Corrective Action Plans

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

The School District has already made the request and received letter from ODE for the FY `23 audit period.

Finding 2022-003 The School District did not provide evidence that it was in compliance with formal procurement methods. The School District will make every attempt, when possible, to remain in compliance with formal procurement methods. School Business Administrator and Superintendent of Schools 2022-2023 fiscal year

Kittitas Reclamation District P.O. Box 276 Ellensburg, WA 98926 Phone: (509) 925-6158 Fax: (509) 925-7425 CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE Kittitas Reclamation District January 1, 2022 through December 31, 2022 This schedule presents the corrective action the District is planning to take for findings included in this report in accordance with Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance). Finding ref number: 2022-001 Finding caption: The District?s internal Controls were inadequate for ensuring it complied with federal procurement requirements. Name, address, and telephone of District contact person: Stacy Berg PO Box 276 Ellensburg, WA 98926 (509)925-6158 Corrective action the auditee plans to take in response to the finding: (If the auditee does not concur with the finding, the auditee must list the reasons for disagreement). Upon receiving the guidance on the current audit, the District would like to move forward by reviewing the procurement policy and making any necessary changes while working under the guidance of the SAO Procurement Specialist to ensure that an updated procurement policy continues to meet the needs of the District and the federal guidelines for federal funding. Anticipated date to complete the corrective action: September 30, 2023

Finding # 2022.001 Procurement and Suspension and Debarment Response Management acknowledges the condition related to following the organization?s procurement policy guidelines. Management is taking steps to correct this condition and has identified areas in the system that will be corrected in order to follow all Federal requirements related to procurement. For example, a member of the Finance department will complete procurement training at least once a year. The Finance Department will also train all Project Managers in Procurement Policies and Procedures as needed. Responsible Party David Ayala, CFO Estimated Completion 12/31/2023

The Board will communicate procurement requirements to purchasing agents in order to avoid future misinterpretation and noncompliance. In most instances, evidence of procurement requirement compliance was observed, but not documented appropriately for compliance requirements.

Finding No. 2022-001: Procurement and Suspension and Debarment ? Significant Deficiency (Program Level) Finding: During testing the Federation?s controls on compliance over procurement and suspension and debarment, the Federation could not provide a procurement policy that is in compliance with prescribed standards in the Uniform Guidance. Corrective Actions Taken or Planned: Management will update its procurement policy to ensure it is in compliance with Uniform Guidance requirements and will take the additional steps of updating the policy as changes in the Uniform Guidance requirements occur. Review and monitoring is effective immediately and will be on-going beginning January 2023 and is expected to be completed by February 2023

The responsible officials within the Foundation acknowledge the findings from the 2022 audit related to our procurement practices under 2 CFR section 200.320. We understand the gravity of the situation, particularly considering that the Foundation did not have a formal procurement policy in place. To address the deficiencies identified in the audit, our planned corrective actions are foundational. Firstly, we will develop and implement a comprehensive procurement policy that adheres to the federal regulations specified in 2 CFR sections 200.318 through 200.326. This policy will provide clear and specific guidance on both competitive and noncompetitive procurement methods, establishing a framework for future procurement activities. Secondly, we recognize the paramount importance of robust documentation. Therefore, we will institute rigorous documentation procedures that mandate the thorough recording of the historical context and rationale for procurement decisions at the time of contract execution. This documentation will be meticulously maintained, adhering to the stringent requirements mandated by the federal regulations. Additionally, we will prioritize staff training to ensure that all personnel involved in the procurement process are well-informed about the new policy and are capable of consistently adhering to the documentation standards. These measures, including the creation of a procurement policy from the ground up, will enable us to rectify the audit findings promptly, establish compliance with federal regulations, and uphold the integrity of our federal award programs.

Significant Deficiency in Internal Controls ? Procurement, Suspension and Debarment Funding Agency: Department of Treasury Program: Emergency Rental Assistance Program Assistance Listing Number: 21.027 Criteria or Specific Requirement: Criteria or specific requirement: 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". Per the Organization's written procurement policy, the adequate number of sources is determined to be three. Condition: For the entire population (two disbursements from one procurement), documentation was not retained for the adequate number of price comparisons prior to exercising the procurement, as required and stated in the Organization's written procurement policy. Context: A sample of two disbursements from a population of one procurement transaction charged to the major program that exceeded the Organization's established micropurchase threshold of $10,000. The transaction was found to be out of compliance with the Procurement requirements, as documentation was not retained for the adequate number of price comparisons. Questioned Costs: Undeterminable Cause/Effect:. An employee charged with the procurement process for these transactions misinterpreted the aggregation rules between capitalization and procurement thresholds, and therefore did not obtain nor retain three contemporaneous quotes. Without adequate records retained, the Organization is at risk of noncompliance with the standards of Procurement. Recommendation: Opportunity Council has already taken steps to communicate the error with the applicable employee and is currently implementing an additional level of fiscal review earlier in the procurement process to ensure that documentation exists prior to procurement and that it is retained with the accounting record. We recommend moving forward with the additional layer of review and emphasizing the importance of the procurement standards and established policy to all authorized purchasers within the Organization. View of Responsible Official and Corrective Action Management accepts the finding and is taking the following corrective action to prevent recurrence: ? Updating Organizational Policies to clearly permit a higher small purchases threshold, combined with annual certification of eligibility, to sharply decrease the likelihood of recurrence of the underlying cause of the finding. ? Implementing accounting system-level controls that will require an additional approval from assigned fiscal staff to transactions exceeding the small purchase threshold prior to payment, ensuring accountability for monitoring of required documentation for procurements in excess of the threshold. ? Procurement training planned throughout the agency to ensure that personnel authorized to initiate procurement transactions are aware of organizational policies and have the guidance necessary to comply with procurement rules.

Finding 2022-012 ? Procurement (Significant Deficiency and Noncompliance) (Repeat finding) Information on the Federal Program: U.S. Department of Education, CFDA No. 84.425, COVID-19 Education Stabilization Fund ? Higher Education Emergency Relief Fund Criteria: 2 CFR 200.320 establishes the methods of procurement to be followed for non-federal entities when acquiring goods and services with federal awards. Aggregate purchases higher than the micro-purchase threshold must use the small purchase procedures which require price quotes be obtained from an adequate number of qualified sources. Condition: We selected a sample of six vendors to test for proper procurement procedures. Of those six, one vendor was not properly procured. Management?s View: Management was made aware of this during the end of the prior year audit. These purchases had already been made by that time. Management has implemented a corrective action plan to ensure that policies and procedures are followed. Corrective Action Plan: Management has informed department heads regarding the need to obtain multiple quotes for purchases higher than the micro-purchase threshold and below the bid threshold. Management is in process of updating Policies and Procedures to include this requirement for Procurement. Going forward, requisitions submitted requiring multiple quotes will not be approved without a minimum of three (3) quotes provided by the requester. This will take effect immediately as the policies are formally updated. Anticipated Completion Date: September 30, 2023

Finding Number: 2022-005 Condition: The Corporation's procurement procedures does not fully conform to the procurement standards identified in ?? 200.317 through 200.327. Planned Corrective Action: The procurement policies will be revised and additional education will be conducted for those individuals responsible for the procurement process. Contact person responsible for corrective action: Kristen St. Peter Anticipated Completion Date: June 2023 Management Response: Management concurs with the finding and will be conducting a thorough review of the current policies to ensure compliance with Uniform Guidance, as well as providing additional training and education to those responsible for procurement.