Corrective Action Plans

Program: AL 21.027 - COVID-19 - Coronavirus State and Local Fiscal Recovery Funds- Suspension & Debarment Corrective Action Planned: The County will implement procedures to ensure when a contractor is paid with federal funds, https://www .Sam.gov will be utilized to verify the entity has not been suspended or debarred and such procedure will be adequately documented. Anticipated Completion Date: Ongoing Responsible Party:Dakota County Board of Commissioners: Robert J. Giese, Troy Launsby, Scott Love, Martin Hohenstein, and Brian VanBerkum.

Contanct Person: Vern R. McAdams, Business Manager Corrective Action Planned: The District has been careful to check for suspension / debarment for all orders placed with a purchase order or voucher on SAM.GOV that are coded to a federal grant. That process is documented on the individual purchase order or voucher before the order is approved by the BUsiness Manager and the order is placed. However, more purchases today are completed using a Distrct credit card. Before the Business Manager processes the monthly payment for credit card charges, he will check each transaction that is coded to a federal grant and check that vendor for suspension / debarment on SAM.GOV. Should a vendor be identified as suspended / debarred the transaction will be coded to a non-federal account or the item will be returned. We followed this process with the October billing cycle.

Corrective Action Planned: The County has discussed checking the SAM (System for Award Management formerly Excluded Parties Listing System (EPLS), which is maintained by the General Services Administration to ensure vendors are not suspended or debarred before entering a transaction. Anticipated Completion Date: Ongoing Responsible Party: Krista Nix, Deputy County Clerk

Finding 2023-002 Program: AL 21.027 – COVID-19 – Coronavirus State and Local Fiscal Recovery Funds – Suspension & Debarment Corrective Action Planned: The County has put procedures in place; when a contractor is hired, sam.gov will be utilized to verify the entity has not been suspended or debarred. Anticipated Completion Date: August 21, 2023 Responsible Party: Karla Zlatkovsky, County Clerk

Chairman of the Board of County Commissioners: These procurement issues originated during the prior County Clerk’s administration, but the current leadership is focused on corrective measures. Together, we are: • developing a SOP to ensure vendor checks for suspension and debarment are conducted on all purchases over $25,000, • establishing written standards of conduct to address conflicts of interest and set clear procurement guidelines, • and enhancing oversight and review to ensure all procurement processes are fully compliant with federal regulations. Our goal is to build a consistent, transparent procurement framework that safeguards both compliance and public trust. County Clerk: I was not the County Clerk in office at this time. To correct this issue, the County plans to develop a SOP to timely and accurately track and report on the SEFA. The SOP will be reviewed, adopted, and monitored by the Board of County Commissioners.

Procurement and Suspension and Debarment: The College agrees with the finding and takes note of the previous corrective actions that did not fully resolve the issue. The College will update its Purchasing and Accounts Payable Policy to require SAM.gov verification prior to awarding contracts. The College will conduct mandatory procurement training to strengthen compliance with federal requirements.

Procurement and Suspension and Debarment College of the Marshall Islands acknowledges the finding and confirms that the gaps noted resulted mainly from the previous manual filing system and limited internal procurement controls. The College has since upgraded and institutionalized a cloud-based filing system to ensure complete documentation, proper retention, and easy retrieval of procurement records. Internal control policies and procedures have been strengthened to ensure compliance with the RMI Procurement Code, including vendor selection documentation, verification of suspension and debarment status, and equitable distribution of micro- purchases. In addition, newly hired staff dedicated to Procurement and Accounts Payable have been onboarded to improve oversight and compliance. With these new systems, strengthened controls, and added staffing capacity, the College is now better positioned to maintain full compliance. Staff have been trained—and will continue to be trained twice a year—on procurement requirements and federal regulations to prevent recurrence of similar issues in future audits.

