Corrective Action Plans

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

FINDINGS - FEDERAL AWARD PROGRAMS AUDIT SIGNFICANT DEFICIENCY/COMPLIANCE 2022-01 Procurement Policies and Procedures Recommendation: Quotes should be obtained whenever possible when purchases are expected to be between $10,000 and $250,000. If purchases are to equal or exceed $250,000, the proper bidding procedures should be followed. Bidding procedures, quotes, and efforts to give preference to minority or women-owned businesses should be documented, including documenting if bids or quotes could not be obtained. A procurement policy should be established as soon as possible and an individual should be assigned to monitor the implementation of the policy. Action Taken: The Organization has begun the process of establishing a procurement policy and have it completed by March 16, 2023. The Organization will also go back to purchases starting July 1, 2022, that exceeded the micro purchase threshold of $10,000 and prepare the required documentation as listed in the recommendation. This will be completed by April 30, 2023. Any purchases exceeding the micro purchase threshold of $10,000 going forward will be supported by the required documentation.

FINDING 2022-001 Contact Person Responsible for Corrective Action: Stacie Light, Director of FNS Daniele Raber, Corporation Treasurer Contact Phone Number: 574-371-5098 ext. 2408 574-371-5098 ext. 2451 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: WCS was fully operating during a pandemic and had to do whatever it took to get products for our students and families. Although we feel we followed the proper procedures for these purchases, we will take your recommendations to make sure we're following protocol. During the pandemic, due to supply chain issues, we had to utilize vendors outside of the co-op in order to meet these needs which resulted in higher total expenditure costs for these vendors. Supply chain issues are not as prevalent as the pandemic has lessened. These purchases to outside co-op vendors are decreasing. We will do payment history checks on the vendors our Child and Nutrition program is utilizing throughout the year to ensure they are under the small purchase threshold and will receive contracts with vendors should they exceed this threshold. We will continue to follow our already established process of checking SAM.gov when new vendors are entered into our system for use. We will begin to do an annual check of vendors that our Child and Nutrition program utilizes to ensure that previously established vendors are not on the suspension or debarment listing. Anticipated Completion Date: We will begin these corrections immediately for the remainder of the school year and will more fully implement these corrections as of the beginning of the 2023-2024 school year.

2022-005 Contact Person Neil Breidenbach Planned Corrective Action The District will create and approve a procurement policy that adheres to state and local regulations as well as 2 CFR Part 200.317 through 200.327. Planned Completion Date December 31, 2023

Criteria: The Partnership must establish and maintain effective internal control over federal awards that provides reasonable assurance that the Partnership is managing the federal awards in compliance with federal statutes, regulations and terms and conditions of the federal award. 2 CFR 200.327 and 2 CFR 200.328 require the auditee to collect financial information and monitor its activities under federal awards to assure compliance with applicable federal requirements and performance expectations are being achieved and report these items in accordance with program requirements. Terms and conditions of the federal award require the Hospital to maintain a debt service reserve fund as bookkeeping accounts or as separate bank accounts. Condition: During 2022, the certificate of deposit that represented the debt service reserve fund matured and the proceeds were commingled with an existing money market fund. Planned Corrective Action: Management agrees with the finding and will deposit the required debt service reserve funds in a separate bank account. Planned Completion Date: June 30, 2023 Person Responsible: Daris Rosencrance, CFO

Criteria: The Partnership must establish and maintain effective internal control over federal awards that provides reasonable assurance that the Partnership is managing the federal awards in compliance with federal statutes, regulations and terms and conditions of the federal award. 2 CFR 200.327 and 2 CFR 200.328 require the auditee to collect financial information and monitor its activities under federal awards to assure compliance with applicable federal requirements and performance expectations are being achieved and report these items in accordance with program requirements. Terms and conditions of the federal award require the audited financial statements to be provided to the federal agency annually within 150 days of fiscal year-end, as well as quarterly internal financial statements. Condition: The Partnership did not submit the audited financial statements within the prescribed period or request an extension and did not submit any quarterly reports to the federal agency. The Partnership was not asked for the information after they failed to submit it. The audited financial statements are readily available to the federal agency through the federal clearinghouse website. Planned Corrective Action: Management agrees with the finding and are implementing procedures to ensure that the required financial reports are submitted in a timely manner in accordance with the terms and conditions of the federal award. Planned Completion Date: June 30, 2023 Person Responsible: Daris Rosencrance, CFO

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

Program: AL 21.023 ? COVID-19 Emergency Rental Assistance ? Allowability & Earmarking Corrective Action Plan: N/A Contact: Lee Will Anticipated Completion Date: N/A

