Corrective Action Plans

FINDING 2023-003 Finding Subject: COVID 19 - Coronavirus State and Local Fiscal Recovery Funds - Procurement and Suspension and Debarment Summary of Finding: The County did not have documented procurement procedures or policies reflecting applicable State or Federal laws and regulations for procuring goods and services paid with Federal funds. One vendor was identified that fell within the small purchase threshold, with total purchases of $117,144.20, of which $7,144.20 was paid from the State and Local Fiscal Recovery Funds received from the Indiana Department of Homeland Security. Price or rate quotations were not obtained, nor was full and open competition provided for the vendor. Additionally, there was no documentation available to support the rationale to limit competition. Contact Person Responsible for Corrective Action: Janet Chadwell Contact Phone Number and Email Address: 812-663-2570 jchadwell@decaturcounty.in.gov INDIANA STATE BOARD OF ACCOUNTS 29 Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: We have discussed a procurement policy with our county attorney who is working us on that. We will present a draft policy to the Commissioners hopefully by mid- November. We will implement internal controls to ensure that the established procurement procedures are followed to ensure open competition. Anticipated Completion Date: December 31, 2024

The Board acknowledges the finding related to procurement practices under Finding 2023-001. We recognize the importance of adhering to federal procurement requirements, specifically those outlined in 2 CFR 200.319(d), to ensure compliance and maintain the integrity of federal funds. Management will review and update policies to ensure they align with federal regulations specified in 2 CFR 200.319(d) and will provide training to relevant personnel on federal procurement requirements.

Management will strengthen its processes and internal control to ensure that report of expenditures is reviewed by Finance prior to submission and only includes expenditures incurred in the period. In addition, Management will amend its procurement policy to ensure the policy includes the required regulations as outlined in the Code of Federal Regulations in relation to Federal Awards and that all relevant documentation will be retained. Christopher Caulfield, Executive Director of Financial Operations, will effectuate the corrective action plan, which is anticipated to be completed by December 31, 2024. caulfieldc@sjhmc.org 973-754-2016

FINDING 2023-003 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds – Procurement and Suspension and Debarment Summary of Finding: The City did not obtain price or rate quotes for the one vendor tested that was less than the simplified acquisition threshold of $150,000 but exceeded the $10,000 micro-purchase threshold. The micro-purchase threshold may be increased, but the City did not provide documentation that the threshold had been increased. Documentation detailing the history of procurement, which must include the reason for the procurement method used, was not available for audit. A population of 9 covered transactions for goods or services were paid from Coronavirus State and Local Fiscal Recovery Fund funds during the audit period. A sample of 3 transactions were selected for testing. Of the 3 transactions tested, 1 vendor was not verified to not suspended nor debarred, or otherwise excluded or disqualified from participating in federal assistance programs or activities. Contact Person Responsible for Corrective Action: Craig Wright - Controller Contact Phone Number and Email Address: 765-747-4828 cwright@muncie.in.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Correcting the audit findings is ongoing. The city has implemented monitoring procedures to review and prevent reoccurring errors. Anticipated Completion Date: The internal control monitoring and checks and balances will be implemented immediately and continue going forward.

FINDING 2023-02 PROCUREMENT POLICY AND DOCUMENTATION (Background info) As mentioned in the audit, the SSTHA Board of Commissioners adopted a new Procurement Policy, and they also adopted an addendum to that policy that was mandated in a previous audit disclosure. Unfortunately, within 2 years the SSTHA had significant employee turnover within its maintenance and development operation. Four employees retired, re-located, and/or deceased. Consequently, the matter of training in procurement is ongoing but vested in that procurement compliance is key in the qualification review process for new grants. FINDING 2023-02 PROCUREMENT POLICY AND DOCUMENTATION (Corrective Action) Procurement training has been an ongoing process, particularly by way of bidding. Additional training shall be initiated through budget cost accounting, purchasing through proposals, document retention, and debarment shall be undertaken with the accounting aspect training referenced in Finding #1 above.

