Corrective Action Plans

Finding number: 2023-003; Finding: While testing the procurement requirement, we were able to test compensating controls, but noted that internal controls were not properly designed over the procurement requirement. Prior to receiving federal funding beginning in August 2022, the program conducted a request for proposal (RFP) process and began contracting with a vendor. When federal funding was obtained, the vendor was not reevaluated in accordance with the Uniform Guidance to ensure the procurement requirements were being met. In addition, we noted UW Health – Madison’s procurement policy documents do not include all of the information that is required by the Uniform Guidance. Correction actions taken or planned: UW Health will develop processes and procedures to ensure compliance with the Uniform Guidance. Vendors will be reevaluated for compliance with the Uniform Guidance prior to being charged to any grant. Anticipated completion Date: June 2024; UW Health employees responsible for Corrective Action Plan: James Hood, Director of Procurement Services, and Sara Schiek, Manager of Procurement Services

Chairman of the Board of County Commissioners: These procurement issues originated during the prior County Clerk’s administration, but the current leadership is focused on corrective measures. Together, we are: • developing a SOP to ensure vendor checks for suspension and debarment are conducted on all purchases over $25,000, • establishing written standards of conduct to address conflicts of interest and set clear procurement guidelines, • and enhancing oversight and review to ensure all procurement processes are fully compliant with federal regulations. Our goal is to build a consistent, transparent procurement framework that safeguards both compliance and public trust. County Clerk: I was not the County Clerk in office at this time. To correct this issue, the County plans to develop a SOP to timely and accurately track and report on the SEFA. The SOP will be reviewed, adopted, and monitored by the Board of County Commissioners.

Management acknowledges this finding, which occurred during a period of rapid program expansion when procurement infrastructure had not yet been fully developed. Since the audit period, we have completely overhauled our procurement process to ensure full compliance with the Federal procurement standards. We have implemented a formal procurement policy, created a dedicated Procurement sub-department within Finance, hired a Procurement Supervisor and support team, and launched a new procurement software platform to ensure proper solicitation, documentation, approval routing, and record retention for all Federally funded programs. These upgrades establish consistent competitive bidding, justification procedures, conflict-of-interest safeguards, and transparent procurement. In addition, we have strengthened oversight, provided staff training on Federal procurement standards, and embedded monitoring practices to ensure ongoing compliance. Management is confident these substantial structural improvements have significantly reduced the risk of noncompliance and positioned the organization for full alignment with federal procurement standards going forward.

Condition: The District has not adopted written policies or procedures regarding procurements or the determination of allowable costs in accordance with the Uniform Guidance. Criteria: 2 CFR 200.302(b)(7), 2 CFR 200.318(a), and 2 CFR 200.319(d). Cause of Condition: Unfamiliarity with requirements stated in 2 CFR 200 of the Uniform Guidance.Effect of Condition: Effect is a state of noncompliance which may impact future grant awards or failure to identify and reject un-allowed costs charged to grant programs. Questioned Costs: none. Recommendation: Draft and adopt policies and procedures to become compliant with Uniform Guidance. Corrective Action Plan: Agency policies and procedures, including a guidance template will be clearly defined to ensure compliance with Uniform Guidance. All department managers and administrative staff will attend training and routine follow-up training on purchasing policies and procedures. A sign in sheet will be required for those attending. Contact Person: Grant Accounting Specialist Anticipated Completion Date: 01/31/2026

2022-003 – Procurement Documentation Planned Corrective Action(s): SIG-NAL will strengthen its procurement controls by fully implementing the updated Procurement Policy and Standard Operating Procedure adopted in 2025. Standardized procurement documentation templates will be developed, including checklists for method of procurement, contractor selection, cost/price analysis, and justification, and will be used for all purchasing actions. The organization will require that all procurement records are completed and retained in accordance with 2 CFR §§ 200.318–320. Anticipated Completion Date ● April 2026 Responsible Party ● Director of Operations, with support from the Finance Team and Executive Director

Procurement and Suspension and Debarment: The College agrees with the finding and takes note of the previous corrective actions that did not fully resolve the issue. The College will update its Purchasing and Accounts Payable Policy to require SAM.gov verification prior to awarding contracts. The College will conduct mandatory procurement training to strengthen compliance with federal requirements.