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

Program: 66.958 Water Infrastructure Finance and Innovation Federal Agency: U.S. Environmental Protection Agency Award No: WIFIA-N18147WI Award Year: 2022 This finding is a repeat finding of 2021-001 Criteria: 2 CFR section 200.318 ? General Procurement Standards, requires non-Federal entity to 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. Condition: We reviewed the water utility's procurement policy and service contracts with costs reimbursed during 2022, noting they did not contain necessary federal language related to conflicts of interest and debarment and suspension. Cause: The water utility has not received federal funding in the past and did not update their procurement policy when they sought federal funding for the Great Lakes Water Supply project. Additionally, service contracts were entered into prior to receiving federal funds. Effect: Without adequate control of contract language the water utility could enter into contracts related to the Great Lakes Water Supply project that do not qualify for federal reimbursement. Questioned Costs: None noted. Recommendation: We recommend the water utility review its procurement policy and make necessary updates to be in compliance with federal standards. Additionally, we recommend the utility enter into contract addendums related to contracts previously executed without required federal language. Management Response: Waukesha Water utility management has worked closely with WIFIA to craft contracts that include all necessary language prior to releasing RFPs for construction contracts. WIFIA was presented all service contracts to review prior to reimbursements received in fiscal year 2022. The finance department is working to update the procurement policy to ensure necessary federal language is included. The finance department will also work with service contractors to execute contract addendums.

Contact Person Responsible for Corrective Action: Jessica Espinoza Contact Phone Number: (219) 836-9111 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: There has been turnover in the finance department and the past employees who would have been responsible for this are no longer here. There are already internal controls in place to ensure that the monthly sponsor claims submitted match the school?s meal count reports. The Treasurer will continue to ensure that everything is correctly entered before submission. Anticipated Completion Date: March 2023

Material Weakness: Criteria: RWHS must establish and maintain effective internal control over federal awards that provides reasonable assurance that RWHS is managing the federal awards in compliance with federal statutes, regulations and terms and conditions of the federal award. 2 CFR 200.327 and 2 CFR 200.328 require the auditee to collect financial information and monitor its activities under federal awards to assure compliance with applicable federal requirements and performance expectations are being achieved and report these items in accordance with program requirements. Terms and conditions of the federal award require the quarterly revenue on an actual and budgeted basis to be reported to the federal agency by March 31, 2023. Condition: RWHS submitted instances of inaccurate actual revenue for quarters 3 and 4 of 2021 and 2022 and inaccurate budgeted revenue for quarters 2 and 3 of 2021. Planned Corrective Action: Management will implement procedures to ensure that the required revenue totals are reported accurately in accordance with the terms and conditions of the federal award. Contact Person: Alan Townsend, CFO Anticipated Completion Date: December 31, 2023

Coronavirus State and Local Fiscal Recovery Funds ? Assistance Listing No. 21.027 Recommendation: We recommend the Town establish and document procurement policies and procedures in conformity with the Federal requirements ?? 200.317 through 200.327. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Town of Easton will modify the current procurement procedures to add an additional section for those services, materials or products procured that have a Federal Grant Revenue source. Name(s) of the contact person(s) responsible for corrective action: Donald Richardson Planned completion date for corrective action plan: June 30, 2023

Finding No. 2022-007: Procurement Policy - Material Weakness in Internal Control Over Financial Reporting U.S. Department of Health and Human Services, Health Center Program Cluster; CDFA No. 93.224 Condition: There is no formal documentation or evidence to support that competitive price analysis for vendors selected by CCI several years ago or that suspension and debarment verifications were performed for vendors, as required by the general procurement standards of the Uniform Guidance. Recommendation: Marcum recommends that CCI update its existing procurement policy governing contracts with vendors that will be reimbursed by federal grants to incorporate all of the provisions included in the general procurement standards of the Uniform Guidance Section 200.318 and the debarment and suspension regulations of Uniform Guidance Section 200.214. Marcum also recommend that a review of all vendor contract files be performed to ensure that the documentation as required under the Uniform Guidance is maintained in the files. Action Taken: CCI is recommending to the board to update its procurement policy by obtaining at a minimum-three separate bids for anything above $50,000.00. We are also in the process of hiring a full-time purchasing manager to oversee procurement policy and strategy. Anticipated Completion/Implementation Date: End of fiscal year 2024.