FINDING 2023-003 Finding Subject: Drinking Water State Revolving Fund (DWSRF) Cluster -Procurement Summary of Finding: The Town did not obtain price or rate quotes for the two vendors tested that were less than the simplified acquisition threshold of $150,000 but exceeded the $10,000 micro-purchase threshold. The micro-purchase threshold may be increased, but the Town did not provide documentation that the threshold had been increased. Documentation detailing the history of procurement, which must include the reason for the procurement method used, was not available for audit. Contact Person Responsible for Corrective Action: Sherry Ervin Contact Phone Number and Email Address: 765-478-3522 cctownclerk@comcast.net Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The Town will document in the minutes when there is only one (1) vendor available for the purchase of equipment Anticipated Completion Date: By year end 12/31/2024

2023-002 U.S. Department of Environment Protection – Assistance Listing # 66.468 Capitalization Grants for Drinking Water State Revolving Fund (Drinking Water State Revolving Fund Cluster) Lack of Required Written Policies & Procedures – Compliance Condition & Criteria: The Authority does not currently have all the written policies and procedures in place as required by the Uniform Guidance as it relates to financial management and determining allowability of costs for the federal program (Title 2 U.S. Code of Federal Regulations (CFR) 200.302 & 200.305). In addition CFR sections 200.318, 200.319, and 200.320 require there to be written policies and procedures regarding procurement and conflicts of interest. Planned Corrective Action: The water systems improvements federally funded project is the Authority’s first time subject to the requirements of the Uniform Guidance as we have not had any significant grant funding since 2004. The Authority does have a set of informal policies and procedures that are followed as it relates to financial management, allowability of costs, procurement, and conflicts of interest, and have been very careful to carry out all federal program activities in accordance with established regulations; however, the Authority was simply not aware of the requirement that these polices and procedures be documented in writing. The Authority has been working over the past year to draft and develop these policies and procedures as they relate to federal programs, and to get them documented in writing. The Authority is currently working with their attorney to have the written polices established and plan to have this completed within the next fiscal year. Once the required policies are written, the Board of the Authority will review the policies, revise as appropriate, and adopt the policies for the Authority to comply with the federal funding requirements.

Finding 2023-001 – Internal control deficiency and noncompliance over Procurement 1) Communication & Awareness: • Debrief by Director, Research and Sponsored Awards with the Community Health Department Senior Leaders and Program Managers regarding the audit finding; including procurement requirements, the nature of the deficiency and failure points. This occurred on 8/27/2024. • Meeting between Director, Research and Sponsored Awards, PHS Communications and Brand Management leadership and VP of Community Health to communicate procurement requirements and clarify responsibilities for communication of applicability of Federal procurement requirements to specific projects for which advertising services are requested. Initial Meeting occurred 8/28/2024. 2) Training & Education: • Targeted Training with the Community Health department (primary recipient of on-going Federal funding) on Federal procurement requirements. This training will be provided by the Research and Sponsored Awards staff and will be extended to any additional departments new to Federal funding. • Enhancement of existing required annual enterprise-wide leadership training that includes a section on grant funding with increased emphasis on procurement. Research and Sponsored Awards department is responsible for content. • Development of materials for new hires or others new to grant funding who are responsible for federally funded projects (collaboration between Research and Sponsored Awards department and Community Health department) 3) Policies & Procedures: • Written Procedures & Toolkits: Development of written procedures for contracting, exclusion checks and general procurement of goods or services to include checklists / toolkits to facilitate actions required for compliance with Federal procurement rules. • Update to existing policy “Federally funded Grants or Contracts – Procurement / Purchase of Supplies, Services and Other Property” to clarify the responsibilities for communication of applicability of Federal procurement requirements when a department receiving Federal funding procures goods or services through other PHS departments. 4) Collaboration with PHS Marketing department to ensure pathways exist for competitive bids, when necessary, including documentation of processes related to procurements under Federal funding. The first meeting was held 9/12/2024. 5) The Director, Research and Sponsored Awards and Community Health Department will review the items identified as questioned costs to identify if any improper payments were made to PHS. Contact Person: Lori Galves, Director, Research and Sponsored Awards Anticipated Completion Date: December 31, 2024

Views of Responsible Officials: The Center will update its procurement policies and ensure staff are trained on all procedures and requires documentation. Name and Title of Responsible Official(s): Vibha Bhatia, Vice President of Finance and Operations Anticipated Completion Date: September 30, 2024

