Corrective Action Plans

COVID 19 Coronavirus State and Local Fiscal Recovery Funds/ ALN 21.027 - Significant Deficiency - Internal Controls over Procurement Prior to purchase, Sarasota County worked with the State of Florida Medical Examiner to create and document procurement policies in conformance with the Uniform Guidance, to include sourcing of quotes, issuance of purchase orders, and certifications by vendors on acknowledgment and adherence to applicable 2 CFR requirements. The County acknowledges that the State of Florida Medical Examiner conformed with these requirements prior to purchase to include noncompetitive purchases which was further supported in a dated letter provided by the Chief Medical Examiner. The Program Division Manager, Steve Hyatt shall require and retain such additional documentation within its procurement files and will conform to sourcing this documented information for these instances prior to any future purchases. Implementation date for this process - Immediately

2023-001 Coronavirus State and Local Fiscal Recovery Funds – Assistance Listing No. 21.027 Recommendation: We recommend that the Organization review its procurement and make necessary changes to comply with the criteria as set out in 2 CFR sections 200.318 through 200.326. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management is in the process of enhancing the federal procurement policy to include sections 200.318 through 200.326. Name of the contact person responsible for corrective action: Shannon Marimón Planned completion date for corrective action plan: February 29, 2024

Specific corrective action plan for finding: Christi Walter, Coordinator Purchasing Department along with the Dom Atcitty, Grants Specialist, will review vendors that are issued requisitions at each approval level to assist in catching $25K or more for Suspension and Debarment. A printed document from SAM.GOV verifying eligibility to Requisitions over $25K should be attached. At the initial setup of new vendors, the Purchasing Department will review vendors in SAM.GOV. A printed document from SAM.GOV verifying eligibility of vendor will be attached to the vendor file. Timeline for completion of corrective action plan: July 1, 2023 Employee position(s) responsible for meeting the timeline: Dom Atcitty, Grants Specialists; Christi Walter, CPO; Lisa Smith, Purchasing Specialist; Bellamie DeHerrera-Presley, Federal Grants Coordinator and Erica Benally, Federal Grants Specialist

Finding 2023-004 Procurement, Suspension, and Debarment Material Weakness in Internal Control over Compliance Finding summary: During the course of the engagement, Eide Bailly identified that the district did not have a procurement policy in compliance with Uniform Guidence. Responsible Individuals: Rhandi Knutson, Director Corrective action plan: A procurement policy in compliance with Uniform Guidance will be approved and implemented. Anticapted Completion Date: June 30, 2024.

Views of responsible officials and planned corrective action: The Town Treasurer is working on updating the current purchasing policy. Within this policy, the Town Treasurer will implement language to reference the Uniform Guidance procurement standards.

INDING 2023-002 – DAVIS-BACON COMPLIANCE – Significant Deficiency Planned corrective action: The School through the education services provider agreement with Entrepreneurial Ventures in Education (EVE) will train operations and business office staff on thecompliance requirements under Davis-Bacon to ensure construction contracts are entered into with qualified contractors and obtain and retain appropriate certified payroll documenta􀆟on during the construction period. Responsible officers: Carlo Hershberger, Director of Finance and Accounting; Javier Dimas, Vice- President of Operations; Martha Arellano, Procurement Manager and Buyer Estimated completion date: March 15, 2024

