Corrective Action Plans

Federal Program Information Federal Agencies: U.S. Department of Health and Human Services and U.S. Department of Defense Federal Cluster: Research and Development (R&D) Pass-Through Entity: The University of Texas Health (93.853, NS119834) Assistance Listing Nos.: 12.420, 93.310, 93.353, 93.393, and 93.853 Award Numbers: W81XWH-15-1-0292 (12.420), OD23121 (93.310), CA246568 (93.353), CA259201 (93.393), NS119834 (93.853), NS122096 (93.853) Award Periods: Various Corrective Action Planned Management conducted an education and training session for procurement teams in June 2024 to reinforce procurement requirements and documentation standards. Management will implement an independent sanction and debarment check for suppliers as part of existing quarterly audits over Supplier AP vendor master tables and related changes to those tables. Persons Responsible for Corrective Action Daniel Schmitz, Division Chair - Supply Chain Management Scott Hammer, Director - Supply Chain Management Target Completion Date June 30, 2024

Views of Responsible Officials: NFHA will review and update its current Procurement Policies to ensure that they meet all current Federal and Uniform Guidance requirements. This will include documentation of contractor selection and single source vendor criteria. NFHA will provide additional training to all staff on the revised policies and procedures.

Going forward, the board will vet any grant offers that require a specific vendor with our legal counsel before accepting funds.

Procurement Policy which includes elements outlined by 2 CFR 200.320 established and adopted.

The School District should be in compliance with the NJ DOE purchasing guidelines.

Sanford Corrective Action Plan December 31, 2023 Finding 2023-001 – Suspension and Debarment/Procurement Information on the federal program: Federal Agency: United States Department of Health and Human Services, Health Resources and Services Administration (HRSA) Assistance Listing: 93.155 Award Year: 2021 Planned corrective actions: As it relates to the reliance on the third-party vendor that conducts suspension and debarment -party vendor searches, the third-party vendor provides Sanford a SOC (System and Organizational Controls) 2 Type II report annually over the effectiveness of its controls. This is reviewed by Sanford’s compliance department to ensure that there are no findings that would be of concern to Sanford’s reliance on the vendor transaction. Considering the third-party vendor is not relied upon for financial controls, the third-party vendor does not have a SOC 1 (System and Organization Controls) Report and therefore did not provide this level of report to Sanford. To provide context on scale of vendors subject to suspension and debarment, Sanford paid a total of 23,754 vendors in 2023. There were three vendors identified through the vendor setup and monitoring process to be suspended or debarred. None of those vendors were associated with the programs funded with federal funds. Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being paid to the vendors that are suspended or debarred. Sanford believes the risk of any material disbursement to suspended and debarred vendor is effectively mitigated through existing preventive and detective internal controls. In August 2023, Sanford began documenting a periodic validation of the suspension and debarment search results performed by the third-party vendor for vendor searches that yield no suspension and debarment match. In addition, Sanford enhanced its procedural documentation regarding retention of evidence related to reconciliation of vendor list when discrepancies are identified and the suspension and debarment results generated through the vendor setup process. Responsible official: Tracy Sattler, Director of Compliance and Melanie Paape, Vice President of Supply Chain Operations As it relates to the procurement of goods and services, Sanford’s preventive and detective controls and operating procedures provide reasonable assurance over the effectiveness of the controls necessary to prevent the risk of federal funds being utilized for procurement. Sanford believes the risk of any material disbursement subject to procurement is effectively mitigated through existing preventive and detective internal controls. To provide context on the scale of procurement under the program $2,298,733 in expenditures exceeded the micro purchase threshold and $307,249 were found to have inadequate documents for sole source. Sanford will provide education to applicable departments related to the compliance requirements subject to procurement. Sanford will document the procurement process from the initial approval to potential sale/disposition items. Responsible official: Kristi Crawford, Director of Office of Grants Anticipated completion date: June 30, 2024

Corrective Action Planned: Management concurs with the finding. The District’s policies will be updated and approved to conform to federal guidance. Additionally, management will begin paying all vendors awarded through competitive procurement, on projects paid with federal funds, directly from the District’s bank accounts and not through a third part grant administrator. Lastly, Management of MSIDD has since obtained express authorization from the pass-through entity to use ED3 as a sole source vendor.

The Organization is in the process of developing a procurement policy and suspension and debarment policies that aligns with Uniform Guidance.