I believe this has to do with the sewer project. I was thrown into the middle of this. I don’t believe proper records were started or kept by the former Fiscal Officer. I only have what happened since I was here.

The Board of County Commissioners, with the cooperation and participation of all elected officials, reviews, develops and implements policies and procedures to create a strong internal control environment. The Board of County Commissioners will work with all elected officials, the third-party administrator, and federal, state and local partners to develop policies, procedures, and internal controls designed to accurately track grants, including the application process, verification, oversight, and reporting of grant requirements. The Board of County Commissioners will work with the third-party administrator to ensure proper grant administration.

Individual(s) Responsible: Chelsea BadHawk, Chief Financial Officer Action: Management will prepare and implement an internal control system that provides effective oversight of operations, reporting, and compliance. The systems and controls will be designed based on standards set forth in the Government Accountability Office Green Book. Anticipated Completion Date: 12/31/2025.

Significant Deficiency in Internal Control over Compliance, Other Matters Description of Finding Coventry Public School’s procurement standards do not include the essential elements as outlined in 2 CFR sections 200.318 through 200.326. Statement of Concurrence or Nonconcurrence Management concurs with the finding. Corrective Action Coventry Public Schools will review the district’s current purchasing policy and make sure that it is following the criteria as set out in the 2 CFR sections 200.318 and 200.326. The policy will then be updated and communicated to all personnel involved in the procurement process. Name of Contact Person Christopher Deverna, CPA, Director of Finance, Coventry Public Schools Projected Completion Date June 30, 2025

The City has identified federal grants subject to the Uniform Guidance and will develop written policies and procedures which include the relevant provisions required by 2 CFR § 200.318 through 2 CFR § 200.326 Contract provisions.

Effective immediately, as a condition to issue a payment, all purchases exceeding the federal limit will require (a) evidence that quotes from at least three qualified vendors were obtained or (b) a written and signed statement that there are no other vendors providing the goods or services or (c) a written and signed statement that the purchase was made to address an emergency as declared by federal or local governments.

The district no longer exists due to consolidation. Procurement policy and procedures will be practiced by the new district. Anticipated completion date: 6/30/23

Our 2021-22 Audit Report had one finding, related to procurement in the Child NutritionProgram.Here is our corrective action plan (CAP)1. We understand that we did not follow all required procurement policies for the2021-22 school year. This finding was somewhat of a surprise to us, as we had aveteran Director in place. For whatever reason, she either believed theserequirements were not in place due to the pandemic, simply chose to ignore thepolicies, or destroyed the entire audit trail as she left the District. Regardless, wedo accept the finding, since we have no way to remedy it for 2021-22.2. We believe we have already correctly satisfied all of the requirements forprocurement under the Child Nutrition Program for 2022-23. We have alsoreviewed the documentation for 2022-23 with our auditors. We also now havetwo people making sure these policies are followed and the documentation ismaintained. These two people are:a. Steve Barekman, Chief Business Official and Executive Director of Food andNutrition Servicesb. Julie Beer, Director of Food and Nutrition Services

