Corrective Action Plans

Management Views and Corrective Action Plan: Management agrees with the finding and recommendation. Name and Title of Responsible Official: Michael Stock, Board Chairman Planned Completion Date: Immediately.

Finding Number: 2022-001 Finding Title: Micro-Purchasing Documentation Program: 93.104 Comprehensive Community Mental Health Services for Children with Serious Emotional Disturbances (Journey to Independence) Name of Contact Person Responsible for Corrective Action: Jolene Lambert, Finance and Benefits Coordinator Corrective Action Planned: To keep policies for managing sponsored projects consistent, PACT for Families Collaborative will ensure Uniform Guidance Procurement Standards for all sponsored projects. We will use an updated expenditure authorization process to assure micro-purchases are distributed equitably among qualified suppliers by updating our EAF (Expenditure Authorization Form) to include a process to assure more than one supplier is priced and documented for the most reasonable purchase. Anticipated Completion Date: Ending December 31, 2023

2022-010 – CORONAVIRUS STATE AND LOCAL FISCAL RECOVERY FUNDS – PROCUREMENT U.S. Department of Treasury Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number: 21.027 Direct Payment Award Period: 2022 Recommendation: We recommend the County follow their federal purchasing policy in all of their federal programs and retain documentation of that process occurring. As necessary, the County may need to add internal controls that are program specific to ensure this properly occurs. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: We will continue to work with SLFRF program managers to understand and adhere to federal purchasing policies. Name of the contact person responsible for corrective action: Peter Skwira, Finance Director Planned completion date for corrective action plan: December 31, 2023

The Town will be updating the Town's procedures and policies to incorporate the requirements of Part 200 of the Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards. Responsible Individual: Patricia Chaffee, Executive Assistant. Anticipated Completion Date: January 30, 2024.

Finding 2022-003 – Inadequate Design of Monitoring Controls over Procurement Policies. Agreed. Although Hamakua Health staff were not able to provide all the procurement records required by the auditors in the short period of time that was given, these procurement documents should have been scanned by those who initiated and completed the procurement processes and kept them in a ShareFile for easier access, especially for those contracts that are still active. This will be the new standard practice for all new procurement processes. Corrective actions have been discussed and will be implemented as soon as new procurement processes are needed. Responsible persons to be contacted regarding management responses: Sharon Espejo, CFO sespejo@hamakua-health.org 808.930.2712 Catherine Marquette CEO cmarquette@hamakua-health.org 808.930.2737

Criteria: In accordance with CFR 200.318(i), 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. In addition, in accordance with CFR 200.318(a) the nonfederal entity must have and use documented procurement procedures consistent with federal procurement standards. Condition: Expenditures tested that met the small purchase threshold (purchases with a cost between $10,000 and $250,000) did not have documentation detailing the history of procurement. Cause: The School does not have procurement policies that follow federal guidelines, specifically 2 CFR 200.320 Methods of procurement to be followed. Effect: Property and equipment additions made using federal funds during the year did not have appropriate a support showing procurement policies were followed. Questioned costs: $83,864 Context: Two out of two purchases tested for procurement did not follow federal procurement methods. Recommendation: We recommend that the School institute procurement policies whereby acquisitions follow appropriate procurement steps as required by 2 CRF 200.350 and documentation of procurement decisions is maintained. Action Plan: The School will develop a Procurement Policy that follows the formal bid process and ensures that the school is able to acquire goods based on the most advantageous balance of price, quality, and performance. The School will maintain procurement decision records in vendor files. Person Responsible: Yvonne Bullock, CEO/Head of School Policies are approved by the Board of Directors

FINDING 2022-005 Craig Wright (765)747-4828 Views of Responsible Official: We concur with the findings. Description of Corrective Action Plan: Correcting the audit findings is ongoing. The city has implemented monitoring procedures to review and prevent reoccurring errors. Anticipated Completion Date: The internal control monitoring and checks and balances will be implemented immediately and continue going forward.

Management Comments and Corrective Action: During the course of the single audit for the year ending August 31, 2022, it was noted that SWK "legacy" contracts did not follow the established procurement policy and procedures which requires SWK to obtain quotes from at least three sources and/or did not document the quotations in the procurement file for one expenditure between $25,000 to $100,000. This instance of noncompliance noted was for a consumer goods (i.e., clothing, and personal healthcare). Due to the growing need to adequately care for the minors at SWK’s shelters coupled with the limitations of access to vendors caused by COVID-19, SWK utilized an existing vendor to minimize significant disruptions to operations. The Organization is aware they are operating under contracts that were procured in previous years that may not have all the records maintained. Reprocuring all of these contracts at once would potentially cause disruptions in operations due to the products/services related those vendors playing an important role in the Organization’s day-to-day operations. In April 2021, the Organization, hired new procurement leadership and invested Full Time Employees (FTEs) to develop a robust procurement department. As a result of this procurement revamp, Procurement adopted a hybrid model, and Desktop Protocols were established to provide universal procedures to fulfill policy. Protocols instruct staff on obtaining three quotes and provided tools for the selection of the vendor. In addition, quality protocols and tools are currently in development to verify a random sample of procurement transactions and files. The Organization still has several active contracts procured under the old policies that they are working on reprocuring as these contracts’ renewal dates arise, if not earlier. Proposed Implementation Date of Corrective Action: In process and to be completed by December 31, 2023. Person Responsible for Corrective Action: Fred Muniz, CFO 2023

