Corrective Action Plans

Finding: 2025-002 Federal Agency Name: U.S. Department of Treasury Assistance Listing Number(s): 21.027 Program Name: Coronavirus State and Local Fiscal Recovery Funds (CSLFRF) Finding Summary: Non-Federal entities other than states, including those operating federal programs as subrecipients of states, must follow the procurement standards set out at 2 CFR sections 200.318 through 200.326. They must use their own documented procurement procedures, which reflect applicable state and local laws and regulations, provided that the procurements conform to applicable federal statutes and the procurement requirements identified in 2 CFR Part 200. 2 CFR sections 200.212 and 200.318(h); 2 CFR section 180.300; 48 CFR section 52.2096 outlines the requirements the Non-Federal entity verify vendors for which it plans to enter into a covered transaction are not debarred, suspended, or otherwise excluded. It was noted that while the County does have a purchasing policy, elements as required by Uniform Guidance are absent from the policy. In addition, we noted the County did not retain the supporting documentation indicating they had verified vendors they were entering into covered transactions with were neither suspended nor debarred. While our testing noted no instances of noncompliance, the absence of internal controls over compliance as it relates to having a Uniform Guidance compliant policy, could lead the County to enter into covered transactions that are not compliant with federal regulations. Responsible Individuals: Kyle Wilmot, Canyon County Controller. Corrective Action Plan: Members of the audit office will review each vendor in the SAM.gov database to ensure that they are not suspended, debarred or otherwise excluded. The search of these entity(s) will then be saved to the shared drive for the upcoming ACFR season and the supervisor will be notified of the search to ensure that the files have been properly saved. Anticipated Completion Date: Canyon County will complete the corrective actions for the September 30, 2026, reporting period.

Suspension and Debarment – Assistance Listing No. 14.267 Recommendation: We recommend that the organization retain documentation that Sam.gov was used to verify that a vendor was not suspended, debarred, or otherwise excluded from participating in the transaction prior to contract. To the extent practicable, the organization can engage with a third party that will verify any new and existing vendors have not been suspended or debarred on a monthly basis. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will update procurement procedures to require documented SAM.gov verification for all new vendors prior to contract execution and periodically for existing vendors. Evidence of verification (e.g., screenshots or confirmation reports) will be retained in procurement files. Management will also evaluate engaging a third‑party service to perform monthly suspension and debarment screenings. Compliance will be reviewed as part of routine procurement oversight. Name(s) of the contact person(s) responsible for corrective action: Scott Russell Planned completion date for corrective action plan: 6/30/2026

The County's current procedure requires documented acknowledgement that the vendor was verfied to not be suspended, debarred, or otherwise excluded prior to entering covered transactions. Effective February 25, 2026, the County's procedure will require documented verfication that vendors are not suspended, debarred, or otherwise excluded prior to entering into covered transactions and retain such documnetation within the procurement file, in accordance with CFR 200.212 and 200.318(h), 2 CFR 180.300, and 48 CFR 52.209-6.

Recommendation: CLA recommends the Agency update its procurement policy to include procedures that a vendor be verified as not being debarred, suspended, or excluded and documentation maintained to support the determination. Explanation of disagreement with audit finding: There is no disagreement with this finding. Action taken in response to finding: The Agency is committed to following the procurement process and requirements outlined within the policies and procedures. The Agency plans to revise current procurement policy to have a process for debarred, suspended, or excluded and documentation maintained to support the determination. All procurement will be monitored through the Sage Intacct and Ramp system, which has already been implemented. Name of the contact person responsible for corrective action: Dhiren Shah, CFO Planned completion date for corrective action plan: Immediately

Finding 2025-001: Significant deficiency in internal controls over compliance and immaterial noncompliance Corrective Action Planned: Connected Lane County updated internal control processes, approved by the board on 05.21.25, which significantly reduced year end processing delays and the number of corrections needed to complete the audit. The audit for fiscal year 2025 ending on June 30, 2025 was completed within seven months of the end of the fiscal year. Person(s) Responsible: Jesse Nelson, Executive Director and Mary Bell, Finance Manager Anticipated Completion Date: 09.01.2025