U.S. Department of Health and Human Services Southern Illinois Healthcare Foundation respectfully submits the following corrective action plan for the year ended December 31, 2023. Audit period: January 1, 2023 – December 31, 2023 The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS—FEDERAL AWARD PROGRAMS AUDITS DEPARTMENT OF HEALTH AND HUMAN SERVICES 2023 – 001 Consolidated Health Centers Recommendation: Management should adhere to or revise the Organization’s existing procurement policy and implement a system of processes and internal controls to ensure that the appropriate level of documentation is maintained based on the procurement methodology selected for a transaction of contract. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Hospital will ensure that controls are put into place to ensure procurement procedures are followed. Name of the contact person responsible for corrective action: John Jeffries, CFO. Planned completion date for corrective action plan: January 1, 2024. If the Department of Health and Human Services has questions regarding this plan, please call John Jeffries at 618-332-5324.

Finding 2023-007: Procurement Finding: The District did not maintain adequate records for procurement transactions in the IDEA and Child Nutrition Clusters. Corrective Actions Planned: The District will train its employees on the documentation trail needed for procurement actions and review its policies and procedures for any needed updates. Expected Implementation Date: June 30, 2024 Contact Person: Dr. Frank Williams

Views of Responsible Officials: The Organization will complete and implement a formal, written procurement policy.

FA 2023-002 Improve Controls over Procurement Compliance Requirement: Procurement and Suspension and Debarment Internal Control Impact: Material Weakness Compliance Impact: Material Noncompliance Federal Awarding Agency: U.S. Department of Education Pass-Through Entity: Georgia Department of Education Assistance Listing Number and Title: 84.027 - Special Education Grants to States COVID-19-84.027 - Special Education Grants to States 84.173 - Special Education Preschool Grants COVID-19-84.173 - Special Education Preschool Grants Federal Award Number: H027A210073 (Year: 2022), H027A220073 (Year: 2023), H027X220073 (Year: 2023), H173A210081 (Year: 2022), H173A220081 (Year: 2022), H173X220081 (Year: 2023) Questioned Costs: $88,074 Prior Year Finding: FA 2022-001 Description: A review of expenditures charged to the Special Education Cluster (Assistance Listing Numbers 84.027 and 84.173) revealed that the School District's internal control procedures were not operating appropriately to ensure that the School District's procurement procedures were followed. Corrective Action Plans: We concur with this finding and as noted it is a repeat finding from the previous year (2022). We have updated our federal purchasing policy with the following verbiage to address micro purchases. "For purchases less that $10,000, no competitive quotations will be required (micro purchase procedures). As defined by FAR 2.101, as in acquisition of supplies or services, the aggregate amount of which does not exceed the micro-purchase threshold ($10,000). For purchases between $10,000 and $250,000, price quotes from at least three qualified." Internal Controls procedures have been reviewed and will be followed to ensure that required procurement methods are being applied to each transaction and that proper documentation is maintained in the expenditure field. Transactions will be reviewed by the Program Directors to ensure that the internal control procedures are operating appropriately and in accordance with Federal Programs Uniform Guidance. Estimated Completion Date: Fiscal Year 2024 Contact Person: Trey Wood, Finance Director Telephone: 706-795-2191 ext. 1023 Email: trey.wood@madison.k12.ga.us

MANAGEMENT’S PLANNED CORRECTIVE ACTION: For noncompetitive procurement, the District will maintain records sufficient to detail the history of procurement. These records will include but are not limited to the rationale for the method of procurement, selection of contract type, contractor selection or rejection, and the basis for the contract price. The District’s timeframe for implementation is effective immediately. Currently, the District has contracted with J. Martin & Associates, LLC (JMA) to provide business office accounting services. Representatives from JMA and the rest of the business office staff will monitor the implementation of noncompetitive procurement procedures to ensure that they are followed appropriately.

Action taken in response to finding: The City will review procurement policies for the entire City to ensure it meets the minimum requirements of 2 CFR 200 for all federal grants.

This compliance finding relates to the previous administration, who did not properly have the vendor bid out in accordance with federal guidelines. The City will review their policies and procedures to ensure that all contracts that have federal expenditures are properly bid in accordance with 2 CFR 200.320.

Personnel Responsible for Corrective Action: Policies and procedures will be supervised by COO, Tracie Thomas, Facilities Operations Manager, Tiffany Durr, Senior Accounting Specialist, Laura Froese, and Grants Specialist, Westen Gehring Anticipated Completion Date: Policies and procedures will be reviewed, drafted, and implemented by May 30, 2024 and reflected in the 2024 audit. Corrective Action Plan: To ensure compliance with federal procurement standards, by 05/30/2024 The Land Institute will develop more robust policies and procedures for tracking purchases in accordance with uniform guidance standards for formal federal procurement and noncompetitive procurement of equipment with federal funds. Updated policies will apply to micro-purchases above the threshold of $10,000 and will include requirement of documentation demonstrating that TLI checked the vendor’s status to ensure they were not suspended or debarred. A sole source justification form will be drafted and made available upon request for purchases where noncompetitive procurement was deemed necessary. These changes will be reflected in an updated procurement policy document as well as the development of a sole source justification template.