FINDING 2022-005Subject: Child Nutrition Cluster - Procurement and Suspension and DebarmentFederal Agency: Department of AgricultureFederal Programs: School Breakfast Program, COVID-19 ? School Breakfast Program, National SchoolLunch Program, COVID-19 ? National School Lunch Program, Summer Food Service Program, COVID-19 ?Summer Food Service ProgramALN Numbers: 10.553, 10.555, 10.559Federal Award Numbers and Years (or Other Identifying Numbers): FY21, FY22Pass-Through Entity: Indiana Department of EducationCompliance Requirements: Procurement and Suspension and DebarmentAudit Findings: Material Weakness, Other MattersContact Person Responsible for Corrective Action: Chad Yencer - SuperintendentContact Phone Number: 765-348-7550Views of Responsible Official: We concur with this findingDescription of Corrective Action Plan:BCS has established the following internal controls to ensure compliance:1. Internal Control: When a purchase is made at $10,000 or more using Federal Funds, thesuperintendent will require that any vendors selected are in compliance with theProcurement and Suspension and Debarment compliance requirement by completing one ofthe following quality checks with each vendor prior to purchase:a. Checking the federal System for Award Management (SAM) database athttps://sam.gov/content/exclusions and maintain a screenshot of the search results.b. Collect a certification from the vendor directlyc. Add a clause or condition to the covered transaction with the vendorAnticipated Completion Date:This corrective action will be implemented and completed immediately with any purchase made that meets theabove threshold.

Finding Number: 2022-002Prior Year Finding: NoFederal Agency: U.S. Department of TreasuryFederal Program: Special Education ClusterAssistance Listing: 84.027, 84.173Pass-Through Entity: Maryland State Department of EducationPass-Through AwardNumber and Period:211021-03 (10/1/20 ? 9/30/22)220391-02 (7/1/21 ? 9/30/23)221324-01 (7/1/21 ? 9/30/23)Compliance Requirement: ProcurementType of Finding Significant Deficiency in Internal Control over Compliance,Other MattersRecommendation:We recommend that the Board ensures that documentation of Procurement's decisions on anypurchases that are excluded from the requirements noted in the Procurement Policy are retainedfor audit purposes.Explanation of disagreement with audit finding: There is no disagreement with the auditfinding.Action taken in response to finding This finding was a result of only one vendor being availableat the time. The Office of Purchasing and Grants staff will comply with the requirement forobtaining quotes and document any exceptions if two quotes cannot obtained.Name(s) of the contact person(s) responsible for corrective action: BCPS Office ofPurchasing staff, grant accountants/fiscal staff.Planned completion date for corrective action plan: For immediate implementation andongoing.

Finding 2022-002 - Procurement, Suspension and DebarmentMaterial Weakness in Internal Control over ComplianceFinding Summary: As part of the audit, Eide Bailly LLP identified that the formally documented policy didnot include many of the necessary procurement provisions. Provisions include a consistent control in placeto check applicable vendors for potential suspension and/or debarment for covered transactions. Inaddition, current controls are to be documented to provide for a proper audit trail.Responsible lndividual(s): Chief Financial OfficerCorrective Action Plan: The policy has been updated to include all federal requirements regardingprocurement controls and suspension and debarment controls as proposed by the auditors. Managementwill retain documentation to support that the control process was followed.Anticipated Completion Date: Ongoing

FINDING 2022-001Contact Person Responsible for Corrective Action: Mayor Terry AmickContact Phone Number: 812-752-3169Views of Responsible Official: I concur with the findings.Description of Corrective Action Plan: The City plans to review existing policies and procedures andmake any needed changes to endure that they are in compliance with the federal compliancerequirements for procurement as well as suspension and debarment. Furthermore, controls will beestablished to ensure that the City?s policies related to compliance with the federal compliancerequirements for procurement as well as suspension and debarment are followed.Anticipated Completion Date: December 31, 2023

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.

The college will strengthen its financial reporting by implementing the following: 1) Review and improve procedure related to procurement 2) Coordination with grantor regarding grant requirements 2) Review and improve recording of transactions and financial statements presentation. Contact Person : Roselle B. Togonon Completion Date: June 30, 2024

Planned Corrective Action: Team Rubicon will institute policies and procedures to ensure compliance with applicable procurement guidelines when accepting federal awards. These will include prohibition against contracts which could be influenced by a perceived or actual conflict of interest, documentation of a search for suspended and debarred parties, and guidelines for approved methods of procurement (including specific situations where noncompetitive procurement may be appropriate, and documentation to be required if so).