Suspension and Debarment Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) Program – Assistance Listing No. 93.323 Condition: The organization did not document that Sam.gov was checked prior to entering into a contract with a vendor. Recommendation: We recommend that the organization retain documentation that Sam.gov was used to verify that a vendor was not suspended, debarred, or otherwise excluded from participating in the transaction prior to contract. To the extent practicable, the organization can engage with a third party that will verify any new and existing vendors have not been suspended or debarred on a monthly basis. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management recognizes that even though none of the vendors utilized were suspended, debarred or otherwise excluded, the potential for violations increase if the verification is not done prior to engaging in transactions. For grant expenses with federal funding, LCHC management has implemented mandatory SAM.gov verification for all vendors prior to contract execution, with documentation retained in procurement files. LCHC has held meetings where applicable staff have been informed of compliance requirements. Name(s) of the contact person(s) responsible for corrective action: Jeffrey Nelson Planned completion date for corrective action plan: 7/1/2025 If there are any questions regarding this plan, please call Jeffrey Nelson at 872-588-3033

Health Center Program Cluster – Assistance Listing No. 93.224/93.527 Recommendation: The auditor recommends management implement suspension and debarment verification process for all covered vendors, regardless of their history or reputation, to ensure compliance with federal regulations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: In response to the recommendation: Management agrees with the finding and acknowledges that timely suspension and debarment verification was not consistently performed across all vendors. To address this deficiency, the Agency is implementing a standardized process to ensure suspension and debarment checks are conducted prior to entering into any covered transaction, regardless of vendor history. This process will include documented verification steps, annual review protocols, and staff training to reinforce compliance with federal procurement regulations. Name(s) of the contact person(s) responsible for corrective action: Chuck Walzel, CPA, Senior Vice President & Chief Financial Officer, 210-334-3724 (office) Planned completion date for corrective action plan: August 31, 2025

Going forward the Center will prepare and implement a procurement policy in accordance with Uniform Guidance requirements and ensure there is documentation that verifies vendors are not suppressed or debarred prior to entering into contracts with the vendors.

USAID Foreign Assistance for Programs Overseas – Assistance Listing No. 98.001 Recommendation: CLA recommends SFP perform suspension and debarment checks prior to entering into the covered transactions paid for with federal funding and to retain documentation evidencing that those checks were performed timely. Increased training may help reinforce the polices and requirements regarding suspension and debarment checks and documentation retention. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: SFP will ensure that suspension and debarment checks are conducted and documented as per the applicable regulations. SFP will ensure all relevant staff receive updated training on procurement policies, including suspension and debarment checks. Name(s) of the contact person(s) responsible for corrective action: Annie Haylon Planned completion date for corrective action plan: October 31, 2025

FINDINGS—FEDERAL AWARD PROGRAMS AUDITS Department of Housing and Urban Development 2024-002 Continuum of Care – Assistance Listing No. 14.267 Recommendation: CLA recommends Share & Care House and Subsidiary to develop and implement a suspension and debarment policy that meets the requirements outlined in Uniform Guidance. CLA also recommends increased training for those individuals involved in the procurement and contract approval process to ensure suspension and debarment checks are performed on all covered transactions. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: To address this finding Share & Care House is developing and adopting a Suspension and Debarment Policy. The policy requires verification that all vendors, contractors, and subrecipients with transactions totaling $25,000 or greater have not been suspended or debarred from participation in federal programs before entering into a covered transaction. Verification will be conducted by checking the System for Award Management (SAM.gov) Documentation of the verification will be maintained in procurement and contract files. Name(s) of the contact person(s) responsible for corrective action: Celina McKenney Planned completion date for corrective action plan: 10/15/2025 If the Department of Housing and Urban Development has questions regarding this plan, please call Celina McKenney at 253-840-3402 ext. 772. Recommendation: CLA recommends Share & Care House and Subsidiary to develop and implement a suspension and debarment policy that meets the requirements outlined in Uniform Guidance. CLA also recommends increased training for those individuals involved in the procurement and contract approval process to ensure suspension and debarment checks are performed on all covered transactions. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: [Describe action planned or taken]. Name(s) of the contact person(s) responsible for corrective action: [Insert name] Planned completion date for corrective action plan: [Insert date] If the [Cognizant or Oversight Agency for Audit] has questions regarding this plan, please call [Insert name] at [Insert Telephone Number].

Corrective Action Plan: During Q4 2025, Shiloh’s general purchasing policy will be updated to consider the requirements included in 2 CFR 200.328 through 200.326. (Note: This update was originally to be implemented in Q4 2024 but was delayed due to unexpected turnover in the Business Department.)

