Corrective Action Plans

Finding Number: 2023-003Condition: HCTD did not have sufficient controls in place to ensure compliance with their procurement policy and appropriate documentation is retained regarding the procurement methodology chosen. Planned Corrective Action: Procurement support is currently provided to HCTD through a contract with Hendrickson Transportation Group. This contract began in January 2024. Under this contract, the Procurement Policies and Procedures Manual and Disadvantaged Business Enterprise (DBE) Program are being updated, procurement forms will be created, and training for HCTD staff will be conducted. Contact person responsible for corrective action: Sara Hernandez, Executive Administrator, EEO & Procurement Manager Anticipated Completion Date: 12/31/2025

All County departments utilizing Federal dollars will be required to complete the Federally mandated procurement procedures. The County previously passed resolution #2018-868 pertaining to this requirement and will ensure all departments are following this policy moving forward.

FINDING 2023-004 Finding Subject: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds – Procurement and Suspension and Debarment Summary of Finding: Suspension and Debarment – Allen County did not have documentation that vendors’ suspension and debarment status were verified through either a) checking the Excluded Parties List System (EPLS), b) collecting a certification, or c) adding a clause or condition to the covered transaction agreement. Procurement – Allen County did not ensure purchases between $10,000 and $150,000 had received the adequate number of quotes or documented why an adequate number of quotes was not received. Contact Person Responsible for Corrective Action: Chris Cloud, Chief of Staff Contact Phone Number and Email Address: 260-449-4752 / chris.cloud@allencounty.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: To correct Finding 2023-004 for Suspension and Debarment, the Chief of Staff to the Board of Commissioners will check the EPLS on SAM.gov every time a contract is placed before the Board of Commissioners for signature not containing the appropriate suspension and debarment language or a county department starts a project with a vendor using State and Local Fiscal Recovery Funds (SLFRF). If a vendor is not found in EPLS, a certification will be solicited from the vendor prior to contract signing or purchase of goods or services verifying that they have not been suspended or disbarred. A new verification must be sought for every contract or purchase. Documentation will be kept on file by the Controller to the Board of Commissioners who is responsible for reviewing claims submitted for payment utilizing SLFRF. To correct Finding 2023-004 for Procurement, the Chief of Staff to the Board of Commissioners will instruct departments who may be spending between $10,000-$150,000 of SLFRF that price or rate quotations must be obtained from an adequate number of qualified sources. When departments submit a claim to the Controller of the Board of Commissioners for payment, they must also provide a cover sheet outlining a) rationale for the method of procurement, b) copies of quotes received, and c) a justification for the selected vendor. This information will be reviewed and if everything is in order, the cover sheet will be uploaded, along with the accompanying invoices, in the Workflow payment system as part of the record. Anticipated Completion Date: This CAP will be completed by December 31, 2024

Corrective Action Plan: A new Procurement policy is currently being drafted and will be approved prior to October 31, 2024. This will include update to policies to align with Shiloh’s general purchasing policy and updated to include requirements identifies in 2 CFR 200.318 through 200.326. Individual responsible for corrective action plan: Steven Ramirez

Condition and Context: For the one procurement selected for testing, ACT did not obtain multiple price or rate quotations. This is an issue of noncompliance relating to the Procurement, Suspension and Debarment compliance requirement. Recommendation: ACT evaluates the policies and procedures to ensure all procurement requirments are followed. Views of Responsible Officials and Planned Corrective Action: ACT accepts the auditors’ recommendation. We will review and update policies and procedures to ensure compliance with the Procurement, Suspension and Debarment requirements, including obtaining multiple price or rate quotations when applicable.