Texas Biomed has detailed procurement policies in place that outline requirements relative to expenditures on federal awards. Historically, training of new employees in Purchasing and employees in other departments with purchasing-related responsibilities was provided periodically. Turnover in 2023 affecting the Purchasing department led to a failure to ensure adequate training was provided such that compliance responsibilities were clearly understood. With the implementation of a new P2P system in Q3 2024, training has been updated for the new system and will incorporate reminders of compliance requirements for federal awards. Separate trainings are planned for September 2024 for Purchasing staff and for staff in other departments involved in the purchasing process. Training will include requirements to obtain and document multiple quotes for purchases over $10,000 and to document sole source justification when there are no other viable suppliers for a purchase. Purchasing staff will review requisitions to ensure the appropriate documentation is saved with the Purchase Order in the purchasing system. Any new employees or temporary workers in the Purchasing department will be trained on the requirements before they are allowed to begin processing purchase requisitions. Responsible Parties: Eva Zepeda, Director, Finance; Patricia Thompson, Assistant Director, Materials Management Completion Date: September 30, 2024

Seymour Public Schools will go out to bid for any purchases over $25,000. Jason Vieira of the Towns Finance Department is responsible for the corrective action plan.

FINDING 2023-002 Finding Subject: Water and Wastewater Disposal Systems for Rural Communities – Procurement Summary of Finding: One vendor was not procured according to the simplified acquisition threshold. Contact Person Responsible for Corrective Action: Tammy Selby Contact Phone Number and Email Address: 812-354-8511 tselby@petersburg.in.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: In the future, we will bid out all professional services. We will follow our same policies for bidding out to other vendors. Anticipated Completion Date: December 31, 2024

Finding 2023-004 Finding Subject: Covid-19 – Coronavirus State and Local Fiscal Recovery Funds – Procurement and Suspension and Debarment Summary of Findings: The County did not have a Board approved procurement policy that would reflect applicable state laws and regulations including procedures to avoid acquisition of unnecessary or duplicative items and procedures to ensure that all solicitations incorporate a clear and accurate description of the technical requirements for the material, product, or service to be procured. The County had five vendors that qualified for testing under small purchase procurement requirements (vendors paid $10,000-$150,000). Of the two chosen for testing, one was awarded a contract without the County obtaining quotes. The contract awarded was $31,000 for engineering services related to drain construction. Contact Person Responsible for Corrective Action: Debbie Morton-Crum, County Auditor Contact Phone Number: 765-482-2940 Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The process was not clear to the Auditor’s Office or the departments submitting the claims for payment. We are more aware of the correct process and procedures that need to take place and will add those procedures to our Internal Control policy to ensure that the vendor is not suspended or debarred. Anticipated Completion Date: October 2024

FINDING 2023-002 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Procurement and Suspension and Debarment Summary of Finding: Material Weakness, Modified Opinion Contact Person Responsible for Corrective Action: Aaron Kaytar Contact Phone Number and Email Address: 317-852-1120 akaytar@brownsburg.org Views of Responsible Officials: We concur with the findings. Description of Corrective Action Plan: In 2023 a Purchasing Policy was implemented for all departments to follow. It states: 1. For Purchases Under $50,000 a. Purchases or Contracts of $1,000 or Less i. Shall be reviewed and approved by the designated Purchasing Agent. ii. The Department Head, Procurement Manager and Town Manager reserve the right to deny any Purchase. iii. Contracts should be submitted to the Clerk-Treasurer’s Office for retention. b. Purchases or Contract between $1,000 and $10,000 i. Shall be reviewed and approved via a Requisition Form by the Purchasing Agent/Department Head. ii. The Procurement Manager and Town Manager reserve the right to deny any Purchase. iii. Contracts should be submitted to the Clerk-Treasurer’s Office for retention. iv. Any new purchase that meets the asset requirement ($5,000 or more) MUST be reported to the Clerk-Treasurer’s Office. c. Purchases or Contracts between $10,000 and $50,000 i. Shall be reviewed and approved via a Requisition Form by the Department Head, Procurement Manager and Town Manager. ii. Should have (3) formal quotes from different vendors. iii. The Procurement Manager and Town Manager reserve the right to deny any Purchase. iv. Contracts should be submitted to the Clerk-Treasurer’s Office for retention. v. Any new purchase that meets the asset requirement ($5,000 or more) MUST be reported to the Clerk-Treasurer’s Office. d. Purchases of at Least $50,000 and Less Than $150,000 i. Shall be reviewed and approved by the Department Head, Procurement Manager, Town Manager and Town Council. ii. The information shall be presented to Town Council and should contain (3) formal quotes from different vendors. iii. Contracts should be submitted to the Clerk-Treasurer’s Office for retention. iv. Any new purchase that meets the asset requirement ($5,000 or more) MUST be reported to the Clerk-Treasurer’s Office. e. Purchases of $150,000 or More i. Shall be submitted via a formal bidding process. ii. Shall be reviewed by Department Heads, Procurement Manager, Town Manager and Town Council. iii. Contracts should be submitted to the Clerk-Treasurer’s Office for retention. iv. Any new purchase that meets the asset requirement ($5,000 or more) MUST be reported to the Clerk-Treasurer’s Office. 2. To provide services to the Town of Brownsburg, you must not be debarred, suspended, or otherwise be excluded from or ineligible for participation in federally assisted programs under Executive Order 12549. Anticipated Completion Date: Policy change 2023. Purchase order change 8/31/2024.

