Corrective Action Plans

FINDING 2023-004 Finding Subject: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds – Procurement and Suspension and Debarment Summary of Finding: Suspension and Debarment – Allen County did not have documentation that vendors’ suspension and debarment status were verified through either a) checking the Excluded Parties List System (EPLS), b) collecting a certification, or c) adding a clause or condition to the covered transaction agreement. Procurement – Allen County did not ensure purchases between $10,000 and $150,000 had received the adequate number of quotes or documented why an adequate number of quotes was not received. Contact Person Responsible for Corrective Action: Chris Cloud, Chief of Staff Contact Phone Number and Email Address: 260-449-4752 / chris.cloud@allencounty.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: To correct Finding 2023-004 for Suspension and Debarment, the Chief of Staff to the Board of Commissioners will check the EPLS on SAM.gov every time a contract is placed before the Board of Commissioners for signature not containing the appropriate suspension and debarment language or a county department starts a project with a vendor using State and Local Fiscal Recovery Funds (SLFRF). If a vendor is not found in EPLS, a certification will be solicited from the vendor prior to contract signing or purchase of goods or services verifying that they have not been suspended or disbarred. A new verification must be sought for every contract or purchase. Documentation will be kept on file by the Controller to the Board of Commissioners who is responsible for reviewing claims submitted for payment utilizing SLFRF. To correct Finding 2023-004 for Procurement, the Chief of Staff to the Board of Commissioners will instruct departments who may be spending between $10,000-$150,000 of SLFRF that price or rate quotations must be obtained from an adequate number of qualified sources. When departments submit a claim to the Controller of the Board of Commissioners for payment, they must also provide a cover sheet outlining a) rationale for the method of procurement, b) copies of quotes received, and c) a justification for the selected vendor. This information will be reviewed and if everything is in order, the cover sheet will be uploaded, along with the accompanying invoices, in the Workflow payment system as part of the record. Anticipated Completion Date: This CAP will be completed by December 31, 2024

Significant Deficiency and Noncompliance – Procurement Documentation Statement of Condition/Criteria: Delta County is not following its procurement policy and is therefore not meeting the requirements of 2 CFR section 200.318 to use documented procurement procedures. The County does not have controls in place to ensure that written records are maintained sufficient to detail the history of procurement including the rationale for the method of procurement, selection of contract type, contractor selection or rejection, and the basis for the contract price. The County did not maintain documentation to sufficiently support a written price analysis on one procurement tested. The County was unable to provide proposals from nonwinning bidders and/or a price analysis when only one bid was received on two contracts tested. The County does not have formal procedures or controls in place to ensure written documentation of a cost analysis or a contract file are maintained. Planned Corrective Action: County management has started to develop controls to ensure the procurement policy is followed and will continue to develop controls to ensure that complete contract files with a price analysis are maintained. Contact person responsible for corrective action: Ashleigh Young, County Controller/Administrator Anticipated Completion Date: March 2025

CLIENT PLANNED ACTION: When a new federally funded construction project or purchase is in the planning stage that is in the price range of $10,000 to $250,000(a small purchase), the Director of Facilities and/or the Purchasing agent will send out solicitations including specs via letter, email or by phone to multiple vendors. They may also look up vendor pricing on the internet. After the quotes are received, they will forward them to the CFO or Director of Finance who will then evaluate the quotes and decide on a vendor. Before the vendor is notified, the business office staff will check SAM.gov for federal disbarment or suspension. The SAM.gov verification will be saved in the accounting vendor files. Copies of the quotes will also be filed in the accounting office. CLIENT RESPONSIBLE PARTY: Name of Contact Person: David A. Goff, MBA Vice President of Administration and Chief Financial Officer. 4851 Independence Street, Wheat Ridge, CO 80033. 303-432-5164, Davidg@jcmh.org COMPLETION DATE: 9/1/2024

Condition: The Authority did not utilize federal procurement requirements cited above for the tele-health services and SUD Peer Recovery Service contracted service providers utilized for the Certified Community Behavioral Health Clinics project. (no documentation for sole source, no proof that it was advertised, google search was provided from 7/24/24 is not sufficient, board cannot waive federal requirement). Recommendation: The Authority follow federal procurement as required in 2 CFR 200.319(d) for all contracts reimbursed with federal funds. Planned Corrective Action: Going forward the Authority will follow federal procurement as required in 2 CFR 200.319(d) for all contracts reimbursed with federal funds. Contact Person: Anthony Shaver, Chief Financial Officer Anticipated Completion Date: 9/30/2024