The County Council and County Executive will work through the Audit Committee and Policy Review Committee to review, update, and strengthen policies and internal controls related to County and Federal procurement policies. The County will provide sufficient training and resources for staff to make sure all County and Federal procurement policies are followed correctly. The County will also monitor these processes through internal audit procedures

Views of Responsible Officials: SAMU had a workshop for procurement practices together with Project Hope back in October/November 2022. The procurement process of Services and (nonrecurring) Goods has been updated in May/June 2023. Therein all the requirements were explained to fulfill the procurement standards established by 2 CFR 200.318. In the meantime, all procurement specialists have been advised to request a minimum of three formal quotes for procurements above $10,000, once those have been received and a proposal with an explanation (via email) of why a certain vendor has been preselected to provide the services and goods in question. With this information, the MD and Finance/Admin head are asked for internal approval and process the procurement of the Services and Goods. The approval is provided by email. An updated procurement policy is in preparation, the procurement process will be discussed again in another workshop in Q1 2024.

A Grant committee of finance, administrative, and program staff should meet regularly to centralize the review of each award. This committee will meet monthly to manage the entire life cycle of each grant. The Grant committee will set documentation standards. They should be familiar with all awards, review expenditure details, and question program staff where needed. In addition, this committee will review all reporting for accuracy and timely submission. Finally, this committee will review all reporting for accuracy and timely compliance. The committee will be in place reviewing all reporting by 12/31/2023.

Views of Responsible Officials: A detailed Procurement process currently exists; however, due to staff attrition we were unable locate all the procurement documentation requested. We will continue to reinforce our Procurement policy (detailed below as it relates to documentation) and now require all documentation be stored in a Central location for all applicable Finance staff. E. Procurement Records and Files: 1. Mary's Center will establish and maintain procurement records and files. The records will be kept in the office of the Chief Executive Officer and/or Finance office and virtual copies will be stored on the Finance shared folder. 2. Mary's Center will document in the procurement files some form of cost or price analysis made in connection with every procurement action. 3. For any contracted service (other than equipment-specific technical support), Mary's Center procurement file will include:  Basis for selection of the contractor,  Justification for lack of competition when competitive bids or prices are not obtained, and  Basis for award cost or price. 4. These records and files will be kept in accordance with Mary's Center's Record Retention and Document Destruction Policy.

FA 2022-002 Strengthen Controls over Procurement and Suspension and Debarment Compliance Requirement: Procurement and Suspension and Debarment Internal Control Impact: Significant Deficiency Compliance Impact: Nonmaterial Noncompliance Federal Awarding Agency: U.S. Department of Agriculture Pass-Through Entity: Georgia Department of Education Assistance Listing Number and Title: 10.553 - School Breakfast Program 10.555 - National School Lunch Program Federal Award Number: 225GA324N1199; 225GA324N1199 Questioned Costs: $474 Description: A review of expenditures charged to the Child Nutrition 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: The School District has returned to following its approved procurement procedures. Estimated Completion Date: July 1, 2023 Contact Person: Chris Johnson, CGFM, Director of Financial Services Telephone: 478-994-2031 Email: chris.johnson@mcschools.org

THE COUNCIL WILL ENSURE THAT ALL FUTURE PROCUREMENTS CORRECTLY USE AND RETAIN A PROCUREMENT SHEET WHICH DOCUMENTS THE ITEM PURCHASED, THE BIDS RECEIVED, AS WELL AS THE ANALYSIS OF THE REASONS FOR THE WINNING BID. THE WINNING CONTRACTOR/VENDOR WILL BE SEARCHED ON THE SAM WEBSITE TO DETERMINE THAT THEY ARE NOT SUSPENDED/DEBARRED.

FEDERAL AWARDS – CORRECTIVE ACTION PLAN 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. (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: Condition: 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 five (5) vendors for procurement Suspension and Debarment compliance testing of total population of 5 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) Use documented 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 must maintain records sufficient to detail the history of procurement. These records should 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. 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: 12/31/2023 Name and Phone # Of Person Responsible for Implementation: Jeanne Stromberg, Major, Divisional Finance Secretary (916) 563-3710

Will follow Ohio statutes and Uniform Guidance rules. The County will review and revise, as necessary, the Policy to be more-in-line with the Uniform Guidance.

