Corrective Action Plans

Procurement and Suspension and Debarment Recommendation: We recommend the County review and update procurement policies for the entire County to ensure it meets the minimum requirements of 2 CFR 200 for all federal grants and establish a procurement process in order to ensure this policy is followed which includes adding language over suspension and debarment. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County is working on reviewing policies and procedures and updating as necessary. Further, training will be available to all those involved in grants. Name(s) of the contact person(s) responsible for corrective action: Cate Wylie Planned completion date for corrective action plan: December 31, 2024

Type of Finding: Material Weakness in Internal Control over Compliance Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Substance Abuse and Mental Health Services Projects of Regional and National Significance Assistance Listing Number: 93.243 Federal Award Identification Number and Year: H79TI081935 – 2022, H79TI080298 – 2022, H79TI085517 – 2022 Pass-Through Agency: Pierce County Pass-Through Number(s): SC-107323, SC-105454, SC-110121 Award Period: May 31, 2022 through May 30, 2023, September 30, 2017 through September 29, 2022, September 30, 2022 through September 29, 2027. 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". 2 CFR 180.300 states that before entering into a covered transaction with another person at the next lower tier, an entity must verify that the person with whom they intend to do business with is not excluded or disqualified. This can be done by “(a) Checking SAM exclusions; or (b) Collecting a certification from that person; or (c) Adding a clause or condition to the covered transaction with that person”. Condition: The Alliance does not have a written procurement, suspension and debarment policy nor procedures in place at the time of the audit in compliance with Uniform Guidance. For procurement, CLA tested all purchases exceeding $3,500 (the minimum micropurchase threshold before it was increased by the FAR to $10,000 for those with an established policy). For the 5 sampled procurement selections, documentation was not retained for the adequate number of price comparisons prior to exercising the procurement, as required by 2 CFR 200.320. For suspension and debarment, CLA tested all payments to vendors exceeding $25,000 as established by Uniform Guidance. Of the 3 tested, there was no documentary evidence that procedures were performed prior to entering into the covered transaction using the allowable methods as described at 2 CFR 180.300. Questioned costs: Undeterminable. Context: Procurement: A sample of 5 was made from a population of 16 procurement transactions charged to the major program that exceeded $3,500 (the minimum micropurchase threshold before it was increased by the FAR to $10,000 for those with an established policy), amounting to $48,099. Of the 5 sampled costs, all were found to be out of compliance with the Procurement requirements, as a written procurement policy was not in place and documentation was not retained for the adequate number of price comparisons. Suspension and Debarment: A sample of 3 (entire population) was made from a population of 3 vendors who received payments exceeding $25,000. Of the 3 sampled vendors, there was no documentary evidence that procedures were performed prior to entering into the covered transaction using the allowable methods as described at 2 CFR 180.300. Cause: Management believes procurement, suspension and debarment standards apply only to the awarding agency, and not to the Alliance. 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: No. Recommendation: We recommended that the Alliance design controls to ensure an adequate review process is in place to review potential contractors to determine they are not suspended or debarred. These procedures should include documenting the date that suspension and debarment verifications are made. In addition, we recommended the Alliance to formally adopt a Procurement, Suspension and Debarment policy in accordance with Uniform Guidance. The Alliance followed this recommendation, pairing prior (non-federally implicated) procurement processes and expenditures. Views of responsible officials: Pierce County Alliance has enjoyed the a decades long relationship with its prior firm. At no time during that relationship has the need for a Procurement, Suspension and Debarment policy been noted as a deficiency, nor has a finding been issued. Corrective Action: Pierce County Alliance will continue to revise its policies and procedures and controls related to Procurement, Suspension and Debarment, including procedures to review potential contractors for suspension or debarment and to achieve full compliance with the Uniform Guidance.

Views of Responsible Officials: The sample was chosen prior to the implementation of our procurement policy. The procurement policy was updated after recommendations made in the audit completed in late 2022. Since the conclusion of 2022, our personnel have undergone comprehensive training on procurement procedures and have diligently adhered to the established guidelines as required.