FINDING 2023-003 Finding Subject: Special Education Cluster (IDEA) - Procurement Summary of Finding: The School Corporation’s management had not developed a system of internal controls that would ensure compliance with procurement and suspension and debarment compliance requirement. Contact Person Responsible for Corrective Action: Tracey Haas, Deputy Treasurer Contact Phone Number and Email Address: thaas@mcas.k12.in.us (219)873-2000 ext. 8346 Views of Responsible Officials: We concur with this finding. We are working on establishing a proper system of internal controls and develop policies and procedures to ensure there are appropriate procurement procedures for goods and services. Description of Corrective Action Plan: We are working on establishing a proper system of internal control and developing policies and procedures to ensure there are appropriate procurement procedures for goods and services. We are working on a checklist for procurement for all federal grants. Moving forward we will ensure required bids and quotes are attached to the claim for payment. Anticipated Completion Date: The Anticipated date of completion for this correction is January 1, 2025.

Correction Action Planned: The contract in question was for a vendor (Healthsource Solutions) already under contract with Lubbock County Hospital District dba University Medical Center prior to the grant application. The vendor in question had been used since at least 2010, with the most recent contract for the current wellness portal (Wellness +) beginning in 2017. Because of the success of the wellness portal and established relationship with the vendor, University Medical Center included expansion of existing platforms and additional services provided by Healthsource Solutions as a large component of the Methodology/Approach in the proposed activities of the grant narrative submitted. Use of this vendor and its applications were specifically outlined in the grant project narrative and a critical component of meeting grant objectives. University Medical Center follows the Lubbock County Purchasing Guidelines, which conform to the Uniform Guidance procurement standards. University Medical Center has reviewed the specified requirements of the Office of Management and Budget Uniform Guidance for procurement standards, specifically related to noncompetitive procurement and concurs that formal procurement methods were not used for expansion of new services with this existing vendor or adequate documentation was provided for noncompetitive procurement. In order to ensure compliance with the Uniform Guidance, the University Medical Center will provide training to existing grant Program Managers on Uniform Guidance procurement standards. Additionally, if a new grant is being pursued the grant committee should receive training on Uniform Guidance procurement standards before completing grant applications. On existing or future grants, any potential contracts or purchases over $75,000 should be reviewed by the grant Program Manager (or Grant Committee lead if a Program Manager has yet been assigned) to ensure all procurement guidelines are followed and sufficient documentation is obtained prior to purchase or contract execution. Contact Person (s) Responsible for Corrective Action: Aaron Davis, VP & Chief Experience Officer Anticipated Completion Date: The Corrective Action will be immediately implemented in response to the auditors’ recommendation.

2023-001 Special Tests and Provisions-Wage Rate Requirements Pleasant Point Housing Authority will be providing training to the following staff and Board of Commissioners- Procurement Policy. In addition, an extra step to the policy will be implemented with a Bid being approved by the Finance Officer and the Director before being advertised. The following items must be included in the bid package-I) Required to submit a completed Wage Hour Form 347(WH 347) and 2) A signed Statement of Compliance with the Davis Bacon Act. These items must be submitted with each request for payment for the vendor who receives the bid. In addition, the Finance Officer and Director will be responsible for making sure that the information is submitted before signing off for payment. Training on the Davis Bacon Act and compliance was held for the Director, Finance Officer, and Payable Person in July 2023 to make sure all payables to contractors have completed necessary paperwork to receive payment. A checklist form was created to attach to all contract payments with items necessaiy before payment is processed.

2023-007: Lack of Formally Adopted Procurement Policy Corrective Action: The organization has since adopted a procurement policy for federal funding in adherence with uniform guidance requirements. Given the additional policy in the organization’s fiscal policies and procedures documents, we do not anticipate any issues in lacking a formally adopted procurement policy moving forward.

9/11 Day takes great care in evaluating and selecting vendors that support its programs, both in terms of the vendors’ abilities to deliver high quality services and their ability to do so cost effectively. For all major expenses we require advance cost estimates and competitively evaluate them. To comply fully with 2 CFR 200 9/11 Day is now in the process of adopting a formal procurement policy. It is the intention of 9/11 Day to finalize and adopt that process by 12/31/2024, and will apply it on a go forward basis to all future federally-supported procurement activities.

Contact Person – Scott Froemming Corrective Action Plan – Meeker Cooperative will create and implement a procurement policy that complies with state and local regulations as well as 2 CFR Part 200.317 through 200.327. Completion Date – October 31, 2024

Management will create a formal, written procurement policy. Management will also review the noncompetitive procurement procedures and will document how and why our vendor(s) meets these requirements, if applicable.

Views of Responsible Officials and Action Taken: We agree with the finding and recommendation and have implemented a verification step in our vendor approval and onboarding process which requires all vendors to be run through the SAM website and debarment search. We also require an annual verification to be performed for all vendors.