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

Finding 2023-001 – Procurement and Suspension and Debarment Federal Grantor: U.S. Department of Education Pass-through Grantor: Pennsylvania Department of Education Program: Early Intervention (Philadelphia), Early Intervention (Chester) Assistance Listing #: 84.027, 84.173 Title: Special Education Cluster (IDEA) Audit Period: 07/01/2022 – 06/30/2023 Passthrough Numbers: 232-210026, 231-210026, 232-210035, 231-210035 Recommendation: We recommend Elwyn enforce its existing policy and procedures to ensure compliance with procurement requirements. Elwyn should provide targeted training to members of the organization involved in procurement processes on its existing policy and procedures to ensure understanding of the Organization’s requirements for documentation of procurement methods. Additionally, Elwyn should ensure all procurement decisions are contemporaneously documented with the information necessary to conclude on appropriateness of the procurement with respect to the procurement policy and requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The purchasing department will conduct an annual training with organizational leadership regarding the Elwyn’s procurement policy. This training will help to reinforce the existing procurement documentation requirements. In addition, the purchasing department will create and distribute a purchasing checklist and tracking form that will be utilized for new procurements and renewals. This form will help to ensure that the procurement method and rationale are appropriately documented and approved by organizational personnel. The completed form will be submitted to the purchasing department for electronic storage and retention. Name of contact person responsible for corrective action: David Bowers, Vice President of Finance and Corporate Controller Email: David.bowers@elwyn.org Phone: 610-891-2028 Planned completion date for corrective action plan: June 30, 2024

Views of Responsible Officials and Planned Corrective Actions: Our management team has acknowledged the finding and is committed to ensuring that we adhere to the $10,000 threshold. To facilitate this, we will conduct a review of all vendor invoices to identify any instances where adjustments may be necessary. We will also assign a dedicated team member to review purchases on a monthly basis. This proactive measure will enable us to stay vigilant and address any potential deviations from the established threshold promptly. Moreover, if during our monthly reviews we identify that we are approaching the $10,000 threshold, we will take the initiative to seek additional quotes if necessary. Contact person responsible for corrective action: Brittany Fuentes, Director Completion date: January 4, 2024

Corrective Action: The District will establish internal controls that will be designed to ensure the compliance with the Wage Rate Requirements (Davis-Bacon Act) provision applicable to contracts that are governed by federally financed and assisted construction projects. The Chief Financial Officer will implement a new Vendor Contract Packet. The Vendor Contract Packet will consist of an EDGAR Certification Form that will address the assurances under the Uniform Administrative Requirements, Cost Principles and Audit Requirements for Federal Awards, 2 CFR 200 (EDGAR). Within the vendor packet, will be the vendor’s agreement and ability to comply with EDGAR regulations. Further, it will require the vendor to agree to the wage rate determinations and a copy of the certified payrolls and a statement of compliance with requirement. Contact person: Sylvia S. Garza, CFO Completion: January 31, 2024

Corrective Action: The District will establish internal controls that will be designed to ensure the compliance with the Wage Rate Requirements (Davis-Bacon Act) provision applicable to contracts that are governed by federally financed and assisted construction projects. The Chief Financial Officer will implement a new Vendor Contract Packet. The Vendor Contract Packet will consist of an EDGAR Certification Form that will address the assurances under the Uniform Administrative Requirements, Cost Principles and Audit Requirements for Federal Awards, 2 CFR 200 (EDGAR). Within the vendor packet, will be the vendor’s agreement and ability to comply with EDGAR regulations. Further, it will require the vendor to agree to the wage rate determinations and a copy of the certified payrolls and a statement of compliance with requirement. Contact person: Sylvia S. Garza, CFO Completion: January 31, 2024

Sheila Nolan, Child Nutrition Supervisor, acknowledges the finding regarding the purchase of produce products for SY 2022-23. There is only one regional produce distributor that successfully delivers to the Franklin Parish area with accurate invoices and timely deliveries based on past history. Due to staff changes and re-assignment of essential job functions, the produce bid was overlooked for this this year only. Moving forward, the CNP Supervisor has established a procurement schedule for developing and revising necessary formal bids in compliance with Federal and State requirements and all CNP central office staff. During SY 2022-23, the Franklin Parish Child Nutrition Program experienced multiple shortages of canned and frozen vegetables and fruits. This made it essential to fill in with fresh produce to meet meal pattern requirements. This created a marked increase in the cost of the fresh produce available to us and increased our reliance on fresh produce.

