Corrective Action Plans

FINDING 2023-005 Finding Subject: Special Education Cluster (IDEA) – Procurement and Suspension and Debarment Summary of Finding: Procurement Federal regulations allow for informal procurement methods when the value of the procurement for goods or services does not exceed the simplified acquisition threshold, which is customarily set at $250,000. However, Indiana Code 5-22-8 has a more restrictive threshold of $150,000 or less for when small purchase procedures may be used. This informal process allows for methods other than the formal bid process. The informal process is divided between two methods based on thresholds. Micro-purchases, typically for those purchases $10,000 or under, and small purchase procedures for those purchases above the micro-purchase threshold, but below the simplified acquisition threshold. Micro-purchases may be awarded without soliciting competitive price rate quotations. If small purchase procedures are used, then price or rate quotations must be obtained from an adequate number of qualified sources. If it is determined a single source provider can be used for a small purchase, documentation must be retained supporting the determination. The Cooperative did not adhere to the requirements necessary for them to be in compliance with the procurement of small purchases during the audit period. Suspension and Debarment The School Corporation did not have internal controls in place to ensure compliance with the suspension and debarment requirement. The Cooperative did not have adequate internal controls in place to ensure all applicable vendors were not suspended or debarred prior to entering into a covered transaction. As such, the Cooperative never entered into a contract, although their payments to the vendor exceeded $50,000. The Cooperative did not perform procedures to ensure that the vendor was not suspended or debarred from participation in federal programs. Contact Person Responsible for Corrective Action: Julie Dudley Contact Phone Number and Email Address: 812.537.7205 jdudley@lburg.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The ROD Special Education Cooperative will make notes in the Board Minutes regarding the fact that only one vendor can provide specific services prior to entering into a contract or purchasing said services. Each company providing services will be checked on the SAM.gov website to ensure that the vendor has not been suspended or debarred. This documentation will be provided to the ROD board for review, and our Superintendent is a member of that board. Anticipated Completion Date: February 1, 2024

FINDING 2023-005 Finding Subject: Child Nutrition Cluster - Procurement and Suspension and Debarment Summary of Finding: Management had not developed a system of internal controls that would have ensured compliance with the grant agreement and the Procurement and Suspension and Debarment compliance requirement. The failure to establish an effective internal controls system enabled material noncompliance to go undetected. Noncompliance with the grant agreement and the Procurement and Suspension and Debarment compliance requirement could result in the loss of future federal funds to the School Corporation. We recommended that the School Corporation's management establish a system of internal controls to ensure compliance with the Procurement and Suspension and Debarment compliance requirement. Contact Person Responsible for Corrective Action: Andrea Miller Contact Phone Number and Email Address: 765-564-2100, millera@delphi.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The Food Service Director will obtain 3 quotes for any purchase over $10,000 from different vendors, in addition if the purchase is over $50,000 a contract will be awarded. Vendors will be verified by SAM.gov for suspension and disbarment, a record of these searches will be printed and kept in the vendor file. In addition, a vendor list will be provided annually to the school board for approval. Anticipated Completion Date: July 2024

The City agrees with the finding. Over the past several years, the City has developed a significant number of guidance documents and trainings in the area of federal procurement. All of the guidance documents for Central Purchasing are housed in the Purchasing SharePoint site. The guidance and training have in the past been directed at the members of the Purchasing Liaison User Group, but given the continued findings, the City intends to reach out to a much broader group to ensure compliance, including Directors, Deputy Directors, and program representatives. This will be complete by June 30, 2024.

This document serves as the response to the 2022-2023 Financial Audit on behalf of BELIEVE Schools, Inc. We’ve identified and reviewed the finding outlined below: The results of our auditing procedures disclosed one instance of noncompliance which is required to be reported in accordance with Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (“Uniform Guidance”) and which is described in the accompanying schedule of findings and questioned costs as Finding No. 2023- 001. Our opinion on the major federal programs is not modified with respect to these matters. In an effort to address the finding and to ensure the school's alignment with federal compliance standards, the following corrective action plan has been implemented for all purchases made with federal and state program funds: 1. For any procurement or contract ranging from $10,000-$250,000, The Principal, Angel Jackson-Anderson, should seek to acquire as many quotes as possible, aiming for up to five. Prior to finalizing any purchase order, invoice, or commencement of production, the school is mandated to receive and assess three price comparisons from different businesses or organizations. These price comparisons must be logged in the BCCHS Quote Comparison Template and reviewed by the following parties: a. The individual conducting the price comparison b. Building Level Operations Leader c. Executive Director for purchases or contracts exceeding $20,000 2. For any purchase or contract exceeding $250,000, a formal bidding process is required. BELIEVE Schools has adopted resources provided by the Indiana Department of Education: a. Procurement Checklist b. Procurement Plan Template (accessible through DOE) This protocol has been incorporated into the Standard Operating Procedures and School Handbooks, with all relevant stakeholders duly informed on February 16th, 2024.