1. The District will obtain more information from the Ohio Purchasing Council going forward on future projects. 2. On the purchase of a used van, the transportation supervisor searched for a van that would suit the needs for our school district. 3. Our maintenance supervisor received 2 quotes for the floor scrubbers that we purchased. The district split the order between the two vendors.

Finding Number: 2023-002 Condition: The Society did not have documentation to support that two covered transactions were checked for potential suspension or debarment before entering into the transaction. There was one covered transaction where the Society did not have documentation to support the procurement process followed or that more than one vendor was reviewed for pricing before selecting the vendor chosen. Planned Corrective Action: Staff turnover in early 2023 resulted in limited capacity for dedicated staff to check for potential suspension or debarment before adding vendors to the system. We have dedicated staff who will be managing this process going forward. The Society has written procurement policies and procedures. Key leadership stakeholders have been apprised of our policies and procedures. The Society will be implementing a training series for government funded procurement stakeholders within the Society to ensure compliance. Contact person responsible for corrective action: Dharshni Sabapathy, Senior Director of Accounting Anticipated Completion Date: April 25, 2024

The district expended Child Nutrition program funds of $71,250. Competitive bids were obtained, but the district failed to advertise for requests for proposals for the purchases.

Person(s) responsible for the corrective action is Jenny Blevins, Child Nutrition Director, and Linda Tullos, Superintendent.

The district updated and strengthened the procurement plan to follow formal purchase procedures. The updated procurement plan was implemented on 11/14/2023.

Finding 2023-001: Internal Control Over Financial Reporting Corrective action: Because of its size, the City does not feel it is cost effective to hire an employee(s) with the experience and technical training to prepare its financial statements. The City is, however, willing to assist with the preparation and will continue to work to gain experience in this area. Responsible Person: Blyann Johnson Anticipated Completion Date: Ongoing Finding 2023-002: Internal Control Environment Corrective action: The City is aware of our lack of controls over accounts payable/disbursements, payroll, property taxes, utility billing and collection and period close. Because of our size, we do not feel it is cost effective to hire the number of employees needed to cure these internal control deficiencies. Responsible Person: Blyann Johnson Anticipated Completion Date: Ongoing Finding 2023-003: Significant Deficiency - Internal Control Over Procurement, Suspension and Debarment Corrective action: Management and the City Council will create and approve a written procurement policy that meets the requirements for Uniform Guidance. Responsible Person: Blyann Johnson Anticipated Completion Date: 12/31/2024

The School District will follow proper procurement procedures related to food purchases.

Views of Responsible Officials: RFE/RL Finance has provided clarification and additional guidance to Department Directors and the Procurement team to reinforce the importance of documenting the steps and decisions that result in a Sole-Source justification in the requisition process. Management has engaged Procurement consultants who have produced clear purchasing guidelines for the company including documentation requirements. RFE/RL has hired a new Procurement Director with the responsibility to improve management of the process and direction to the procurement team to ensure that support for sole source purchases is complete, maintained, and made available for review during the audit process and upon management request. Management believes that substantial progress has been made in either justifying sole source acquisitions within the limits of 2 CFR 200.320 or requiring competitive bids since the new Procurement Director has been appointed. It is Management’s intent to continue to operate in a way that removes this significant deficiency as a concern.

The Center did not follow the appropriate procedures to comply with Uniform Grant Guidance. During testing, it was noted that the Center made procurements through noncompetitive procurement arrangements. Consistent with 2 CFR § 200.320(c)(3), an LEA may determine that its response to the COVID-19 pandemic qualifies as a public exigency or emergency that does not permit the delay that would result from competitive bidding. Under these circumstances, and to the degree doing so is consistent with its own policies and procedures, the Center could use noncompetitive procurement. The Center should consult with the Pennsylvania Department of Education before using this authority. Subsequently, the Center paid for this purchase utilizing the Education Stabilization Fund and Career and Technical Education monies. In using federal funds to pay for these items, the Center inadvertently did not follow its procurement policy. Response and Planned Corrective Action: The Center acknowledges this finding, and has since revised its procurement process to include the requisite items as required by the US DoE (ED) Uniform Grant Guidance (UGG) in its subsequent purchases with Federal Funds. It is also noted that most if not all of these purchases were made in response to the COVID-19 Pandemic, and with delayed guidance from PA Department of Education’s Federal Programs Office. When alerted to the guidance, the Center implemented the proper procedures. Planned Corrective Action: • When using federal funds, the Business Manager/Asst. Business Manager will ensure that cooperative purchasing programs or noncompetitive purchasing arrangements comply with the UGG procurement policy. • The Business Manager/Asst. Business Manager will document the process and how it complied with the procurement standards and keep such documentation with Federal Award budget/procurement documents.