement standards and the City Charter. Contact person responsible for corrective action: Kathryn Beemer, City Administrator Email: kbeemer@fennville.com Office Phone: 269-561-8321 Cell Phone: 269-543-2645 Anticipated Completion Date: 10/03/22

Identifying Number: 2022-004: U.S. Department of Education: Education Stabilization Fund: Institutional Portion ? 84.425F (HEERF) Finding: For one vendor paid with HEERF funding, the District did not maintain documentation to support they obtained sufficient quotes for purchase of software. Corrective Action Taken or Planned: STC will utilize and vet purchases in excess of $25,000 through the District?s purchase order process. Utilization of this process will ensure that quotes are obtained prior to purchase commitments. Contact person: Rich Kluin, Vice President ? Finance and Operations, Southeast Technical College Status of finding ? The corrective action will be implemented on April 1, 2023.

County Judge/Executive?s Response: See answer to 2022-002. County Judge/Executive?s Response: The Fiscal Court hired the County Judge's brother as road foreman because he was the only person who met the requirements for the position and would accept the job, other people were offered the job before the brother, in addition the brother also served in the same position under a previous administration and left on good terms. At the time of the Fiscal Court acceptance of bids from the vendor, the son-in-law of the Judge Executive was not listed as an officer of the entity. The County Judge does not vote on fiscal court matter other than as a tie breaker. All votes cast by the Judge executive are either for tie breaking purposes or purely symbolic to show unity on the Court. All future hiring's and/or vendor purchases that require Ethics Commission approval will be submitted to the Ethics Committee in advance and will be in compliance with all state and federal statutes and guidelines.

County Judge/Executive?s Response: The two purchases made by the county were made at different times for different items. Although both purchases were paid for at the same time, due to the fiscal court approval needed to pay the bills, neither of them separately required a bid process. The County does acknowledge the $29,999.00 price tag being close to the allowable amount to spend without bidding, however, the county would state that the purchase price was agreed upon out of good faith and with no attempt to circumvent the bidding requirements. The final $30,000.00 accounted for in this section was for the rental of a dozer. The anticipated rental time and need far exceeded initial estimates. During the initial rental period, the dozer was rented to level the new soccer field, during the work on the soccer field the adjacent land was given to the county and the work on that field exceeded the initial estimates, leading to the overage. Upon realizing the amount was getting close to the $30,000.00 bid requirement the county contacted the owner of the dozer and explained the situation. At that point the owner of the dozer made an offer to sell the dozer to the county at a discounted price which would include a portion of the balance the county already owed. The county bid the purchase of a new dozer. The only bid received by the county for a dozer was from the rented dozer's owner. The county has put into place controls that will require opening of bids no matter the anticipated and/or expected outcomes in adherence to all statutory authority.

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