Finding 2024-002: Significant deficiency in internal controls over compliance and immaterial non- compliance. Corrective Action Planned: Connected Lane County has updated internal control processes to ensure timely reporting and closing of the books and records are stored both electronically and in paper files in the finance department for easy access during the course of the audit. Person(s) Responsible: Mary Bell, Finance Manager Anticipated Completion Date: September 1, 2025

Action taken in response to finding: • LMC Staff will be re-trained on the process and importance of retaining documentation that SAM.gov was used to verify that a vendor was not suspended, debarred or otherwise excluded from participating in the transaction prior to contract. • LMC staff will review the OIG exclusions list prior to onboarding or signing contracts with vendors. • LMC staff will print and retain proof of each review for reporting purposes Name(s) of the contact person(s) responsible for corrective action: Melissa D’Onorio, CEO, and Donna Landy, CFO. Planned completion date for corrective action plan: 07/14/2025

Going forward the Organization will ensure there is documentation that verification of vendors are not suppressed or debarred.

Federal Agency Name: U.S. Department of Treasury Assistance Listing Number(s): 21.027 Program Name: Coronavirus State and Local Fiscal Recovery Funds (CSLFRF) Finding Summary: Non-Federal entities other than states, including those operating federal programs as subrecipients of states, must follow the procurement standards set out at 2 CFR sections 200.318 through 200.326. They must use their own documented procurement procedures, which reflect applicable state and local laws and regulations, provided that the procurements conform to applicable federal statutes and the procurement requirements identified in 2 CFR Part 200. 2 CFR sections 200.212 and 200.318(h); 2 CFR section 180.300; 48 CFR section 52.2096 outlines the requirements the Non-Federal entity verify vendors for which it plans to enter into a covered transaction are not debarred, suspended, or otherwise excluded. It was noted that while the County does have a purchasing policy, elements as required by Uniform Guidance are absent from the policy. In addition, we noted the County did not retain the supporting documentation indicating they had verified vendors they were entering into covered transactions with were neither suspended nor debarred. While our testing noted no instances of noncompliance, the absence of internal controls over compliance as it relates to having a Uniform Guidance compliant policy, could lead the County to enter into covered transactions that are not compliant with federal regulations. Responsible Individuals: Kyle Wilmot Canyon County Controller Corrective Action Plan: Members of the audit office will review each vendor in the SAM.gov database to ensure that they are not suspended, debarred or otherwise excluded. The search of these entity(s) will then be saved to the shared drive for the upcoming ACFR season and the supervisor will be notified of the search to ensure that the files have been properly saved. Anticipated Completion Date: Canyon County will complete the corrective actions for the September 30, 2025, reporting period.

Identifying Number: 2024-003 – Procurement and Suspension and Debarment Finding: The University’s controls were not operating effectively to reasonably ensure the University verified the vendor was not suspended or debarred from participation in federal programs/grants prior to entering into a contract with the vendor. The University’s procurement policy requires vendor transactions equal to or greater than $25,000 undergo verification to ensure the vendor is not suspended or debarred, prior to entering into a contract with the vendor. A lack of controls to reasonably ensure this verification was performed. Corrective Actions Taken or Planned: We agree with the auditors’ findings. Correcting actions will be included in the checklist referred to in 2024-002 above. Person(s) Responsible for Correction Actions: Christine Seitz McCauslin, Ph.D. Anticipated Completion Date: April 30, 2025

2024-002: Suspension and Debarment Recommendation: CLA recommends the Agency update its procurement policy to include procedures that a vendor be verified as not being debarred, suspended, or excluded and documentation maintained to support the determination. Explanation of disagreement with audit finding: There is no disagreement with this finding. Action taken in response to finding: The Agency is committed to following the procurement process and requirements outlined within the policies and procedures. The Agency plans to revise current procurement policy to have a process for debarred, suspended, or excluded and documentation maintained to support the determination. All procurement will be monitored through the Sage Intacct and Ramp system, which has already been implemented. Name of the contact person responsible for corrective action: Dhiren Shah, CFO Planned completion date for corrective action plan: Immediately If the U.S. Department of Housing and Urban Development has questions regarding this plan, please call Dhiren Shah, CFO, at 630-248-1181.

