Corrective Action Plans

Views of Responsible Officials The Organization agrees with this finding. Corrective Action Plan The Organization will continue to abide by its procurement policy and will check its vendors against the exclusion list on the System for Award Management website. Name(s) of Responsible Individuals Lacy Kimes, Board President Anticipated Completion Date October 31, 2024

Material weakness in internal control over compliance with procurement procedures meeting the requirements of 2 CFR Part 200. Management Response: We acknowledge the finding and provide the following corrective action plan. Corrective Action Plan: Action steps Who At least quarterly program level review of budget vs. actuals to discuss trends, variances, potential errors in coding of transaction Finance Team and Executive Directors At least quarterly review of admin costs, to review for trends against budget and errors in classification of transactions Finance Team and Executive Directors Adjust cadence /deadlines for balance sheet reconciliations and incorporate Finance Director level review. Ensure adjustments are made in a timely manner. Finance Team Email weekly cash deposit report for Executive Directors and Finance Director to review for proper classification in the general ledger Finance Team and Executive Directors Streamline key processes which will allow finance team the time and flexibility to analyze and strategize and get ahead of firedrills; this will allow them to understand the story that the numbers are telling. Finance Team Continue to document procedures. This will ensure proper backup when team members are out due to vacation or illness. Comprehensive, documented procedures are the teams bench strength. Finance Team Ensure all transaction in the general ledger have proper backup to ensure understanding of underlying transaction Finance Team Anticipated Completion Date: End of 2024 Name(s) of the Contact Person(s) Responsible for Corrective Action: Barbara Donohue, Director of Finance Lisa Daugaard and Tara Moss, Co-Executive Directors

Views of Responsible Officials and Planned Corrective Action - Our Chief Procurement Officer has been trained on entering into covered transactions and the requirement to check for any suspension or debarment by vendors in SAM.gov. The County will also maintain quotations for items over the micro-purchase threshold. This will be a documented process in the new policy and procedures manual for federal guidelines for Commission approval in November 2024. Responsible Official -Andrea Montoya, Deputy County Manager, and Robert Placencio, Finance Director Timeline and Estimated Completion Date - Resolved.

Views of Responsible Officials and Planned Corrective Action - The County has written Policy and Procedures to be reviewed by the commission in November 2024 for approval. Responsible Official -Andrea Montoya, Deputy County Manager and Robert Placencio, Finance Director Timeline and Estimated Completion Date -November 2024.

Implementation of plan of action - Management will review its procurement policies to ensure that the School complies with 2 CFR 200.320 of the Uniform Guidance. Implementation date - Anticipated completion October 15, 2024. Persons responsible for the implementation - The Board of Directors and Head of School.

Incorporate a Federal Procurement Policy (Res # 24-11)

Action taken in response to finding: 1. Review Current Procurement Policy: in progress a. Conduct a comprehensive review of Promise Healthcare’s existing procurement policy. b. Identify and revise and discrepancies or non-compliance with the requirements of the Uniform Guidance. c. Integrate industry best practices into revised policy to enhance compliance and efficiency 2. Training and Education: to start a. Provide training sessions for staff authorized to purchase along with relevant personnel on the revised procurement policy and procedures and raise awareness of the requirements of the Uniform Guidance and implications of non-compliance. b. Establish training on documentation standards for procurement activities including requisitions, solicitations, evaluations and contract awards. c. Establish training and procedure for retention of procurement-related documentation 3. Internal Controls and oversight: to start a. Implement mechanisms for monitoring and oversight to ensure compliance with the procurement policy. b. Conduct periodic internal audits to assess adherence to procurement procedures and identify areas for improvement or corrective action Name of the contact person responsible for corrective action: Keith Flores, CFO Planned completion date for corrective action plan: Winter 2025