FA 2022-003 Improve Controls over Procurement Compliance Requirement: Procurement Suspension and Debarment Internal Control Impact: Significant Deficiency Compliance Impact: Nonmaterial Noncompliance Federal Awarding Agency: U.S. Department of Education Pass-Through Entity: Georgia Department of Education AL Numbers and Titles: 84.027 - Special Education Grants to States 84.173 – Special Education Preschool Grants Federal Award Numbers: HO27A200073(Year: 2021), HO27A210073 (Year: 2022), HO27X210073 (Year: 2022), S371C190016-19A (Years: 2017-21) Questioned Costs: None Identified Description: A review of expenditures charged to the Special Education Cluster 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: [Insert Corrective Action Plan(s) Here] Estimated Completion Date: A review of costs and expenditures for all purchases and contracts involving rates of pay for the purpose of education students with disabilities will be completed prior to the approval of purchases and contractual agreements. A minimum of 2 quotes per expenditure and/or contracted service agreement will be procured prior to approval of the expenditure and/or contractual agreement. For contractual agreements, the student services director will be responsible for obtaining quotes, and the individual requesting the purchase of required items will be responsible for obtaining and providing quotes to the director prior to approval. These records will be kept on file within the student services department. Contact Person: Angela Williams, Superintendent Telephone: 706-554-5101 Email: amwilliams@burke.k12.ga.us

FA 2022-002 Improve Controls over Procurement Compliance Requirement: ‘Procurement 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 AL Number and Title: 84.371C – Comprehensive Literacy Development Federal Award Number: S371C190016-19A (Years: 2017-21) Questioned Costs: ‘$177,213.73 Description: A review of expenditures charged to the Comprehensive Literacy Development program 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: The Comprehensive Literacy Director will review and update the current procedures to ensure that the required procurement methods are properly identified and followed, and that required procurement documentation is properly identified, safeguarded, and retained. Estimated Completion Date: May 1, 2024 Contact Person: Angela Williams, Superintendent Telephone: 706-554-5101 Email: amwilliams@burke.k12.ga.us

There is no disagreement with the finding. The City will establish a procurement policy that is in compliance with Uniform Guidance standards and follow that policy for all future federal grants. Name of responsible official: Amanda Toney, Finance Director Expected date of completion: The planned completion date is September 1, 2024

FINDING 2022-002 Finding Subject: Special Education Cluster (IDEA) - Procurement and Suspension and Debarment Summary of Finding: An effective internal control system was not in place at the School Corporation to ensure compliance with requirements related to the grant agreement and the Procurement and Suspension and Debarment compliance requirement. The School Corporation had not designed or implemented adequate policies or procedures to ensure that proper procurement procedures for small purchases were followed. There was no oversight, review, or approval process in place and documented at the School Corporation to ensure proper procedures were followed and price or rate quotations were obtained, or documentation to support limited procurement procedures conducted. Federal regulations allow for informal procurement methods when the value of the procurement for property or services does not exceed the simplified acquisition threshold, which is set at $150,000 per Indiana Code. This informal process allows for methods other than the formal bid process. The informal process is divided between two methods based on thresholds. Micropurchases, 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. The School Corporation did not obtain price or rate quotes for the five vendors tested that was less than the simplified acquisition threshold of $150,000 but exceeded the $10,000 micropurchase threshold. Documentation detailing the history of procurement, which must include the reason for the procurement method used, was not available for audit. The School Corporation also did not follow procurement requirements for contracted services which exceeded the simplified acquisition threshold of $150,000. The School Corporation did not correctly procure a contract for the one vendor that exceeded the simplified acquisition threshold. Additionally, the School Corporation did not adequately maintain documentation of the procurement history or rationale. Finally, the School Corporation did not verify that this vendor was not excluded or disqualified from participation in federal assistance programs or activities. Contact Person Responsible for Corrective Action: Matthew Miles, CFO 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: 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 INDIANA STATE BOARD OF ACCOUNTS 34 will check for suspension and debarment, create a write-up of our findings, and obtain Board approval for the contract. Anticipated Completion Date: The School District will implement changes described in the Corrective Action Plan February in 2024.

2022-005 Significant Deficiency in Controls over Compliance: Administrative Requirements of Uniform Guidance-Administrative Policies The schools have documented their administrative policies effective 3/1/2023.