Corrective Action: The Department of Treasury will work closely with the Procurement, Grants, and Contracts program to monitor and enforce proper internal controls and reviews for vendors. Procurement and Accounts Payable teams have been notified of the required SAM.gov checks, and these documents will now be uploaded into Sage when a vendor is added or updated. Person(s) Responsible: Acting Treasurer, Controller, AP Manager and PG&C Director Estimated Completion Date: January 1, 2025

Views of responsible official and planned corrective actions: The Trust will review and enhance its current procedures to ensure that vendors who are debarred, suspended, or otherwise excluded from participation in Federal assistance programs or activities are restricted from receiving Federal awards, sub-awards, and contracts. The Trust will conduct internal audits at regular intervals to ensure the new procedures are being followed and that all required documentation is maintained properly in procurement files. The Trust's CEO and CFO, who joined the company in 2024, have been actively conducting internal reviews of the financials and ongoing projects. These officials are currently overseeing a course correction to ensure better alignment with the Trust's strategic goals. Contact Person: Melanie Lawrence Aiseam, Chief Financial Officer Expected Completion Date: March 31, 2025

Finding 2022-018 U.S Department of Housing and Urban Development Emergency Solutions Grant Program - 14.231, Award number E-22-MC-0001 COVID-19 Emergency Solutions Grant Program - 14.231, Award number E-20-MW-20-0001 Management’s Response: Management will work with Procurement & departments to make sure debarment checks are completed. Views of Responsible Officials and Corrective Action: Departmental stakeholders should work with central accounting to be sure payments are made in time and develop solutions where there could potentially be a shortfall. Management will ensure this is addressed by December 31, 2024. Responsible Official: Dr. Shelley Kneuvean Chief Financial Officer Unified Government of Wyandotte County & Kansas City KS

Finding 2022-011 U.S Department of Treasury COVID 19 – Coronavirus State and Local Fisal Recovery Funds – 21.027 Management’s Response: Management agrees that debarment and suspension checks are a important aspect of award management. Views of Responsible Officials and Corrective Action: Management will train department staff related to the debarment and suspension checks and ensure that Procurement is aware of this requirement as part of the procurement process. Management will ensure this is addressed by December 31, 2024. Responsible Official: Dr. Shelley Kneuvean Chief Financial Officer Unified Government of Wyandotte County & Kansas City KS

Finding 2022-007 U.S. Department of Health and Human Services, passed through Kansas Department of Aging Aging Cluster – ALN 93.044 - Special Programs for the Aging_Title III, Part B_Grants for Supportive Services and Senior Centers - 2201KSOASS and 2201KSOACM ALN 93.045 – Speicl Programs for the Aging_Title III, Part C_Nutrition Services – 2201KSOCAHC Management’s Response: Management concurs. Debarment and suspension checks are an important aspect of award management. Views of Responsible Officials and Corrective Action: Department grant management personnel and procurement will need to ensure that these checks are happening prior to engaging in supply chain events with suppliers. Management will ensure this is addressed by December 31, 2024. Responsible Official: Dr. Shelley Kneuvean Chief Financial Officer Unified Government of Wyandotte County & Kansas City KS

Health Centers Cluster – Assistance Listing No. 93.2242/93.527 Recommendation: We recommend the Organization follow existing policy, but ensure procedures are in place to retain sufficient documentation to support review of vendors against federal exclusion list. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will review procedures to ensure proper check of vendors is performed against federal exclusion list, and that documentation is maintained to support that review. Name(s) of the contact person(s) responsible for corrective action: Duke Fokuo Planned completion date for corrective action plan: December 2024

Management Response #2022-010: Due to the staff shortages and turnover in FY2020-2022 the company did not have adequate personnel in place to monitor or document grant activity. Formal documentation of policies and procedures were also deficient. Additionally, documents were not stored centrally, which made it extremely difficult to find supporting documentation. Corrective Action Plan: In mid-2023, the company established policies and procedures that formally document the current compliance practices that are in place for dissemination and training throughout the organization. Detailed in the procedures was a hard stop by the manager of procurement that would require three bids prior to a purchase order being created. Once a vendor is selected, the manager of the procurement will send the vendor information to the compliance department to check for debarments and federal eligibility requirements. Added to the procedures is the creation of a central repository platform to keep all bids and price analysis performed for each vendor. To further enhance compliance, all Accounts Payable invoices that are designated for grant funding are routed for approval to the respective grants program manager prior to payment being made via the WorkPlace software. Responsible Party: Tamara Barnes, CFO