Finding # 2022-001 Response Management agrees with the finding and recommendation and will update its procurement policy to comply with 2 CFR 200.318 through 2 CFR 200.327. Responsible Party Bobby Splinter Estimated Completion December 31, 2023

FEDERAL PROCUREMENT Name of contact person: Mayor and Clerk Corrective Action: The City understands and agrees that it must order a rule which governs the spending of federally procured recovery funds and grants. More specifically, said rule shall create a standard of conduct which prevents the bestowal of federally procured recovery funds based upon relationship rather than merit. See, Mont. Code Ann. ? 2-2-301. To that end, the City shall draft and pass via majority vote of City Council Members a resolution to address this issue which complies with State and Federal regulation of said funds. Said resolution will be passed in 2023 prior to the conclusion of the City's fiscal year. Proposed Completion Date: Fiscal Year 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 Number: 2022-001, 2021-002, 2020-002, 2019-007 Program Name/Assistance Listing Titles: Indian School Equalization; Indian Education Facilities, Operations, and Maintenance Assistance Listing Numbers: 15.042, 15.047 Contact Person: Lolita Paddock, Principal Anticipated Completion Date: June 30, 2023 Planned Corrective Action: The School has a policy to follow the minimum general standard accounting procedures to ensure submission of accurate reports. The school administration consisting of the business manager or business services consultant will submit SF-425 reports accurately, ensuring not to include the reporting of non-federal revenues and non-federal disbursements in each quarter of reporting to the federal government.

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

Effective immediately, the Chief Financial Analyst has created a schedule for all Westward Heights Care Center monthly financial statements be completed and sent to the Administrator by approximately the 20th of each month. This will allow time to get the quarterly reports completed and sent to the USDA. The annual budget was not completed on time as there was a new administrator. The administrator now has the experience and education to get the budget completed by November 30th and sent to the USDA.

Finding No. 2022-004: Procurement Policy ? Material Weakness in Internal Control Over Financial Reporting; U.S. Department of Health and Human Services, Rare Disorders: Research, Surveillance, Health Promotion, and Education; Assistance Listing Number 93.315 Condition There is no evidence of a documented formal procurement policy with regards to federal grant awards and expenditures, no documented support that a competitive price analysis for vendors and organizations funded with federal grant funds were performed and no evidence that suspension and debarment verifications were performed for certain vendors and organizations, as required by the general procurement standards of the Uniform Guidance. Recommendation It was recommended that the Association establish a written procurement policy governing contracts with vendors that will be reimbursed by federal grants to incorporate all of the provisions included in the general procurement standards of the Uniform Guidance Section 200.318 and the debarment and suspension regulations of Uniform Guidance Section 200.214. It was also recommended that a review of all existing vendor or sub-awardee contract files be performed to ensure that the documentation as required under the Uniform Guidance is maintained in the files. Action Taken The Spina Bifida Association will take action to ensure an up-to-date Procurement Policy is approved by the Board of Directors. Anticipated Completion Date December 2023

Finding 2022-002 Department of Transportation Airport Improvement Program, CFDA #20.106 AIP3-46-0050-57, AIP3-46-0050-61 Finding Summary: Federal share of expenditures reported within SF-425 annual report for grants #57 and #61 did not reconcile to supporting client records. Responsible Individuals: Dan Letellier, Executive Director Corrective Action Plan: Management will ensure correct support documentation is provided to 3rd party account for correct submission of FAA Forms 5100-126 and 127. Director will also verify that annual report form SF-425 is completed either by the Airport or the State of South Dakota DOT as it has been in the past. Anticipated Completion Date: Ongoing

INTERNAL CONTROLS OVER FINANCIAL STATEMENT PREPARATION, GRANT CLOSE OUT AND COMPLIANCE WITH RELATED PROVISIONS OF GRANTS AND CONTRACTS SHOULD BE IMPROVED HEAD START AND EARLY HEAD START PROGRAMS LOW-INCOME HOME ENERGY and WATER ASSISTANCE PROGRAM CFDA # 93.600, 93.568 and 93.499 (Questioned Costs - Undetermined) Management is in the process of assessing the organizational structure and capacity to provide adequate financial reporting. With Board review and approval of the agency?s financial funding sources, the agency will hire additional fiscal clerk to further support financial requirements and segregation of duties to ensure adequate internal controls are fully implemented. The CFO will have the overall responsibility of properly reconciling and closing out the accounting system and grant activity each month in an efficient and timely manner to eliminate the risk of significant errors occurring. Budget-to-actual schedules will be an integral part of the grant accountant analyst?s basic responsibilities. The fiscal policies and procedures will be updated with the enhancements implemented within the fiscal department. Staff will be trained on revised policies and procedures and uniform guidance regulations. The new automated financial system, will support financial reporting to meet GAAP requirements and to provide informative reports for Board and Management. All enhancements will be implemented by December 31, 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.

U.S. DEPARTMENT OF TREASURY 2022-001 Coronavirus State and Local Fiscal Recovery Funds- ALN No. 21.027 Recommendation: We recommend the Town design and document a procurement policy in accordance with the compliance requirements outlined in Title 2 of the U.S. Code of Federal Regulations part 200.318. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We agree with the auditor?s findings. Management will design a formal procurement policy. Name(s) of the contact person(s) responsible for corrective action: Sue Nickerson, Town Accountant. Planned completion date for corrective action plan: Immediately.