FINDING 2022-004 Contact Person Responsible for Corrective Action: Sue Hart Contact Phone Number: 812-752-8921 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Each vendor who has received payment from the school district from federal Child Nutrition funds, or is expected to in the future, shall be required to have at least one of the following filed with the school district each year: 1) SAM Exclusions without the vendor being listed as excluded or disqualified; or, 2) Certification of the vendor not being excluded or disqualified; or, 3) Including a clause or condition on any and all contracts or invoices confirming the vendor is not excluded or disqualified. The Director of Food Services shall maintain files with evidence of the above documentation and it shall be updated at least annually and no fewer than once per calendar year. In addition, the Director shall ensure price or rate quotes are acquired from all vendors the Director reasonably expects to pay more than the micro-purchase threshold and contracts shall be executed with vendors when purchases are between $50,000 and $150,000. Such contracts shall also be Board approved with copies uploaded to the Gateway system for ease of access by SBOA or the district in the future. Anticipated Completion Date: June 2023

REFERENCE # 2022-001 PROCUREMENT SUSPENSION AND DEBARMENT ? MATERIAL WEAKNESS- NON-COMPLIANCE Program Name/ALN Emergency Solutions Grant Program (ALN # 14.231) Criteria: As per ? 200.318 General procurement standards. (a) The Non-Federal entity must have and use documented procurement procedures, consistent with State, local, and tribal laws and regulations and the standards of this section, for the acquisition of property or services required under a Federal award or subaward. The non-Federal entity's documented procurement procedures must conform to the procurement standards identified in ?? 200.317 through 200.327. (b) Non-Federal entities must maintain oversight to ensure that contractors perform in accordance with the terms, conditions, and specifications of their contracts or purchase orders. (d) The Non-Federal entity must maintain records 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. Condition/Context: Based on our review of the Procurement compliance requirements, we noted that the Division has written procurement policies and competitive policies as required by CFR ? 200.318 General procurement standards. We selected two (2) vendors for procurement Suspension and Debarment compliance testing of total population of 2 vendors subject to procurement and we were not provided with Procurement comparative bids therefore, we were unable: ? To verify that the procurement method used was appropriate based on the dollar amount and conditions specified in 2 CFR section 200.320. ? To Verify that procurements provide full and open competition (2 CFR section 200.319 and 48 CFR section 52.244-5). Questioned Costs: Cannot be determined Recommendation: We recommend that the Division must: (1) document procurement procedures, consistent with State, and local, laws and regulations and the standards, for the acquisition of property or services required under a federal award or subaward. (2) The Division?s documented procurement procedures must conform to the procurement standards identified in ?? 200.318 through 200.327. . Corrective Action Plan: The Division will work with Territorial Headquarters to document procedures as outlined in the Recommendations above. Step 1 Action Date: Ongoing Final Implementation Date: 9/30/2023 Name and Phone # Of Person Responsible for Implementation: Jeanne Stromberg, Major, Divisional Finance Secretary (916) 563-3710

FINDING 2022-002 Contact Person Responsible for Corrective Action: Greg Hopkins Contact Phone Number: 812-967-3926 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Small Purchases The Food Service Director of the local School Food Authority will work with the Food Service Management Company to ensure all items purchased are procured properly using the correct thresholds set by the state and federal government. Suspension and Debarment The Corporation is now contracted with a Food Service Management Company (Aramark). The Food Service Director reviews all agreements/contracts related to Food Service to ensure that they meet the requirements related to suspension and debarment. Once contracts/agreements are reviewed, the Food Service Director signs off. Anticipated Completion Date: Effective Immediately

SD 2022-006 Subrecipient Procurement Policy Recommendation: Prior to approving funding to a subrecipient, and annually thereafter, the Organization should require subrecipients to submit procurement policies which ensure competitive procurement and the use of vendors who are not suspended or debarred for grant-funded expenditures. Management Response: Since the prior audit, we implemented several changes which affect the repeated findings. The fiscal year 20-21 audit report was issued on June 30, 2022. The change in the fiscal year resulted in a 12-hour turnaround making it difficult to clear the findings and implement the recommended changes from last year's audit. We addressed the procurement policies with our existing subcontractors during their fiscal year 21-22 Monitoring visits in May, 2022. We added to any new and/or existing contracts the requirement for the Agency to supply their Procurement policies that ensure competitive procurement and the use of vendors who are not suspended or debarred for grant-funded expenditures. All new sub-recipient contracts that went into effect July 1, 2022 made the implementation of the recommended change effective outside of the fiscal year in review. This finding will be cleared in our next audit. RESPONSIBLE PARTY - AMBER CARROLL