Current plan & Actions being taken and developed. 1. Develop and Update Procurement Policies Create Comprehensive Policies: Ensure that the procurement policy covers all aspects of the procurement process, including vendor selection, bidding, contract management, and expenditure approvals. Regular Reviews: Periodically review and update the policies to reflect changes in laws, regulations, or best practices. 2. Establish Clear Procedures Document Procedures: Develop detailed procedures for each step of the procurement process, from requisition to payment. Create a procurement checklist. Standardize Processes: Ensure consistency across departments by standardizing procedures for procurement activities. Provide each department with the procurement check list. 3. Training and Awareness Conduct Training: Provide regular training for all staff involved in procurement to ensure they understand the policies and procedures. Promote Awareness: Increase awareness about the importance of compliance with procurement policies. 4. Implement Controls and Checks Segregation of Duties: Divide procurement responsibilities among different staff to reduce the risk of errors or fraud. Approval Processes: Establish clear approval hierarchies and limits for procurement activities and expenditures. Audit Trails: Maintain detailed records and documentation for all procurement transactions. 5. Monitor and Review Compliance Regular Audits: Conduct regular internal and external audits of procurement activities to ensure adherence to policies. Performance Metrics: Develop metrics to evaluate the effectiveness of procurement processes and identify areas for improvement. 6. Enforce Accountability Responsibility Assignments: Assign clear responsibilities for monitoring and enforcing procurement policies. 7. Utilize Technology Data Analysis: Use data analytics to track spending patterns, vendor performance, and policy compliance. 8. Encourage Transparency Open Bidding Processes: Ensure that procurement opportunities are advertised openly and fairly. 9. Feedback and Continuous Improvement Solicit Feedback: Gather feedback from staff and vendors on the procurement process to identify areas for improvement. Continuous Improvement: Regularly update procedures and policies based on feedback and audit findings. 10. Departmental Integration Cross-Department Coordination: Ensure that all departments are aligned with procurement policies and procedures. Provide each department with the procurement check list. Name(s) of the contact person(s) responsible for corrective action: All Department Directors, in conjunction with the Finance Department, are collectively accountable for the implementation and oversight of this corrective action plan. Requests for Proposals (RFPs) will be reviewed and approved in an open Town Meeting, with decisions made by the Mayor and Commissioners. Planned completion date for corrective action plan: Implementation commenced around June 1, 2024 and is projected to be fully operational within a year June 1, 2025.

Condition: One vendor was awarded a contract without a proper competitive procurement process. Corrective Action Planned: The City and School Department has implemented procedures to perform procurement procedures on all applicable contracts for goods and services that will be in compliance with both Federal and State procurement laws. We feel the finding has been resolved going forward. Anticipated Completion Date: June 30, 2024 Contact: Gary Frisch, School Chief Financial Officer

2023-003: Procurement Federal Program Title: Research and Development Cluster Assistance Listing Number: Various Type of Finding: Significant Deficiency in Internal Control over Compliance Other Matters Recommendation: ISU should evaluate its procedures and implement an additional control to document reasons for obtaining competitive bids. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Grant Accounting and Purchasing will both review requisitions within Jaggaer to make sure appropriate bids, and or exemptions are documented or attached. Name(s) of the contact person(s) responsible for corrective action: Lisa Leyshon, AVP Finance/Controller and Kirsten Broughton, Director of Grant Accounting Planned completion date for corrective action plan: Implemented in February 2024.

Hawaiʻi Council for the Humanities Fiscal year ended Oct 31, 2023 Finding No.: 2023-001 Procurement July 15, 2024 Views of Responsible Official(s) and Planned Corrective Action: HCH concurs with the finding. Management notes additional context: HCH was dealing with staff shortage/transition at the time. Documentation was created but was not filed/kept appropriately. HCH can strengthen staff understanding of the policy as well as procedure for keeping documentation. Corrective action plan: Fiscal and Admin Assistant to create a formal filing system for procurement documentation. Executive Director and Deputy Director to review HCH procurement policies with all staff and with accountants. Person Responsible: Aiko Yamashiro, HCH Executive Director Anticipated Completion Date: Aug 1 2024

Management agrees with the finding. Our current federal project is substantially completed, however, should the Township receive additional federal grants, the Township will adopt the required written procedures. The anticipated completion date is prior to receiving another federal award.