Management Comments and Corrective Action: Due to the growing need to adequately care for the minors at SWK’s shelters coupled with the limitations of access to vendors caused by COVID-19, SWK utilized existing vendor to minimize significant disruptions to operations. The Organization is aware they are operating under contracts that were procured in previous years that may not have all the records maintained. Reprocuring all of these contracts at once would potentially cause disruptions in operations due to the products/services related to those vendors playing an important role in the Organization’s day-to-day operations. In April 2021, the Organization hired new procurement leadership and invested in Full Time Employees (FTEs) to develop a robust procurement department. Due to this procurement revamp, Procurement adopted a hybrid model, and Desktop Protocols were established to provide universal procedures to fulfill policy. Protocols instruct staff on obtaining three quotes and provide tools for selecting the vendor. In addition, quality protocols and tools are currently in development to verify a random sample of procurement transactions and files. The Organization still has several active contracts procured under the old policies that they are working on reprocuring as these contracts’ renewal dates arise, if not earlier. Proposed Implementation Date of Corrective Action: In process and to be completed by December 31, 2025. Person Responsible for Corrective Action: Steven Beckman, CFO

Coronavirus State and Local Fiscal Recovery Fund – Assistance Listing No. 21.027 Recommendation: We recommend the County carefully review federal procurement requirements for proper documentation needed. The County should consider use of a Federal procurement checklist. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Any new vendors selected for the SLFRF program will be reviewed for suspension or debarment by the Auditor’s office in SAM.gov. Auditor’s office has discussed the process of procurement documentation of all SLFRF program vendors with administrative personnel. Name(s) of the contact person(s) responsible for corrective action: Eric Black, Chief Deputy Auditor. Planned completion date for corrective action plan: November 30, 2024

Reference: 2023-003 Corrective Action: The City will work on updating the procurement policy to include clearer expectations. Responsible Person: Kristopher Hanus Frederickson, Mayor; Patrick Reagan, City Administrator; Wendi Bixby, Finance Director/Treasurer Anticipated Completion Date: 12/31/2025

THE COUNCIL WILL ENSURE THAT ALL FUTURE PROCUREMENTS CORRECTLY USE AND RETAIN A PROCUREMENT SHEET WHICH DOCUMENTS THE ITEMS PURCHASED, THE BIDS RECEIVED/REQUESTED, AS WELL AS AN ANALYSIS OF THE REASONS FOR THE WINNING BID. THE WINNING CONTRACTOR/VENDOR WILL BE SEARCHED ON THE SAM WEBSITE TO DETERMINE THAT THEY ARE NOT SUSPENDED/DEBARRED.

We value your guidance and are committed to enhancing our compliance with the Uniform Guidance. In response, we will: 1. Documentation Procedures: We will implement procedures to properly document procurement activities. This will help us maintain consistency and ensure compliance with the Uniform Guidance. 2. Monitoring and Accountability: Additionally, we will establish a system to regularly monitor our compliance with these policies and procedures. This will enable us to quickly address any issues that may arise. The Finance Department will be responsible for implementing these changes and will have everything ready before the end of 2024. We are dedicated to making these improvements and truly value your support as we work through this process. Personnel responsible: Eduardo Cedeno, Director of Finance Anticipated completion date: December 31, 2024

Management will develop, adopt and implement a procurement policy for federal purchases that aligns with the requirement of the 2 CFR 200 Uniform Guidance. This process will include steps within the interview and application process to ensure contractors and subrecipients are eligible (not suspended, debarred, or otherwise excluded) to enter into an agreement, contract, or subaward with the City. The process will also include steps to ensure all necessary language, such as the Buy America Build America Provisions are included in the final contracts.

Management of the Town will work to adopt a formal procurement policy that is in compliance with Federal Uniform Guidance and State requirement. The Town will also assign a federal procurement leader that will help determine requirements for federal versus nonfederal awards as well as ensuring the Town's new procurement policy is followed.

Management has implemented and adopted a new procurement policy effective May 2023 regardless of dollar value that will maximize open and free competition and that the Trust shall not engage in procurement practices which may be considered arbitrary or restrictive. Purchases will be reviewed by the Tule Trust Finance Committee to prevent duplication and to ensure that costs are reasonable.

Management of the City will work to adopt a formal procurement policy that is in compliance with Federal Uniform Guidance and State requirements. The City will also assign a federal procurement leader that will help determine requirements for federal versus nonfederal awards as well as ensuring the City’s new procurement policy is followed.