Management will develop, adopt and implement a procurement policy for federal purchases that aligns with the requirement of the 2 CFR 200 Uniform Guidance. This process will include steps within the interview and application process to ensure contractors and subrecipients are eligible (not suspended, debarred, or otherwise excluded) to enter into an agreement, contract, or subaward with the City. The process will also include steps to ensure all necessary language, such as the Buy America Build America Provisions are included in the final contracts.

Management of the Town will work to adopt a formal procurement policy that is in compliance with Federal Uniform Guidance and State requirement. The Town will also assign a federal procurement leader that will help determine requirements for federal versus nonfederal awards as well as ensuring the Town's new procurement policy is followed.

Management of the City will work to adopt a formal procurement policy that is in compliance with Federal Uniform Guidance and State requirements. The City will also assign a federal procurement leader that will help determine requirements for federal versus nonfederal awards as well as ensuring the City’s new procurement policy is followed.

Finding 2023-003: Procurement The auditors noted the following areas for improvement: ● The SDA did not perform timely debarment or suspension checks for some contractors hired. ● The SDA could not justify the rationale for selection of 2 awarded contracts as part of the BGS request for qualification process. ● Note: The auditors provided a suggested recommendation to update all 1099 contract language to include reference to the specific 2 CFR 200 Appendix II reference. The auditors recommend the following: 1. Management should adhere to written procurement policies and maintain sufficient documentation, including justification memos and debarment/suspension verification, to support federally funded procurement decisions. SDA Response The SDA accepts the above findings with notes on those findings, and would like to add the following information for context: • Stronger implementation and compliance efforts are required from Management to ensure the adopted procurement procedures are followed. SDA Corrective Actions The SDA is implementing a new checklist tool to bolster compliance. This checklist will help the Director of Finance and Administration identify and correct any missing compliance well in advance of the next audit. In addition, Management is implementing a new quarterly review process to assess both compliance and financial accounts. The new quarterly review process will ensure documentation is maintained and accounted for each transaction, particularly for restricted grants, to minimize any post-close adjustments. The combination of both the new checklist tool and review process will support continued timeliness and eliminate this finding in future audits. The Director of Finance and Administration will also meet with all business line leads to provide additional training and support on the procurement process, including requesting additional information for all active contracts for 2024. Lastly, Management will immediately update 1099 contract agreements to include specific CFR language in 1099 as suggested by the auditors.

Corrective Action Planned: We will review the Uniform Guidance Standards and update the procedures needed to be in full accordance. Name(s) of Contact Person(s) Responsible for Corrective Action: Lynette Bacchus will make the changes and John Pinto and Lawrence Boord will approve. Anticipated Completion Date: October 31, 2024.

FINDING 2023-002 (Auditor Assigned Reference Number) Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds – Procurement and Suspension and Debarment Summary of Finding: The Town's policies related to SLFRF suspension and debarment requirement did not include checking the EPLS for vendor suspension and debarment. All three covered transactions tested did not have documentation provided to show the vendor was checked for suspension and debarment. Additionally, the Town did not have a formalized procurement policy outlining its processes and procedures with regards to the procurement of goods and services using federal grant funds. Contact Person Responsible for Corrective Action: Matt Sumner Contact Phone Number and Email Address: 317-732-4532, msumner@whitestown.in.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: We will be more diligent in finding out if our grants are federal and what requirements they have for us to follow. We will check applicable vendors for suspension and debarment and implement a control/review over those searches. Anticipated Completion Date: November 1, 2024

Additional training and review of the procurement process will take place. This office will coordinate with other departments with training and expectations.

The Distilled Spirits Council of the U.S. recognizes the importance of implementing a procurement process in accordance with 2 CFR 200.318(a). The International Team (with feedback from the Finance Team), will adopt an updated procurement process with procedures to address various methods of procurement and ensure all vendors entered a covered transaction are not debarred, suspended,or otherwise excluded. The procurement policy was updated; however, it did not take effect until the 2024 fiscal year due to the finalization of the 2022 audit, which occurred near the end of the 2023

FINDING 2023-003 Finding Subject: COVID-19 CORONAVIRUS STATE AND LOCAL FISCAL RECOVERY - PROCUREMENT AND SUSPENSION AND DEBARMENT. Summary of Finding: There were deficiencies in the internal control system of the City resulting in noncompliance with the grant’s procurement and suspension and debarment requirements. Contact Person Responsible for Corrective Action: Ashley Huffman Contact Phone Number and Email Address: 765-521-6803 nccityclerk@gmail.com Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The City did not follow its policy for Federal Grant Disbursements. The Clerk Treasurer's office will ensure compliance with the Procurement requirement. The City has implemented maintaining contract files with the Deputy Clerk Treasurer reviewing to ensure they contain documentation of the history of the procurement, including the rationale for the method of procurement and selection of the vendor. Anticipated completion date: September 1, 2024