2023-005 – Procurement, Suspension & Debarment – Significant Deficiency in Internal Controls over Compliance Recommendation: The auditors recommend the University implement controls to ensure all employees making federal purchases on behalf of the University are aware of the University’s documented procurement policy that is in accordance with 2 CFR Part 200. In addition, the auditors recommend the University document its standard of conduct that covers conflicts of interest and governs the performance of its employees engaged in the selection, award, and administration of contracts. Planned corrective actions: The university puts measures in place to guarantee that every employee who makes federal purchases on the university's behalf is aware of the documented procurement policy that complies with 2 CFR Part 200. The University will formalize its code of conduct, which addresses conflicts of interest and sets performance standards for staff members who choose, award, and manage contracts. Name of Responsible Party: 1. Aaron Krantz, IT Director 2. Jeffrey Beehler, Physical Plant Director 3. Yolanda Maltos, Grant Accountant 4. Melissa Hill, Provost 5. Alysia Stevens, Controller 6. VP of Administration/CFO 7. Dr. Andrew Sund, President Anticipated completion date: 6/30/2024

Findings and Questioned Costs Related to Federal Awards Finding Number: 2023‐001 Program Name/Assistance Listing Title: Education Stabilization Fund Assistance Listing Number: 84.425U Contact Person: Diana Fitzpatrick, Director of Finance Anticipated Completion Date: April 30, 2024 Planned Corrective Action: When notified by the audit firm of the error in procurement procedures, district employees were notified of the correct procedures. This information has been and will continue to be made known to district employees who are delegated authority to procure goods and services during monthly leadership meetings. During this spring’s annual budget workshop with district staff, a brief training session will be held on Federal, State, and Board procurement policies and procedures. Also, a record of vetting vendors has been implemented this current fiscal year via the Sam.gov website.

The District agrees with the finding and will institute the additional training and review process recommended.

Finding 2023-001 Information on the federal program: Federal Program Name: COVID-19 Higher Education Emergency Relief Fund (HEERF) – COVID-19 HEERF Minority Serving Institutions (MSIs) Federal Agency: U.S. Department of Education Federal Assistance Listing Number: 84.425L Award Year: July 6, 2020 – June 30, 2023 Criteria or Specific Requirement: Procurement, Suspension and Debarment Condition: The University’s procurement policy does not contain adequate documentation to demonstrate compliance with federal procurement regulations. (Deficiency) Corrective Action Planned: The University will review the federal procurement requirements and revise procurement policies to incorporate all required elements of the federal procurement regulations. Contact Person Responsible for Corrective Action: Sharon Maxwell, Senior Vice President for Business and Finance Anticipated Completion Date: October 31, 2023

FINDING 2023-009: Wage Rate Compliance Response: We are implementing robust measures to ensure adherence to prevailing wage standards in all future construction contracts. This includes the inclusion of prevailing wage clauses and the requirement of weekly certified payrolls as part of our standard contracting process. Additionally, it's important to note that for the projects referenced in this finding, we did obtain certified payrolls, it just wasn’t done weekly. These additional safeguards will ensure compliance with wage rate regulations and reinforce our commitment to fair labor practices.

Finding 2023-001: Procurement and Suspension and Debarment Description of Finding: The City’s procurement standards do not include the essential elements as outlined in 2 CFR sections 200.318 through 200.326. Statement of Concurrence or Nonconcurrence: The City concurs. Corrective Action: The City will enhance their existing policies for procurement to be in accordance with Uniform Guidance Procurement Standards and plans to be adopted by June 30, 2024. Name of Contact Person: Henry Dachowitz, Chief Financial Officer Projected Completion Date: June 30, 2024

Auditee Response: Management of the District has reviewed the processes and internal controls related to construction contracts and have implemented changes to ensure that the Wage Rate Requirements are adhered to when applicable. Corrective Action Plan: (1) Any contracts over $2,000 will include the proper language that the contractor must comply with the Davis-Bacon Act. These contracts will be reviewed by Business Administrator and Superintendent before being signed and (2) Weekly certified reports will be obtained from contractor and reminders have been set up with both parties to ensure this happens timely. Person Responsible: Lane Mecham, Business Administrator Timeline: Management of the District will ensure all construction contracts using federal dollars will have the Davis-Bacon language in the contract – November 2023 Certified weekly payroll reports obtained from contractor – November 2023