Management thought the bidding for the Township engineer a number of years ago, met the bidding requirements. In the future, if the Township obtains any federal grant that requires engineering services, the Township will make sure that we bid engineering services. The anticpated completion date is prior to receiving another federal grant award requiring engineering services.

Views of Responsible Officials:This instance was largely due to staff turnover. ASCB will train all grant-related and all finance staff in proper processes and procedures based on contract price thresholds. This will create awareness throughout both departments which will result in everyone taking ownership of the process and not being reliant on any one staff member.

2CFR 320, Methods of Procurement Standards are to be followed by each department requesting federal award. The County Auditor has instructed our employees and admin people of the changes made to our system to be followed for methods of procurements. County Auditors have provided an easy sheet to be followed and dated to be turned into the auditor's office to be approved prior to purchases as to see all steps have been completed of the procurement policy prior of purchasing items on any federal award. All items by County Auditor will be processed and looked at again prior to a check written.

Item 2023‐002 Written policies, procedures, and standards of conduct Recommendation: Grantees should have written policies, procedures, and standards of conduct as required by 2 CFR 200, Subparts D & E of the Uniform Guidance. 2 CFR 200, Subparts D & E requires the non‐Federal entity to establish and maintain written policies, procedures, and standards of conduct including internal controls over the Federal awards that provides reasonable assurance that the non‐Federal entity is managing the Federal statutes, regulations, and the terms and conditions of the Federal award. Specific requirements relate to the following: § 200.302 Financial management  § 200.305 Payment  § 200.319 Competition  § 200.320 Methods of procurement to be followed  § 200.430 Compensation—personal services  § 200.431 Compensation—fringe benefits We recommend that the City implement the required written policies and procedures. Action Taken: Management, namely Jan Boutwell, City Clerk, agrees with the finding and will implement the necessary written policies to comply with the UG. Management anticipates completion by September 30, 2024.

Failure to Follow Procurement Policy Finding 2023-003 Auditor Description of Condition and Effect: The Authority did not comply with the current procurement policy as procedures were not fully followed and required forms were not completed. The following forms required by either 2 CFR 200 and/or the Authority’s own procurement policy were not completed for the current year capital asset purchases: Written Record of Procurement Checklist Form, Method of Procurement Decision Matrix, Advertisement and Solicitation Form, Bid Quotations, Fewer Than 3 Offers Received Evaluation if applicable, Proposal Tabulation, Certification of Compliance with Federal Clauses for the assets less than $25,000, Responsibility Determination (sam.gov debarred verification), and Cost/Price Analysis. Also, as stated in the prior finding, the procurement policy needs to be updated. As a result, the Authority is noncompliant with 2 CFR 200 and its own procurement policy. Auditor Recommendation: We direct the Authority to implement procedures to ensure that the fiscal year 2022 is certified within the required nine-month deadline. Corrective Action Plan: The Authority will review and update its procurement policy to comply with federal requirements. The Authority’s management, consultant, and finance director will review the procedures in the policy to ensure they are being acted upon accordingly going forward. Responsible Official: Contact person is Rufus Adams, Executive Director,275 East Wall Street, P.O. Box 837, Benton Harbor, Michigan 49023. Telephone (269) 927-2268. Due Date: September 30, 2024

Federal Aid Policies Finding 2023-002 Auditor Description of Condition and Effect: The Authority’s management has completely turned over and been restructured. However, the Authority’s policies for federal aid approved in 2021 have not been revised to update for the current management structure. The policies have also not been updated for changes in the 2 CFR 200 that have occurred. As a result, the Authority is noncompliant with 2 CFR 200. Auditor Recommendation: We direct the Authority review and update all federal aid policies and implement procedures to ensure that they are being reviewed at least once a year for changes in the Authority’s management structure or changes that occur in the 2 CFR 200. Corrective Action Plan: The Authority will update their federal policies to comply with 2 CFR 200 and will review all policies on an annual basis going forward. Responsible Official: Contact person is Rufus Adams, Executive Director,275 East Wall Street, P.O. Box 837, Benton Harbor, Michigan 49023. Telephone (269) 927-2268. Due Date: September 30, 2024