Finding 2022-002 ? Procurement in Compliance with Uniform Guidance Corrective Action Plan The County will adopt a procurement policy in compliance with the requirements of the Uniform Guidance. Person(s) Responsible: Mike Doty, County Administrator Timing for Implementation: November 30, 2022

Finding 2022-004 ? Special Education Cluster ? Procurement and Suspension and Debarment Contact Person Responsible for Corrective Action: Michael Huber Contact Phone Number: 765-853-5464 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: When our current contract is nearing its end we will follow procurement bid procedures. Anticipated Completion Date: 2029

2022-008. Finding: Procurement Requirements Not Followed ? Edwardsville Campus Response: We agree that procurement requirements were not followed for the identified purchases. Corrective Action Plan: Steps will be taken to reduce the risk of noncompliance going forward in instances where the procuring department may not regularly utilize grants funds for procurements. Contact Person: Matt Brown (SIUE Purchasing Director) Anticipated completion date: June 30, 2023

2022-002: DOCUMENTATION OF PROCUREMENT, SUSPENSION, AND DEBARMENT PROCEDURES (CODE 50000) Name of contact person: Beth Anderson Corrective Action: The district has a procurement policy with sample forms. The district will use the forms to document review of multiple vendor quotes and to document verification that vendors have not been suspended or disbarred for all federal programs/funding. Proposed Completion Date: Ongoing

December 19, 2022 U.S. Department of Health and Human Services Kennebec Behavioral Health respectfully submits the following corrective action plan of the year ended June 30, 2022. Name and address of independent public accounting firm: One River CPAs 46 FirstPark Drive, Oakland, ME 04963 FINDING ? FINANCIAL STATEMENT AUDIT None FINDING ? FEDERAL AWARD PROGRAMS AUDIT U.S. Department of Health and Human Services 2022-001 - 93.829 Section 223 Demonstration Programs to Improve Community Mental Health Services; 1-1-H79SM085158-01 Noncompliance and Significant Deficiency: The Organization did not follow guidelines and their policies for competitive bids on small purchases and for the documentation of verification of suspension and debarment for one transaction tested. Recommendation: Management should strengthen their processes, controls, and review over procurement, suspension, and debarment processes and ensure compliance with Uniform Administrative Requirements, as well as their own procurement policies. Responsible Person for Corrective Action: Josee L. Shelley, CPA Corrective Action to be Taken: Senior management has formally reminded and reviewed KBH?s policies for procurement and sanction screening for exclusion/suspension/debarment with the full management team and Business Operations group. To assist with the process, a checklist for large purchases and/or service contracts will be developed and required to be attached to any appropriate purchases and/or contracts. KBH?s Policy 1520, Procurement Bidding Requirements, has been revised to include the checklist requirement. As specifically related to the contract noted above, KBH developed an RFP and reissued solicitations for Evaluator effective 10/31/22. The anticipated completion date for this corrective action is December 31, 2022. If the U.S. Department of Health and Human Services has questions regarding this plan, please contact Josee L. Shelley, CPA at 207-873-2136 or jshelley@kbhmaine.org. Sincerely, Thomas J. McAdam, Chief Executive Officer

FINDING 2022-002, 2021-001 ? Repeat finding: Corrective Action Plan: Based on the prior year recommendation to the FY21 finding, dated December 15, 2021, in April, 2022, CPS revised the policies in the Procurement Manual to reflect the current standard. The Oracle procurement module was tested and upgraded to implement further controls to require the collection of three quotes for any purchase using federal grant funds between $2,000.01 and $25,000 in value. In addition, communication and reenforcement of the procurement policies in the CPS Procurement Manual at the program and school level has been completed through the mandatory training and district wide announcement. On May 9, 2022, US department of Education issued the determination letter concluding this finding resolved and closed. Contact person: Patrick T. Alforque, Controller

FINDING NUMBER: 2022-002 FINDING: CCCTMA failed to properly document formal procurement policy procedures for procurements of property and services exceeding the simplified acquisition threshold established in compliance with the Uniform Guidance. CORRECTIVE ACTION: CCCTMA has updated the procurement policy to include the required federal procurement policy language. The Procurement Policy is attached. CORRECTED BY: Ronda R. Urkowitz, Executive Director, July 25, 2023