FINDING 2023-003 Finding Subject: Subject: Child Nutrition Cluster - Procurement Summary of Finding: An adequate number of quotes were not obtained for small purchases. Contact Person Responsible for Corrective Action: Kellie Romer (Corporation Treasurer/Finance Director), Shelley Gardner (Corporation School Food Authority) Contact Phone Number and Email Address: 765-653-9771 Ext. 1010, kromer@greencastle.k12.in.us, 765-653-9771 Ext. 1011, sgardner@greencastle.k12.in.us Views of Responsible Officials: We concur with the finding Description of Corrective Action Plan: The procurement (small and micro purchases) will be verified by a two-person internal control; the food services director and food services assistant, finance director or deputy treasurer. We will also establish a process to address small and micro purchases. This would include acquiring bids for any combined expenditure(s) over a $150,000, acquiring quotes for any small purchase(s) between $10,000 and $150,000, and documenting equitable distribution among vendors concerning any micro purchases under $10,000. All vendor contracts will be approved yearly. All quotes and purchases will be verified by two-person internal control. Anticipated Completion Date: Immediately 2/8/2024

Condition: The organization did not have adequate controls in place to ensure compliance with the applicable procurement and suspension and debarment standards and its own internal procurement policy. Planned Corrective Action: Management has revised the Finance Management Manual with an updated procurement policy in accordance with federal regulations. The Council has developed detailed procedures and required documentation for staff to ensure compliance. Mandatory training will be provided to staff that engage in purchasing activities. Contact person responsible for corrective action: Misty Jordan, Director of Administration Anticipated Completion Date: 11/14/2023

2023-001 Procurement Corrective action: Competitive quotes should be obtained and retained as specified in the procurement policy. Non-competitive procurement should be documented and approved prior to incurring expenses. Vendor debarment checks should be performed and documented prior to entering into covered transactions. Management Response: The audit uncovered a non-compliance with required competitive quotes for a procurement of meeting services which did not comply with CASIS policy. The predecessor management team had previously advised the responsible purchaser that these services did not require competitive quotes. This matter is also complicated by the fact that the procurements are not just for meeting space, logistics and meals, but also includes lodging, which is not subject to the three quote rule. Management acknowledges that this was a process escapement and provides for the following corrective action. Typically lodging expenses are included in the procurement because it results in discounts that are unavailable if not included. CASIS implemented a policy of requiring competitive quotes for purchases over $1,000 in the most recent revision of the procurement policy. This change was made to assure compliance with Federal Regulations. While the amount noted is within the limits established by Federal Micro-purchase regulations, it did not comply with internal policies as noted. Meeting space is a commonly used service that is highly competitive in pricing and most facilities charge competitive rates, but most of the time those quotes are not useable given the time of year, and more importantly the occupancy rate of the facility. Starting in 2024, we are requesting quotes from three facilities in the local area that will be valid for a period of one year. These rates will be updated manually and a single additional quote will be obtained to assure the “reasonableness” of the price. This process will represent an annual price survey that will satisfy the three quote rule of our procurement policy. For rental of facilities outside of the local area, we will obtain a minimum of three quotes as required by our procurement policy. Management also acknowledges the process escapement for SAM checks on new vendors. Our normal process is that annually, Finance performs a SAM check for all approved vendors. The agreement for Trust Factory came in late during the year resulting in this deficiency. When a new vendor is setup in our system, it will automatically trigger a SAM check. Responsible Party: Jonathan Bobbitt, CPA, Finance Manager Date Expected to be Corrected: September 30, 2024

The District subsequently confirmed vendors receiving over $25,000 in FY 2023 were not included on the Federal SAM.gov website as exclusions and going forward, will review procedures and train staff to ensure that the District's procurement policy is consistently followed. Responsible official: Denise Guex, Interim Finance Director – dguex@shawanoschools.org Anticipated Completion Date: June 30, 2024

Corrective Action Planned: This was first brought to the Authority’s attention in the current year. At such a late date in the federal project that has been in the works for multiple years, the Authority determined established procurement procedures would not be written and approved. The Authority did not make this decision in haste. The Authority met compliance guidelines for the procedures of items during the project. What we lack is an approved written document, which at this time is something we do not have the resources to undertake. Anticipated Completion Date: Ongoing Contact Person Responsible: Jennie Weary, Treasurer/Secretary