Type of Finding: Material Weakness in Compliance and Internal Control over Compliance Federal Agency: U.S. Department of Defense Federal Program Name: Conservation and Rehabilitation of Natural Resources on Military Installations Assistance Listing Number: 12.005 Federal Award Identification Number and Year: H79TI083313 - 2020 Award Period: September 28, 2020, through September 27, 2025 Criteria or specific requirement: 2 CFR 200.320 requires non-federal entities to have and use documented procurement procedures. 2 CFR 200.318(i) states that "the non-Federal entity must maintain record 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, 2 CFR 200.320(a)(2)(i) states that "... If small purchase procedures are used, price or rate quotations must be obtained from an adequate number of qualified sources as determined appropriate by the non-Federal entity". Furthermore, 2 CFR 200.320(b) states that "When the value of the procurement for property or services under a Federal financial assistance award exceeds the SAT, or a lower threshold established by a non-Federal entity, formal procurement methods are required. Formal procurement methods require following documented procedures. Formal procurement methods also require public advertising unless a non-competitive procurement can be used in accordance with § 200.319 or paragraph (c) of this section.". Condition: During our testing, it was noted that the Organization was not performing suspension and debarment checks prior to entering into vendor contracts to ensure the vendor was not listed in the suspended or debarred database maintained by the General Services Administration. In addition, the Organization does not have an established procurement policy nor procedures in place at the time of the audit in compliance with Uniform Guidance. Questioned costs: None. Context: For procurement, a sample of 8 was made from a population of 30 procurement transactions charged to the major program that exceeded $3,000 (the Organization's procurement policy after 2023 and below the minimum micropurchase threshold before it was increased by the FAR to $10,000 for those with a written established policy). Of the 8 sampled procurement selections, three did not retain an adequate number of price comparisons prior to exercising the procurement, four did not follow the formal procurement methods for proposals when required, and all lacked evidence of controls over procurement considerations. For suspension and debarment, a sample of 3 was made from a population of 3 (entire population) suspension and debarment transactions charged to the major program. Of the 3 sampled, all were not checked for suspension or debarment prior to entering into the transaction. Cause: Prior to completing the prior year’s audit, staff were not aware of the specific compliance requirements and procedures for procurement, suspension, and debarment status. Effect: Purchases may occur that do not follow the procurement, suspension and debarment standards as required by Uniform Guidance, and contracts to vendors that had been suspended or debarred could be awarded and not detected. Repeat Finding: The finding is a repeat of a finding in the immediately prior year. Prior year finding number was 2022-002. Recommendation: We recommend the Organization ensure its current process to review potential contractors for suspension and debarment is taking place prior to entering into transactions with such entities. The Organization has already taken steps to address considerations around procurement by implementing a Procurement Approval form. CLA recommends the use of this form, including signature, and emphasizes the importance of retaining adequate price rate quotations, RFP documentation, sole-source evidence, and price analyses in accordance with their established thresholds. Views of responsible officials: There is no disagreement with the audit finding. Action taken in response to finding: Previous corrective actions were completed in April 2024 upon receipt of our FY 2022 Audit from CLA. We believe these corrective actions would have captured most, if not all, of the findings if they were in place for the entire FY23 period. That said we have further reviewed and expanded our internal controls around procurement, suspension, and debarment, including the process for reviewing potential contractors for suspension and debarment. Specifically, we have added language in all agreement templates to ensure we are in accordance with Uniform Guidance. As noted, we have also added a procurement approval form and a standardized process for approval signature, quotes, sole source evidence and price analyses. As part of that effort, we have also updated threshold amounts for micro-purchase, small purchase, and procurement standards to be consistent with FAR and we are providing additional training to staff. Name(s) of the contact person(s) responsible for corrective action: Gary Slater Planned completion date for corrective action plan: 10/1/2024

Management is dedicated to enhancing the competencies of our federal grant personnel. The College will offer focused and comprehensive re-training on both our internal procurement policies and the procurement requirements outlined in the Uniform Guidance to workforce members responsible for procurement under federal awards. This re-training will ensure that all staff members understand protocols and regulations, thereby promoting compliance and efficiency in our procurement processes. The Privacy and Research Compliance Officer will monitor Program Management staff to ensure that price and rate quotations are obtained from a sufficient number of qualified sources. The Legal Department will not move forward in contract drafting until evidence of compliance with the College’s federal procurement policies is confirmed. This collaborative effort ensures informed purchasing decisions based on competitive pricing. Additionally, the Privacy and Research Compliance Officer will maintain evidence of price and rate quotation consistent with procurement policies. Through these initiatives, management aims to ensure procurement that aligns with both internal standards and federal regulations, ultimately supporting the effective and responsible use of federal funds.