CONDITION: In connection with the Cambria Heights School District’s RTU Replacement Project, the District did not perform debarment and suspension checks for contractors through SAM.gov. CRITERIA: In accordance with Section 2 CFR 200.214 of the Uniform Guidance, the District is subject to the non-procurement debarment and suspension regulations implementing Executive Orders 12549 and 12689, 2 CFR part 180. These regulations restrict the awarding of contracts to certain parties that are debarred, suspended, or otherwise ineligible to participate in federal assistance programs. RECOMMENDATION: I am recommending that the management of the School District utilize the SAM.gov website for determining whether contractors/vendors are debarred or suspended from participating in federal assistance programs on all future applicable contract awards to ensure compliance with Section 2 CFR 200.214 of the Uniform Guidance. MANAGEMENT’S CORRECTIVE ACTION PLAN: Effective immediately, management will implement the practice of properly vetting future third-party contractors for debarment and suspension in federal assistance programs by utilizing the SAM.gov website, to ensure compliance with Section 2 CFR 200.214 of the Uniform Guidance and Executive Orders 12549 and 12689, 2 CFR part 180.

Suspension and Debarment – Assistance Listing No. 93.224/93.527 Recommendation: We recommend that Promise Healthcare verify that vendors are not suspended or debarred prior to signing contracts or create an approved vendor list. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: 1. Create procedure to verify vendors are not suspended or debarred: in progress a. Develop steps in the vendor diligence and procurement process to verify that the vendor is not suspended or debarred. b. Identify role or job that will handle responsibility for following procedure. c. Formalize the process into a written procedure and add to the procurement or other relevant policy. d. Conduct periodic audits to assess adherence to the procedure and train as necessary to ensure compliance.

FINDING 2022-005 Finding Subject: Comprehensive Community Mental Health Services for Children with Serious Emotional Disturbances (SED) – Suspension and Debarment Summary of Finding: The County stated procedures were not in place to ensure vendors were not suspended or debarred prior to entering into covered transactions. One covered transaction for funds passed through to a subrecipient was identified during the audit period. The amount passed through to the subrecipient was $914,863. The identified transaction was examined to determine if the County verified the suspension and debarment status of the subrecipient prior to payment. Upon review we determined that the County entered into a Memorandum of Understanding (MOU) with the subrecipient on June 22, 2020. However, the County had not performed procedures to ensure the subrecipient was not suspended or debarred, or otherwise excluded or disqualified from participation in federal assistance programs or activities at the time of the initial MOU or at any time during the audit period. Recommendation We recommended that management of the County establish a proper system of internal controls and develop policies and procedures to ensure contractors and subrecipients, as appropriate, are not suspended, debarred, or otherwise excluded prior to entering into any contracts or subawards. We also recommended that supporting documentation be retained in order to be presented for audit. Contact Person Responsible for Corrective Action: Concetta Sanfilippo Contact Phone Number and Email Address: 574.523.2101 csanfilippo@elkhartcounty.com Views of Responsible Officials: We concur that suspension and debarment was not run within the audit period. However, it was not done under the direction of CLA Auditing team 2021 who instructed it was not necessary, rather the most current audit report should be run which Elkhart County did do and had on file for their subrecipient Oaklawn Psychiatric. Description of Corrective Action Plan: The Elkhart County Health Department and Auditor’s Office Grants Administrator are working collaboratively to administer this grant award with strong internal controls. The Grant’s Administrator has taken the role to routinely run Suspension and Debarment verification on this subrecipient. The date it is run is recorded and a pdf is retained for records. Anticipated Completion Date: This procedure is in place as of 2023 and correction is completed.