Action taken in response to finding: Esperanza will: 1. For new vendors – review if the vendor is included in the federal list of debarred, suspended, or excluded vendors 2. For existing vendors – review, on an annual basis, if vendors are included in the federal list of debarred, suspended, or excluded vendors Name(s) of the contact person(s) responsible for corrective action: Ryan Gadia Planned completion date for corrective action plan: June 30, 2025

Views of Responsible Officials The Health Department agrees with this finding. Corrective Action Plan The Health Department will establish a robust system of controls to ensure it complies with its procurement policy when entering into covered transactions. Name of Responsible Individual Teresa Anderson, Health Director Anticipated Completion Date January 31, 2025

Suspension and Debarment, Child Nutrition Cluster Recommendation: We recommend the district implement a process to check for suspension and debarment for all vendors exceeding the threshold for purchases. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: The Food Service Director will be checking for suspension or debarment and keeping track of this on a spreadsheet. Responsible official: Michael VandenBush, Food Service Director Anticipated completion date: 2024-25 Fiscal Year

Identifying Number: 2024-003 Suspension and Debarment—Material Weakness U.S. Department of Agriculture Passed through Missouri Department of Elementary and Secondary Education Child Nutrition Cluster, Assistance Listing No. 10.555 (National School Lunch Program), 10.553 (School Breakfast Program), 10.582 (Fresh Fruit and Vegetable Program) Federal award year 2023-2024 Summary of Finding: Criteria: The Uniform Guidance (2 CFR 200.303) requires nonfederal entities receiving federal awards to establish and maintain internal controls designed to reasonably ensure compliance with federal laws, regulations, and program compliance retirements. Also, the Uniform Guidance (2 CFR 200.212 and 200.318(h)) stipulates that when a nonfederal entity enters into a contract or purchase with an entity (vendor or subrecipient), the nonfederal entity must verify the entity is not suspended or debarred from participation in federal programs/grants when expending $25,000 or more in a year. Condition: The District did not have controls in place to reasonably ensure any entity receiving more than $25,000 in federal grant funds was not suspended or debarred, prior to providing them with federal funds. Cause: A lack of controls to reasonably ensure this verification was performed. Effect or potential effect: The District did not have controls in place to reasonably ensure compliance with suspension and debarment requirements of the Uniform Guidance. The potential effect is submitting unallowable costs, or loss of federal funding. Corrective Action: Management has developed the following procedures to ensure that vendors are not suspended or debarred: • All current vendors will be checked against Sam.gov on a quarterly basis. • All vendors receiving Federal funds of $25,000 or greater will be checked prior to completion of any purchase requisition. • All vendor applicants will be required to sign a Certified document that they are not suspended or debarred along with the Vendor App. • All bids will have a Certified document included for vendors to submit that declares they are not suspended or debarred. Anticipated Completion Date: December 2024 (for the year ending June 30, 2025). Contact Person: Stacy Swenson, Director of Purchasing 816-321-5016 Stacy.swenson@nkcschools.org

Suspension and Debarment Recommendation: The auditor recommends the organization retain documentation that Sam.gov was used to verify that a vendor was not suspended, debarred, or otherwise excluded from participating in the transaction prior to contract. The organization can keep screenshots that Sam.gov was checked or a PDF print out of the web page which includes the date verified. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Consulting with TACHC to develop policies to be approved by the organization’s Board of Directors and implement procedures to properly complete vendor’s sam.gov verification. Name(s) of the contact person(s) responsible for corrective action: David Rodrigues. Planned completion date for corrective action plan: December 2025.

Vendors will be reviewed and documented that they are not debarred, suspended, or otherwise excluded from participation in federal award programs by use of the System for Award Management (SAM), the Official U.S. Government system. Based on the timeline of the 2022 audit, many of the corrective actions were made in late Oct/November 2023.

Condition: During procurement testing of the Certified Community Behavior Health Clinic Expansion Grant, we noted that the Authority did not have documentation that sam.gov was reviewed to ensure the consultant utilized was not suspended or debarred for two of the three contracts expended. The Authority checked suspension and debarment on the individual clinicians, however, did not check it for the company. Recommendation: The Authority should implement adequate controls to ensure verification of debarment, suspension or exclusion takes place before entering covered transactions. Planned Corrective Action: Going forward the agency will implement policy changes that will include the organization as well as the individual prior to entering into any contract. Contact Person: Anthony Shaver, Chief Financial Officer Anticipated Completion Date: 9/30/2024

Views of Responsible Officials The Organization agrees with this finding. Corrective Action Plan The Organization will continue to abide by its procurement policy and will check its vendors against the exclusion list on the System for Award Management website. Name(s) of Responsible Individuals Lacy Kimes, Board President Anticipated Completion Date October 31, 2024