Action taken in response to finding: A Federal Procurement Checklist which addresses the above finding has been distributed to all County departments who receive grant funding. The County will implement this Checklist into its internal County Procurement Ordinance, Procurement policies & Procedures, and Grant Administration forms. Name(s) of the contact person(s) responsible for corrective action: Eric Black, Chief Deputy Auditor. Planned completion date for corrective action plan: November 30, 2023

Corrective Action Plan for the Calendar Year Ended December 31, 2022 In response to the finding from the Federal single audit for the fiscal year ended December 31, 2022. Major Program: COVID-19 Coronavirus State and Local Fiscal Recovery Funds (Assistance Listing Number 21.027) (G2022-09) Finding: 2022-002 - Reporting and Procurement (Material Weakness and Material Non-Compliance) Management Response: Management will strengthen its processes and internal controls to ensure the report of expenditures is reviewed by Finance prior to submission and only includes expenditures incurred in the period. In addition, Management will amend its procurement policy to ensure the policy includes the required regulations as outlined in the Code of Federal Regulations in relation to Federal Awards. Christopher Caulfield, Executive Director of Financial Operations, will implement the corrective action plan, which is anticipated to be completed by December 31, 2023. caulfieldc@sihmc.org 973-754-2016

The organization has made various changes to personnel within the Finance Department, as well as outsourcing of Finance Director duties to an outside CPA firm. The organization will take better care to ensure that purchases above $10,000 that are applied to our grants are put through a competitive process. The organization will take better care to ensure that purchase above $10,000, which are not put through a competitive process, are not applied to our grant. The organization will consult the board about raising the level of micro-purchases from $10,000 TO $50,000

2022-005: Procurement, Suspension, and Debarment – Material Weakness in Internal Control and Material Noncompliance  Management will review procurement policies and update as needed to ensure they are at least as restrictive as the policies required per the Code of Federal Regulation.  Anticipated completion: December 2023

Agency: National Center for the Advancement of STEM Education, Inc. (nCASE) Person Responsible for Corrective Action: Name: Nancy Priselac Title: Executive Director Anticipated Completion Date: December 8, 2023 Response to Finding: Management concurs with audit recommendation. Correction Action to be Taken: nCASE has taken corrective measures in our accounting software by detailing the audit log and recording all changes with supporting documentation. There will be final weekly review and approval of the changes. nCASE also keeps a log of items that are backordered or have shipping delays. This log includes: item ordered, date ordered, and date shipped/charged. This corresponds to subsequent changes in the above- mentioned audit log. These measures are detailed in our policies and procedures. nCASE has obtained and put into practice, a log for detailing adjustments to journal entries that are included in our policies and procedures. DoD has reviewed the matters covered in the audit report thoroughly, and the grant was closed out without any repayment of funds to DoD. Upon subsequent review and reconciliation, amounts were not overcharged.

Contact Person – Aimee Sugden, County Administrator Corrective Action Plan – The County will review policies and procedures over uniform guidance procurement. Completion Date – January 1, 2025

CONDITION: The City of McKeesport contracted with Applied Concepts, Inc. for police trailers, and A&H Equipment for the purchase of a vactor truck. These contracts individually exceeded the Uniform Guidance micro purchase threshold of $10,000, but did not exceed the Simplified Acquisition Threshold of $250,000. Both of these purchases were procured through a cooperative purchasing group (COSTARS). The City was unable to 1) provide records sufficient to detail the history of procurement for these two contracts and 2) provide documentation to verify that price or rate quotations were obtained from an adequate number of qualified sources.CRITERIA: Section 2 CFR 200.320(a)(2)(i) of the Uniform Guidance prescribes the bidding requirements for equipment, supplies, and work of any nature made by a non-federal entity whereby the cost exceeds certain dollar thresholds as adjusted periodically. In instances where the cost incurred exceeds the Uniform Guidance micro purchase threshold of $10,000 but does not exceed the Simplified Acquisition Threshold of $250,000, price or rate quotations must be obtained from an adequate number of qualified sources. In addition, as specified in 2 CFR 200. 318(i) of the Uniform Guidance, the City must maintain sufficient records to detail the history of procurement. • MANAGEMENT’S CORRECTIVE ACTION PLAN: Management of the City will review and update as necessary its procurement policies to ensure In instances where the procurement cost incurred for goods and/or services exceeds the Uniform Guidance micro purchase threshold of $10,000 but does not exceed the Simplified Acquisition Threshold of $250,000, that 1) price or rate quotations are obtained from an adequate number of qualified sources, and 2) sufficient records are maintained to detail the history of procurement. The timeframe for completion of this review will occur during the first nine months of calendar year 2025 with the intention of having the City be in full compliance with Sections 2 CFR 200.320(a)(2)(i) and 2 CFR 200. 318(i) of the Uniform Guidance.

Preparation of written federal procurement procedures for compliance purposes

Material weakness in internal control over compliance with procurement procedures meeting the requirements of 2 CFR Part 200. Management Response: We acknowledge the finding and provide the following corrective action plan. Corrective Action Plan: PDA worked with Clark Nuber team to revise and update the procurement policy to be in-line with the Uniform Administrative Requirements, Cost Principles and Audit Requirements for Federal Awards procurement standards. Anticipated completion date: Third quarter 2024 Name(s) of the contact person(s) responsible for corrective action: Co-Executive Directors, Directors, Finance team