Finding 2022-002 Federal Agency Name: Department of Treasury, State of South Dakota Governor?s Office of Economic Development Program Name: Coronavirus State and Local Fiscal Recovery Funds Federal Financial Assistance Listing: 21.027 Finding Summary: The Company has not documented their internal controls for compliance with the procurement, suspension and debarment compliance requirement of Uniform Guidance as outlined above. The Company does not have a written policy related to procurement or written standards of conduct for employees involved in contracting, awarding contracts only to responsible contractors, and maintaining records to document history of procurement, as well as, established procedures in place related to suspension and debarment. The Company did not follow the procurement method required based on the dollar amount and conditions specified in 2 CFR 200.320. For contracted vendors with expenditures in excess of $25,000, the Company did not verify vendors were not suspended or debarred prior to entering into transaction with the vendor. Responsible Individuals: James Groft, CEO Corrective Action Plan: The Company will draft and adopt policies that implement internal controls consistent with the compliance requirements for procurement, suspension and debarment. The Company will follow the new documented policies and retain documentation to support compliance with the requirements. Anticipated Completion Date: June 1st, 2023

Contact Person Responsible for Corrective Action: Sean Begley Contact Phone Number: (219) 836-9111 Views of Responsible Official: We concur with the finding partially. All purchases from C&T Design were for different types of kitchen equipment located in different schools throughout the school district. For the time period audited, there were eight purchase orders. Of these purchase orders, three were created prior to the hiring of the new Director of Operations in July 2021. For the five purchase orders created by the Director of Operations, the five POs are for different types of equipment in two different schools and should be considered different projects. For each purchase a minimum of three different qualified vendors were provided the same scope, the same time, and deadline for providing a quote. In each case, C&T Design was the lowest. At the same time, the IDOE Division of School and Community Nutrition Program is expecting the School Town of Munster to follow a spend down plan in order to comply with maintaining an appropriate cash balance in the food service account. As specified in Finding 2022-005, barring a vendor from bidding due to the aggregate amount of goods and/or services provided to multiple School Town of Munster schools in one year would disqualify a company that consistently provided the lowest bid. Description of Corrective Action Plan: The School Town of Munster will have the school attorney conduct a legal review for all projects with an estimated cost over $50,000 to ensure compliance under Indiana Code 4-13.6-5 Chapter 5 ? Bidding Requirements. We will use SAM.GOV to verify that vendors we use are neither suspended nor debarred. Anticipated Completion Date: August 2023

CORRECTIVE ACTION PLAN FOR THE YEAR ENDED SEPTEMBER 30, 2022 The Jefferson County Department of Health submits the following corrective action plan for the year ended September 30, 2022: FINDINGS ? FEDERAL AWARDS: Audit Finding Reference 2022-001 Procurement Corrective Action Plan Rate quotes will be obtained from at least three (3) law firms as required for ?small purchases? by 2 C.F.R. 200.320. Person Responsible Rodney Holmes, Finance Director Estimated Completion Date May 31, 2023

Views of Responsible Officials and Planned Corrective Actions: Personnel involved with Federal grant programs will receive additional training on the Compliance Supplement to ensure all compliance requirements are met for future grant reimbursement requests. Also, the District reimbursed $105,273 to NDE during September 2022.

2022-002 Sufficient documentation of competitive bid price or rate quotations obtained from an adequate number of qualified sources for all transactions selected for audit testing was not maintained. Contact Pern Mary Benedict Anticipated Completion Date 12/31/2023 Action Plan: There was signficant improvement made in this area. The Tribal Administrator will monitor transactions closely to ensure documentation. A checklist will be created to go accompany all purchases requiring bids.

Program: COVID-19 ? Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) CFDA No.: 93.323 Federal Agency: U.S. Department of Health and Human Services Passed-through: California Department of Public Health Award Year: 2021-2022 Compliance Requirement: Procurement and Suspension and Debarment Grant Award Number: COVID-19 ELC39 and COVID-19 ELC97 Type of Finding: Material Noncompliance and Material Weakness in Internal Control over Compliance Repeat Finding from Prior Year: Yes, prior year finding 2021-09. Management?s or Department?s Response: We Concur. Views of Responsible Officials and Corrective Action: Procedures have been developed and implemented to comply with the County?s policies over procurement and suspension and debarment. Name of Responsible Person: Bruce Cosby Name of Department Contact: Bruce Cosby Projected Implementation Date: July 1, 2023