Additional training and review of the procurement process will take place. This office will coordinate with other departments with training and expectations.

Home Builders Care, Inc. will update its procurement policy in accordance with the recommendations.

Management is looking into systems to track the spending on contractors so they can ensure to request price quotes when the contracted amount rises over the micro-purchase threshold. Management is also retraining Program and Grants Management staff on procurement standards and requirements. The responsibility for this will be handled by the VP of Finance, or in the absence of the VP of Finance, it will be the responsibility of the Director of Development. The above corrective actions will be taken by the end of this year, December 31, 2024.

FINDING 2023-003 Finding Subject: COVID-19 CORONAVIRUS STATE AND LOCAL FISCAL RECOVERY - PROCUREMENT AND SUSPENSION AND DEBARMENT. Summary of Finding: There were deficiencies in the internal control system of the City resulting in noncompliance with the grant’s procurement and suspension and debarment requirements. Contact Person Responsible for Corrective Action: Ashley Huffman Contact Phone Number and Email Address: 765-521-6803 nccityclerk@gmail.com Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The City did not follow its policy for Federal Grant Disbursements. The Clerk Treasurer's office will ensure compliance with the Procurement requirement. The City has implemented maintaining contract files with the Deputy Clerk Treasurer reviewing to ensure they contain documentation of the history of the procurement, including the rationale for the method of procurement and selection of the vendor. Anticipated completion date: September 1, 2024

FINDING 2023-005 Finding Subject: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds – Procurement and Suspension and Debarment Summary of Finding: Procurement - Policy The County had not established a purchasing policy that would reflect applicable state laws and regulations including procedures to avoid acquisition of unnecessary or duplicative items, 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 and did not maintain written standards of conduct covering conflicts of interest and governing actions of its employees engaged in the selection, award, and administration of contracts. Procurement – Small Purchases The County had one vendor that was identified as being less than the simplified acquisition threshold of $150,000 but exceeding the $50,000 micro-purchase threshold. The one vendor was selected for testing. For the one vendor, the County did not obtain price or rate quotes nor was there documentation detailing the history of procurement, which must include the reason for the procurement method used. Suspension and Debarment One covered transaction paid with SLFRF grant funds was identified during the audit period. The covered transaction totaled $66,000 with $46,752 paid in the audit period. Upon review, the County had not performed procedures to ensure the vendor was not suspended or debarred, or otherwise excluded or disqualified, from participation in federal assistance programs or activities at any time during the audit period Contact Person Responsible for Corrective Action: Bryan Lewis Contact Phone Number and Email Address: 574-223-4764 and blewis@co.fulton.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The County will work on establishing a purchasing policy which will address federal procurement requirements. Before entering into contracts we will ensure the procurement procedures in the policy are followed and obtain quotes for vendors that meet the small purchase threshold as well as verify the suspension and debarment status. The Commissioners and Auditor’s office will work together to ensure requirements are met before payment is processed. Anticipated Completion Date: No later than December 31, 2024

Finding 2023-001 Procurement, Suspension and Debarment (Repeat Finding 2022-001 and 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: a. The Purchasing Manual was revised in 2023 to incorporate procedures relating to suspension and debarment checks. Purchasing will 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. b. City staff will work with the City’s Purchasing Department to follow and adhere to applicable Procurement procedures. c. Ensure all departments are following applicable procedure in a uniform manner. Contact Person: Hitesh Desai, Chief Financial Officer 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 Finding: The County entered into an interlocal agreement with the City of Sullivan to procure services for a Sewer Lift Station Improvement/Line Extension to the New County Jail project. The County could not provide any documentation required to verify compliance with the procurement and Suspension and Debarment requirements for the SWIF funds spent on the project. Contact Person Responsible for Corrective Action: Amy Scarbrough Contact Phone Number and Email Address: (812)268-4491 ascarbrough@sullivancounty.in.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The County will adopt a procurement policy. In addition, the County will work with the City of Sullivan to obtain the necessary documentation related to the interlocal agreement and maintain the documentation for future audit periods. Anticipated Completion Date: October, 2024