The County has identified federal grants subject to the Uniform Guidance and will develop written policies and procedures which include the relevant provisions required by 2 CFR § 200.318 through 2 CFR § 200.326 Contract provisions.

Coronavirus State and Local Fiscal Recovery Funds- Assistance Listing No. 21.027 Recommendation: We recommend that the Organization adopt a formal and written procurement policy. Additionally, management should develop controls to help ensure procurement procedures are followeed and to monitor the amount spent with vendors throughout the year to ensure procurement procedures will help ensure compliance ith Compilance Supplement and the Code of Federal Regulations related to procurement and suspension and debarment provisions. Explanation of disagreement with audit finding: there is no disagreement with the audit finding. Action taken in response to finding: The Organization will develop a written procurement policy and will develop controls to monitor when expenses approach the various procurement thresholds to help us complete the appropriate procurement procedures in compliance with out policy. Name(s) of the contact person(s) responsible for corrective action: Frank Caruso, Director of Finance and Operations. Planned completion date for corrective action plan: Sarted in January 2024. If the the U.S. Department of the Treasury has questions regarding this plan, please call Frank Caruso, Director of Finance and Operations at (602) 241-4645.

FINDING 2022-002 Finding Subject: Special Education Cluster (IDEA) - Procurement and Suspension and Debarment Summary of Finding: An effective internal control system was not in place at the School Corporation to ensure compliance with requirements related to the grant agreement and the Procurement and Suspension and Debarment compliance requirement. The School Corporation had not designed or implemented adequate policies or procedures to ensure that proper procurement procedures for small purchases were followed. There was no oversight, review, or approval process in place and documented at the School Corporation to ensure proper procedures were followed and price or rate quotations were obtained, or documentation to support limited procurement procedures conducted. Federal regulations allow for informal procurement methods when the value of the procurement for property or services does not exceed the simplified acquisition threshold, which is set at $150,000 per Indiana Code. This informal process allows for methods other than the formal bid process. The informal process is divided between two methods based on thresholds. Micropurchases, typically for those purchases $10,000 or under, and small purchase procedures for those purchases above the micro-purchase threshold, but below the simplified acquisition threshold. Micro-purchases may be awarded without soliciting competitive price rate quotations. If small purchase procedures are used, then price or rate quotations must be obtained from an adequate number of qualified sources. The School Corporation did not obtain price or rate quotes for the five vendors tested that was less than the simplified acquisition threshold of $150,000 but exceeded the $10,000 micropurchase threshold. Documentation detailing the history of procurement, which must include the reason for the procurement method used, was not available for audit. The School Corporation also did not follow procurement requirements for contracted services which exceeded the simplified acquisition threshold of $150,000. The School Corporation did not correctly procure a contract for the one vendor that exceeded the simplified acquisition threshold. Additionally, the School Corporation did not adequately maintain documentation of the procurement history or rationale. Finally, the School Corporation did not verify that this vendor was not excluded or disqualified from participation in federal assistance programs or activities. Contact Person Responsible for Corrective Action: Matthew Miles, CFO Contact Phone Number and Email Address: 317-423-8380 mattmiles@msdlt.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The School District will obtain 3 quotes or do a bid process in the future. If there is limited availability, we will document the reason 3 quotes are not possible. Additionally, the District INDIANA STATE BOARD OF ACCOUNTS 34 will check for suspension and debarment, create a write-up of our findings, and obtain Board approval for the contract. Anticipated Completion Date: The School District will implement changes described in the Corrective Action Plan February in 2024.

Corrective Action: Written internal controls will be developed in accordance with federal regulations. Responsible Parties: Tyson Moreno, Comptroller Michelle Eubanks, Chancery Clerk Anticipated Completion Date: Immediately