93.493 Congressional Directives Complete documentation of vendor suspension and disbarment verification was not maintained. While outside vendor verification services were performed monthly, adequate documentation for all vendors is not provided, only vendors with suspension or disbarment issues are identified and communicated to management. Management will coordinate with appropriate departments to review federal provisions for grant procurement and adjust policies and procedures to comply. Management will work with appropriate departments and the outside vendor to identify all grant related vendors and request positive verification monthly. All grant project directors will be educated on the procurement requirements for all federal awards. Contact Person: Jane Hardy – VP Corporate Accounting jane.hardy@childrens.com Expected Completion Date: December 31, 2024

FINDING 2023-001 Finding Subject: Special Education Cluster – Procurement, Suspension, and Debarment Summary of Finding: The School Corporation did not obtain price or rate quotes for the four vendors tested that was less than the simplified acquisition threshold of $150,000 but exceeded the $10,000 micro-purchase threshold. Documentation detailing the history of procurement, which must include the reason for the procurement method used, was not available for audit. There was no evidence of the School Corporation verifying two vendors tested for Suspension and Debarment that these vendors were not excluded or disqualified from participation in federal assistance programs or activities. Contact Person Responsible for Corrective Action: Matt Miles 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: This is a repeat finding due to the immediate timing of the prior audit and a lag for new controls to take effect. 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 will check for suspension and debarment, create a write-up of our findings, and obtain Board approval for the contract. Anticipated Completion Date: Corrective action steps have been implemented and will be refreshed.

Finding 2023-003 – Procurement Non-Compliance (Material Weakness) Federal Program Title: U.S. Department of Treasury – ALN 21.027, Covid-19 Coronavirus State and Local Fiscal Recovery Funds (CSLFRF), and Research and Development Cluster Assistance Listing Number: Various Action taken in response to finding: We have taken steps to identify all active federal awards that are subject to Federal procurement requirements under 2 CFR Part 200; these actions will ensure that all purchase orders and other subcontract arrangements under existing federal awards are subject to our purchasing system policies and procedures for Federal awards. Southern Research’s existing purchasing policies and procedures for Federal awards were reviewed and deemed acceptable in 2017 by the Defense Contract Management Agency (DCMA) Huntsville, AL. Contracts appropriately classified as Federal awards will be subject to purchasing policies and procedures that are compliant with Federal regulations. As part of the business process review, we will implement processes to ensure that all new Federal awards are classified correctly, and that Southern Research’s Federal purchasing system policies and procedures are applied to all Federal awards. Name of Person Responsible for the Corrective Action Plan: David A. Rutledge, Sr. Advisor - Finance Planned Completion Date for Corrective Action Plan: We anticipate that new process recommendations from the business process review related to purchasing will be implemented no later than 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 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 $33,100. 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. One vendor was identified that fell within the Simplified Acquisition Threshold, with total purchases of $213,734. Sealed bids or competitive proposals were not obtained, nor was a circumstance met that would have allowed for a noncompetitive procurement for the purchases. The County did not have any policies or procedures in place for verifying that an entity with which it plans to enter into a covered transaction is not suspended, debarred, or otherwise excluded. A population of six covered transactions, totaling $470,435, that equaled or exceeded $25,000 paid from SLFRF funds was identified. Four of the six covered transactions, totaling $312,745, were selected for testing. For each of the four transactions, the County did not verify the vendors' suspension or debarment status prior to payment due to the County not having any policies or procedures in place to verify that contractors were neither suspended nor debarred, or otherwise excluded or disqualified, from participating in federal assistance programs or activities. Contact Person Responsible for Corrective Action: Janet Chadwell Contact Phone Number and Email Address: 812-663-2570 jchadwell@decaturcounty.in.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: We have begun a procurement policy discussion with our county attorney who is working us on that. We will include in this procurement policy requirements to all entities requesting grant funds to provide documentation of requests for proposals, quotes and or sealed bids and explanations on why vendor was chosen. A procedure for proof of a vendors’ no suspensions or debarments from receiving federal funds will be also be added to this “policy in progress”. We will implement internal controls to ensure that the established procurement procedures are followed to ensure open competition. Anticipated Completion Date: December 31, 2024

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

A tracking procedure has been developed and a written procurement policy will be approved prior to the end of fiscal 2024 to further define procurement processes to align with Federal program standards and Village ordinance to address this deficiency.