THE DISTRICT DOES NOT HAVE DOCUMENTED PROCUREMENT PROCEDURES IN ACCORDANCE WITH THE PROCURMENT STANDARDS SET OUT AT 2 CFR SECTION 200.318 THROUGH 200.326. STATEMENT OF OCCURRENCE: MANAGEMENT AGREES WITH THE AUDIT FINDING CORRECTIVE ACTION: THE INTERIM EXECUTIVE DIRECTOR WILL DEVELOP A PROCURMENT POLICY IN ACCORDANCE WITH FEDERAL STANDARDS TO INCLUDE ALL GENERAL REQUIREMENTS SUCH AS OVERSIGHT OF CONTRACTORS' PERFORMANCE, MAINTAINING WRITTEN STANDARDS OF CONDUCT FOR EMPLOYEES INVOLVED IN CONTRACTING, AWARDING CONTRACTS ONLY TO RESPONSIBLE CONTRACTORS, MAINTAINING RECORDS TO DOCUMENT HISTORY OF PROCUREMENTS AND CONDUCTING PROCUREMENT TRANSACTIONS IN A MANNER PROVIDING FULL AND OPEN COMPETITION. PROJECTED COMPLETION DATE OF FINDING: FULL IMPLEMENTATION OF CORRECTIVE ACTION IS EXPECTED IN CALENDAR YEAR 2024. NAME OF CONTACT PERSON REGARDING FINDINGS: BRIAN KALOSKY, INTERIM EXECUTIVE DIRECTOR (860) 489-2535 BJKALOSKY@CT-TRANSWB.COM

To mitigate this issue in the future, County Counsel reminded departments of the importance of understanding the requirements tied to the source being used to procure goods and services and to notify Counsel when federal monies are being used. Furthermore, County Counsel will include the suspension and debarment clause in the County’s standard contract templates, and the County Purchasing Policy (4-03) will be updated to reflect the importance of complying with requirements tied to a specific funding source. Lastly, County Counsel and Internal Audit will develop and provide training to departments. Antipcated Completion Date: 04/01/2024. Responsible Contact Person: Peter Philbrick

Polk County acknowledges the finding stated in the audit and is in the process of developing a corrective action plan. To address the finding the County will increase its monitoring of procurement procedures related to federal award purchases. Increased monitoring will include additional reviews and discussions by County staff (Finance Director/Administrative Officer/County Counsel) during the initial stages to be certain we meet all federal requirements.

To Whom It May Concern, As required by the standards applicable to financial audits contained in Government Auditing Standards, issued by the Comptroller General of the United States and Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance), we have provided below our response and corrective action plan addressing the finding in the Report of Independent Auditors on Compliance for the Major Federal Program and Report on Internal Control Over Compliance Required by the Uniform Guidance for the year ended September 30, 2023. Response and Corrective Action Plan Finding 2023-001: Department of Housing and Urban Development - Continuum of Care Program -Assistance Listing No. 14.267; Grant period: Year Ended December 31, 2023. Cause: Management did not obtain rate quotations from an adequate number of vendors, and did not retain sufficient documentation nor perform a formal assessment to proceed with the contracted services. Management Response: The Marjaree Mason Center (MMC) did not maintain proper records of the procurement process for two vendors associated with janitorial services and the client statistical database. MMC has formally started a new procurement policy for all vendors where the vendors will have their own procurement documents. The chosen vendors can be MMC's selected vendor from 1 - 3 years depending on the type of service. All quotes and bids will be maintained on MMC's server.

Corrective Action Planned: The District has reviewed the applicable Uniform Guidance from the Federal Office of Management and Budget, its own existing Board Policies, and has developed administrative procedures to aid with ensuring that all procurements financed with federal funding fully comply with Uniform Guidance procurement requirements. Effective for the 23-24 fiscal year and going forward the District will fully deploy the administrative procedures and controls to all applicable District stakeholders and monitor all such procurements for compliance purposes. The District followed appropriate procedures to ensure that procurements financed with federal funding fully comply with Uniform Guidance procurement. The District sought competitive proposals for major Middle School HVAC replacement project. The District maintains record of the process. Anticipated Completion Date: Action has already been taken by the District to resolve the underlying issue of the finding in the current fiscal year. Contact Person Responsible: Cory Hoffman, Business Manager/Board Secretary

Mechanicsburg Area School District respectfully submits the following corrective action plan for the year ended June 30, 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 of findings and questioned costs. Finding 2023-001 - Procurement Federal Agency: U.S. Department of Agriculture Pass-through agency: Pennsylvania Department of Education Assistance Listing Number: Child Nutrition Cluster – 10.553/10.555 Corrective Action Planned: The District will establish processes to ensure that the procurement policy is followed when applicable and necessary. Anticipated Completion Date: Action has already been taken by the District to resolve the underlying issue of this finding. Contact Person Responsible: Greg Longwell, Director of Business Operations/CFO If there are any questions regarding this plan, please call Greg Longwell, Director of Business Operations / CFO, at 717-506-0869 or email at glongwell@mbgsd.org

