Corrective Action Plans

U.S Department of Treasury COVID 19 – Coronavirus State and Local Fisal Recovery Funds – 21.027 Management’s Response: The amount of the expense with this vendor was below $5,000 for three separate invoices and events. The Unified Government’s purchasing policy does not require competitive quotes for purchases under $5,000. However, we understand that we should be viewing these expenses in the aggregate not as individual transactions. We will work with the department to ensure these are competitively procured going forward. Views of Responsible Officials and Corrective Action: Departments have been informed of the procurement requirements and the procurement policy will be adhered to on a go forward basis. Management will ensure this is addressed by December 31, 2025. Responsible Official: Dr. Shelley Kneuvean Chief Financial Officer Unified Government of Wyandotte County & Kansas City KS

MATERIAL WEAKNESS 2023-002 Policies and Procedures Auditor’s Recommendation: We recommend that the Foundation adopt a formal written procurement policy in the format and with the elements required by 2 CFR Sections 200.318 to 200.327. Action Taken: • As a First Year Single Auditee, the management team will ensure that senior leadership team, finance and accounting team, as well as program manager/directors for federal awards receive some form of training and certify receipt of this training within six-months of these findings no later than December 31st, 2024. • As a First Year Single Auditee, the management team will ensure that specific policies are created to ensure a procurement process for goods and services expensed from federal funds is established and in alignment with UG (Uniform Guidance) standards for federal awards no later than December 31st, 2024. • As a First Year Single Auditee, the management team will have an independent audit firm review this policy to ensure they are in alignment and conformance with UG (Uniform Guidance) standards no later than December 31st, 2024.

The Program will develop an internal procurement policy with reference to the appropriate Federal, State, and local laws, regulations, and standards. The documented policy will be used when initiating and approving purchases under Federal grant programs. Individual(s) Responsible Sherry Bradley Completion Date The plan was implemented.

Personnel changes, including the introduction and departure of a new Director of Grants position, resulted in vulnerabilities in the College’s master calendar strategy, leading to missed deadlines in isolated and unique circumstances. To mitigate this situation, the College will implement a new master calendar policy that includes cross-checks to ensure that critical deadlines are met and to provide better oversight of key dates. In addition, we will create a backup resource who will be granted access to Grant Solutions system. In addition, the College will seek written documentation to any amendments related to filing deadlines. Patrick Grimes is the individual responsible for oversight of this corrective action plan.

Management Response #2023-007: Due to staff shortages and turnover, the company lacked adequate personnel to effectively monitor or document grant activity. Additionally, formal documentation of policies and procedures was insufficient, and supporting documents were not stored in a centralized location, creating challenges in retrieving necessary information. Corrective Action Plan: In response to these issues, the company implemented the following corrective measures starting in mid-2023: • The Corporation established comprehensive, formal policies and procedures that document the current compliance practices. These procedures have been disseminated across the organization and incorporated into training programs to ensure all employees are aligned with the updated standards. • A procedure enhancement has been implemented in the procurement process, which requires the procurement manager to obtain three bids prior to the creation of certain purchase orders. This ensures competitive bidding and transparency in vendor selection. • Once a vendor is selected, the procurement manager will forward the vendor’s details to the compliance department. The compliance team will then verify the vendor's debarment status and federal eligibility to ensure compliance with all regulatory requirements. • A central repository platform has been created to store all vendor bids, price analyses, and related procurement documentation. This ensures that all relevant information is easily accessible and properly organized. • All accounts payable invoices designated for grant funding are now routed for prior approval to the respective grant program manager via the WorkPlace software before any payments are processed. This ensures proper oversight and alignment with grant requirements. These corrective actions aim to strengthen compliance, improve document management, and streamline oversight processes to prevent future issues related to grant monitoring and procurement. Responsible Party: Tamara Barnes, CFO

Assistance listing number and program name: 14.267 Continuum of Care Program Agency: Arizona Department of Housing (DOH) Name of contact person and title: Lori Moreno, DOH Human Resources and Procurement Administrator Anticipated completion date: March 31, 2025 Agency’s Response: Concur The Department will update written policies and procedures related to procurement to incorporate applicable aspects of Federal Regulations 2 CFR §§200.321, 200.322, 200.323, and 200.327. The updated policy will address competition through competitive bids, sole source selections, and retention of procurement documents. In addition, the policy will state the Federal requirements that are to be included in purchase orders and contracts.

Auditor’s Recommendation: The Organization should develop and document procurement procedures that meet state, local, and Uniform Guidance requirements. Internal controls should be designed, implemented, and documented within the procurement procedures to ensure compliance with 2 CFR sections 200.317 through 200.327. At a minimum, the procurement history including rationale for the method, procurement method support, contract selections and rejections, suspension and debarment, and bases for contract prices should be documented. Corrective Action: Implement Policy A10 – “Grant Management Protocols.” Utilize Donor Database for managing subawards. Responsible for Corrective Action: Finance Team (Outsourced accounting firm, Operations Manager, Executive Director) 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: 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