FINDING 2023-005 Finding Subject: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds – Procurement and Suspension and Debarment Summary of Finding: Procurement - Policy The County had not established a purchasing policy that would reflect applicable state laws and regulations including procedures to avoid acquisition of unnecessary or duplicative items, procedures to ensure that all solicitations incorporate a clear and accurate description of the technical requirements for the material, product, or service to be procured and did not maintain written standards of conduct covering conflicts of interest and governing actions of its employees engaged in the selection, award, and administration of contracts. Procurement – Small Purchases The County had one vendor that was identified as being less than the simplified acquisition threshold of $150,000 but exceeding the $50,000 micro-purchase threshold. The one vendor was selected for testing. For the one vendor, the County did not obtain price or rate quotes nor was there documentation detailing the history of procurement, which must include the reason for the procurement method used. Suspension and Debarment One covered transaction paid with SLFRF grant funds was identified during the audit period. The covered transaction totaled $66,000 with $46,752 paid in the audit period. Upon review, the County had not performed procedures to ensure the vendor was not suspended or debarred, or otherwise excluded or disqualified, from participation in federal assistance programs or activities at any time during the audit period Contact Person Responsible for Corrective Action: Bryan Lewis Contact Phone Number and Email Address: 574-223-4764 and blewis@co.fulton.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The County will work on establishing a purchasing policy which will address federal procurement requirements. Before entering into contracts we will ensure the procurement procedures in the policy are followed and obtain quotes for vendors that meet the small purchase threshold as well as verify the suspension and debarment status. The Commissioners and Auditor’s office will work together to ensure requirements are met before payment is processed. Anticipated Completion Date: No later than December 31, 2024

Finding 2023-001 Procurement, Suspension and Debarment (Repeat Finding 2022-001 and 2021-001) Federal Agency: U.S. Department of the Treasury Federal Program: 21.027 Coronavirus State and Local Fiscal Recovery Funds (CSLFRF) Questioned Cost: N/A Corrective Action: a. The Purchasing Manual was revised in 2023 to incorporate procedures relating to suspension and debarment checks. Purchasing will communicate and reinforce its procurement policies and procedures to ensure compliance with applicable requirements by: Provide revised Purchasing Manual to staff with yearly reminder from Purchasing and Community Development Federal Grants Manager. b. City staff will work with the City’s Purchasing Department to follow and adhere to applicable Procurement procedures. c. Ensure all departments are following applicable procedure in a uniform manner. Contact Person: Hitesh Desai, Chief Financial Officer Anticipated Completion Date: December 31, 2024

FINDING 2023-004 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds – Procurement and Suspension and Debarment Summary of Finding: The County entered into an interlocal agreement with the City of Sullivan to procure services for a Sewer Lift Station Improvement/Line Extension to the New County Jail project. The County could not provide any documentation required to verify compliance with the procurement and Suspension and Debarment requirements for the SWIF funds spent on the project. Contact Person Responsible for Corrective Action: Amy Scarbrough Contact Phone Number and Email Address: (812)268-4491 ascarbrough@sullivancounty.in.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The County will adopt a procurement policy. In addition, the County will work with the City of Sullivan to obtain the necessary documentation related to the interlocal agreement and maintain the documentation for future audit periods. Anticipated Completion Date: October, 2024

FINDING 2023-002 Finding Subject: COVID-19 Coronavirus State and Local Fiscal Recovery Funds – Procurement and Suspension and Debarment Summary of Finding: The County had not implemented procurement policy or procedures for procuring goods and services paid with Federal funds. The County did not have policies or procedures in place to verify that the entities which they entered into covered transactions were not suspended, debarred, or otherwise excluded. Four out of seven covered transactions were selected for testing, and none of the contractors’ suspension or debarment statuses were checked prior to payment. Contact Person Responsible for Corrective Action: Pia O’Connor Contact Phone Number and Email Address: 812-379-1510 and pia.oconnor@bartholomew.in.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The Auditor’s Office will continue to work with the Commissioner’s Office and other county departments to improve upon the process of administering the COVID-19 Coronavirus State and Local Fiscal Recovery Fund. The County implemented a Procurement, Suspension and Debarment Policy; however it did not specifically reference federal funds. The County will amend the current policy to include the necessary verbiage and information related to the federal funds. By establishing this system of Internal Controls and developing the proper policies and procedures, this should help ensure contractors and sub recipients, as appropriate are not suspended, debarred or otherwise excluded prior to entering any contacts or sub awards. Anticipated Completion Date: December 31, 2024