Recommendation: The Auditor recommends that the procurement policy be updated to comply with all relevant federal procurement requirements and reviewed for necessary revisions regularly. Action Taken: The HEERF award should have been setup as a restricted fund. Going forward, all grants and contracts will be classified as a restricted fund and federal compliance will be followed if it is applicable. Due Date of Completion: Done Responsible Official: Stephanie Gonzales – VPFA/Comptroller and Office of Research and Sponsored Projects

Higher Education Emergency Relief Funds - Institutional Portion – Assistance Listing No. 84.425F Recommendation: Recommendation for the College to revise their processes to establish procedures that will ensure procurement policies are properly followed and documented for all general disbursements paid for by federal funds. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: All contracts under consideration will go through the college’s procurement process even if there is an existing comparable contract with an existing vendor. Name(s) of the contact person(s) responsible for corrective action: Leigh FitzHenry Planned completion date for corrective action plan: 11/30/2023

The District has responded with corrective action and implemented a process in which the Facilities Director will communicate the Davis-Bacon prevailing wage requirements to the contractors of equipment purchased with federal grant funds. The Director of Business Services will verify and oversee that these requirements are met.

Broadlawns Medical Center respectfully submits the following corrective action plan for the year ended June 30, 2023. Audit period: July 1, 2022 – June 30, 2023 The finding from the schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the numbers assigned in the schedule. FINDING—FEDERAL AWARD PROGRAMS AUDITS DEPARTMENT OF AGRICULTURE 2019-001 Special Supplemental Nutrition Program for Women, Infants and Children – CFDA No. 10.557 Recommendation; We recommend the Organization obtain quotes or bids as necessary for purchases that exceed the micro-purchase threshold. Additionally, we recommend the Organization maintain documentation of all quotes and bids to support the vendor chosen. In situations where there is an alternative method utilized, we recommend clearly documenting that process to ensure compliance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization adopted a procurement policy meeting the recommendations above and the requirements noted in 2 CFR Part 200 §200.318 in December 2020. The policy will be reviewed annually with staff involved in the purchasing process to ensure compliance. Additional procedures will be put in place for WIC department expenditures. Non-salary expenditures of the WIC department expected to be over $5,000 or more will be discussed with the CNO for approval prior to purchase. The Purchase Requisition form will be used to document purchasing approvals. Quotes or bids along with a written rational for vendor selection will be included with the Purchasing Requisition form. Once reviewed and approved by the CON, the Purchase Requisition, quotes/bids, and selection rationale will be sent to Director of Accounting and Cost Accountant. The Director of Accounting will timely review the documentation and forward it to the purchasing department to place the order. Both the Director of Accounting and the Cost Accountant will maintain copies of the documentation for reporting and auditing purposes. Name of the contact person responsible for corrective action: Jim Lynch Planned completion date for corrective action plan: January 31, 2024 If there are questions regarding this plan, please call Jim Lynch at 515-282-2296

We will revise our policies and procedures on purchases with federal awards so that we will meet these newly required federal procurement regulations. We will start including Appendix II to Part II Summary where applicable in future contracts.

Condition: We identified 4 expenditures, during testing, that the City did not verify were in accordance with their internal procurement policy, pursuant to 2 CFR 200.319 and 200.320 prior to entering into contracts with award funds. Planned Corrective Action: Procedures have already been put into place to ensure that each purchase adheres to the internal purchasing policies. City of Port Huron management and staff will continue to improve communication with and between departments to ensure all staff understands the purchasing policy. Contact person responsible for corrective action: Lee Ward, Director of Finance. Anticipated Completion Date: 12/15/2023

The Business Department will review the Uniform Guidance requirements with all grant administrators and procurement staff to ensure compliance with federal regulations and district policy; and it will establish a more thorough review process for contracts to ensure compliance with all requirements.

Finding: 2023-002 – Procurement, Suspension, and Debarment – Contract Bidding Auditor Description of Condition and Effect. The District did not obtain price or rate quotations for the purchase of services for one vendor that met the small purchase threshold. As a result of this condition, the District paid a vendor with federal funding that was not procured in accordance with federal regulations. Auditor Recommendation. We recommend that the District update its procedures to ensure that all services are appropriately procured in accordance with federal and state requirements. Corrective Action. Management concurs with finding. The District will only allocate costs to the food service program that have been properly bid out and obtain quotes for all services in excess of the Federal micropurchase threshold. Responsible Person: Emili Jones, Director of Business and Finance Anticipated Completion Date: November 1, 2023

Contact Person – Lora Papacheck, CEO Planned Corrective Action – Entity management will review a list of vendors and update documentation in accordance with Procurement standards. Completion Date – Fiscal year 2024

Management Views and Corrective Action Plan: Management agrees with the finding and recommendation. Name and Title of Responsible Official: Rouba Anka, Chief Financial Officer Planned Completion Date: Immediately