Schedule of Corrective Action Plan For the Year Ended June 30, 2023 Finding 2023-003: Significant deficiency over Procurement and Suspension and Debarment Responsible Official’s Response and Corrective Action Plan We concur with the finding. BCI has an informal process of reviewing vendors and determining if they have been suspended or debarred. However, there is not a formal process where proper documentation such as screenshots of the search are saved. Due to the transition in the accounting department, we were not aware of these specific criteria at the time. We were notified of these requirements after the end of fiscal year 2024. To address these issues, we will implement a comprehensive process during fiscal year 2025 to ensure proper documentation and compliance with procurement regulations. This process will include: 1. Ensuring that all sole source vendor selections are properly documented and justified. 2. Verifying and maintaining records that confirm vendors are not debarred or suspended from doing business with the Federal Government before entering into contractual agreements. We are committed to improving our procedures and ensuring compliance with all applicable regulations moving forward. Planned Implementation Date of Corrective Action Plan September 1, 2024 Person Responsible for Corrective Action Plan Caryn York, Executive Director

Finding 2023-001: Significant deficiency over Procurement and Suspension and Debarment Responsible Official’s Response and Corrective Action Plan We concur with the finding. Due to the transition in the accounting department, we were not aware of these specific criteria at the time. We were notified of these requirements after the end of fiscal year 2023. To address this issue, WE in the World implemented a procurement policy as of March 2024. We will continue to use this comprehensive process during fiscal year 2024 and beyond to ensure proper documentation and compliance with procurement regulations. This process will include: 1. Ensuring that all sole source vendor selections are properly documented and justified. 2. Verifying and maintaining records that confirm vendors are not debarred or suspended from doing business with the Federal Government before entering into contractual agreements. We are committed to improving our procedures and ensuring compliance with all applicable regulations moving forward. Planned Implementation Date of Corrective Action Plan Instituted March 2024 Person Responsible for Corrective Action Plan Marta Bustos Kuperwasser Finance Director

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.

We concur with this finding and have implemented measures to mitigate the repetition or additional occurrences. In 2020, we implemented an electronic system to more efficiently collect and store expenditures and supporting documentation, eliminating a paper filing system. We updated our fiscal policies and procedures in 2022 to include procurement and implemented a procedure for ensuring compliance with obtaining required bids, etc. Responsible person(s): Jemea Dorsey, CEO and Jeanetta Johnson, Fiscal Manager Anticipated Completion Date: FY 2022

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.

Corrective action plan: Management believes that the procurement process has improved during the last year. The threshold for obtaining quotes was raised to $10,000 from $2,000, so there are significantly fewer transactions to monitor for compliance. The program managers are practicing more price comparison and obtaining quotes for purchases over $10,000, but not in every instance. The Finance Manager and the Accounts Payable Clerk will continue to monitor the documents submitted with purchase requests. Finance will not issue a check for payment to a vendor over $10,000, unless an adequate number of quotes and/or a sole source justification for the purchase has been submitted to document compliance with procurement standards For purchase requests over $10,000, the Finance Manager will perform a search of the database records on Sam.gov to determine if a vendor has been suspended or debarred. The Finance Manager will note on the purchase request the status of the organization according to Sam.gov and the date of the search. For those entities that are determined to be suspended or debarred, the purchase will not be approved. Personnel responsible for corrective action: Lisa Donham (Finance Manager), Deidre Moyer (Accounts Payable), and Program Managers Estimated corrective action completion date: December 31, 2024

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

Finding 2023-002 – Inadequate Design of Monitoring Controls over Procurement Policies Although Hamakua Health staff were not able to provide all the procurement records required by the auditors in the short period of time that was given, these procurement documents should have been scanned by those who initiated and completed the procurement processes and kept them in a ShareFile for easier access, especially for those contracts that are still active. This is now the new standard practice for all new procurement processes. Procurement policies that are complete, correct, and compliant exist have been and are in use at the Health Center. A process has been implemented where a daily purchases receipts log is kept, Purchase Orders and Packing Slips are scanned and attached to invoices to process for payment. Corrective actions have already been implemented at this time. Responsible person to be contacted regarding management responses: John R. White, MHA, BA, CHW Chief Executive Officer jwhite@hamakua-health.org 808.930.2745

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.