United States Department of the Education 2023-002 Special Education Cluster – AL No. 84.027/84.173 Recommendation: We recommend that the BOE review its formal procurement policies and make necessary changes to comply with the criteria as set out in 2 CFR sections 200.318 and 200.326. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management agrees with this finding. Management will update their purchasing policy to ensure compliance with Uniform Guidance. The of the contact person responsible for corrective action: Elio Longo

Program: Choice Neighborhoods Implementation Grants Federal Agency: Department of Housing and Urban Development AL #: 14.889 Federal Award Identification Number and Year: Various - See SEFA Pass-through Entity: N/A Type of Compliance Finding: N - Special Test and Provisions Internal Control Impact: Material Weakness Finding: The City did not provide evidence supporting the City's compliance with this requirement. Status: Resolved Corrective Action Plan: Since the CNI grant has ended, the corrective action plan will apply to future grants. When the City obtains future grants utilizing and/or funding projects in multiple City Departments, operating procedures will be in place to ensure compliance and the required grant documentation will centrally located and identified. Person(s) Responsible for Implementation: Jeffrey Williams, Director of City Planning, Telephone: (816) 513-8803; Email: Jeffrey.Williams@kcmo.org

Program: Choice Neighborhoods Implementation Grants Federal Agency: Department of Housing and Urban Development AL #: 14.889 Federal Award Identification Number and Year: Various - See SEFA Pass-through Entity: N/A Type of Compliance Finding: I - Procurement, Suspension, & Debarment Internal Control Impact: Material Weakness Finding: The City did not provide evidence supporting the City's compliance with this requirement. Status: Resolved Corrective Action Plan: Since the CNI grant has ended, the corrective action plan will apply to future grants. When the City obtains future grants utilizing and/or funding projects in multiple City Departments, operating procedures will be in place to comply with 2 CFR sections 200.318 through 200.326 to ensure compliance and the required grant documentation will be centrally located and filed. Person(s) Responsible for Implementation: Jeffrey Williams, Director of City Planning, Telephone: (816) 513-8803; Email: Jeffrey.Williams@kcmo.org

Landesa will revise it’s Procurement Policy to meet the standards of the United States Federal Government and all components of 2 CFR Section 200.320. Landesa will revise the Procurement Policy to include clear thresholds for small purchases and simplified acquisitions and clearly address the topics of sealed bids, price analysis, and acquisition costs. Landesa will revise existing procurement forms, such as the third-party due diligence form, to ensure compliance with the revised policy. Landesa will provide training to all relevant staff on the revisions to the Procurement Policy by March 2024. The Director of Program Effectiveness will monitor staff implementation of the revised policy and procedures to ensure compliance with revised policy. Contact person: Director of Program Effectiveness and Anticipated completion date: March 2024

Finding, #2023-001 and #2023-002· Material Weakness - Other Matters, Government Auditing Standards; Major Federal Award Finding - Procurement and Suspension and Debarment Corrective Action Plan: We recognize the carry over nature of these findings in that the contract with the vendor that triggered the finding began in fiscal year 2022 and the work was not completed until fiscal year 2023. Revise the current procurement policy to include federal regulations 2 CFR Section 200.317-200-326 per the thresholds in CFR 200.320. The revised policy will be reviewed with managers responsible for procurement that could potentially exceed these thresholds. Our procurement procedure will be revised to clearly specify the requirements for Small Purchase Procedures for purchases between the micro-purchase threshold and the simplified acquisition threshold per federal government regulations.

Coronavirus State and Local Fiscal Recovery Funds – Assistance Listing No. 21.027 Substance Abuse and Mental Health Services Projects of Regional and National Significance – Assistance Listing No. 93.243 Recommendation: We recommend that the Organization review its procurement policy and conflict of interest policy and make necessary changes to comply with the criteria as set out in 2 CFR sections 200.318 and 200.326. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The conflict-of-interest policy has been added to the fiscal policies. Management is in the process of enhancing the federal procurement policy to include sections 200.318 – 200.326. Name of the contact person responsible for corrective action: Lisa Maraia, CFO Planned completion date for corrective action plan: December 1, 2023