View of Responsible Official and Corrective Action Plan Heading Home management is in agreement with this finding. Management has reviewed the existing procurement policies and procedures found in Section III Policy #301 of Heading Homes fiscal policies and procedures with appropriate staff and will enforce the policies and procedures to ensure competitive bids are obtained where required. Management has also reviewed the existing suspension and debarment policies and procedures found in Section III Policy #302 with appropriate staff and which requires these vendors to be reviewed on the SAM website to ensure they have not been suspended or debarred. While after the fact, each of the five vendors noted in this finding have since been reviewed on the SAM website and none of them returned any notices of having been suspended or debarred. Management is in the process of going back and reviewing all vendors paid $10,000 or more against the SAM website and will ensure all vendors are checked against the website who currently meet this requirement as well as for those it is anticipated will meet this threshold. Proof of the SAM website review and approval will be maintained in each vendor file. Management anticipates the above corrective action plan to be fully implemented by June 30, 2024. Personnel responsible for ensuring implementation include Connie Chavez, Chief Executive Officer, Debbie Brickman, Chief Financial Officer, and Armando Sanchez, contract accountants team lead.

FINDING 2022-003 Finding Subject: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds – Procurement and Suspension and Debarment Summary of Finding: Material Weakness, Modified Opinion. Three contracts out of seven did not include the suspension and debarment requirements. The County has already executed addendums with the contractors to correct this issue. Contact Person Responsible for Corrective Action: Adam Gadberry Contact Phone Number and Email Address: 317.346.4392 agadberry@co.johnson.in.us Views of Responsible Officials: “We concur with the finding.” Description of Corrective Action Plan: The County has already added the suspension and debarment language to the County’s standard contracts for SLRF projects. County has also added checking for suspension and debarment to the County’s contract checklist. Anticipated Completion Date: December 31, 2023

Finding 2022-006: Procurement, Suspension, and Debarment – Material Weakness. The buying policy ordering process has been updated to include blocking GSA (Government Services Administration) & HHS (Health & Human Services) disbarred sellers in accordance with SAM (System of Award Management) system. The overall Procurement policy, contracts and forms will be updated to include suspension and debarment language.

Audit Finding Reference: 2022-003 Management's View: The town agrees that we had not properly prepared formal policies to ensure that the suspension and debarment testing would be carried out and documented prior to entering into a covered transaction with an entity. Planned Corrective Action: The Town will develop and implement policies and procedures to formally verify and document the suspension and debarment process for all entities that we enter into transactions with when using Federal funds. Name of Contact Person and Completion Date: Danielle Basora Assistant Town Administrator/Finance Director/Treasurer 603-497-8990 ext. 104 Danielle.Basora@GoffstownNH.gov Derek Horne Town Administrator/Deputy Treasurer 603-497-8990 ext. 101 Derek.Horne@GoffstownNH.gov Anticipated Completion Date: April 30, 2024

Finding 2022-01 Federal Program Title: Education Stabilization Fund ?Higher Education Emergency Relief Fund Compliance Requirement: Procurement, Suspension and Debarment Name of Contact Person: Lynn Feeken, Financial Controller Corrective Action: The College developed and implemented a procurement policy which addressed Uniform Guidance Procurement, Suspension and Debarment requirements. Date of Completion: January 5, 2023

The Town of Mashpee, Massachusetts respectfully submits the following corrective action plan for the year ended June 30, 2022. Audit period: July 1, 2021 ? June 30, 2022 The finding from the schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. FINDING?FEDERAL AWARD PROGRAMS AUDITS DEPARTMENT OF AGRICULTURE 2022-001 Child Nutrition Cluster ? Assistance Listing Numbers 10.553 and 10.555 Recommendation: We recommend to annually (at a minimum) document the verification that all vendors are not suspended or debarred from participation in Federal assistance programs or activities. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Mashpee Public Schools will document the verification that all the vendors are not suspended or debarred from participation in the Federal assistance programs or activities. At a minimum the verification will happen once per fiscal year by the Director of Food Service or their representative. Name(s) of the contact person(s) responsible for corrective action: Catherine Kingsbury - Food Service Director (start date 9/21/23) and/or Kristen Hurlburt - Assistant Food Service Director (start date 9/21/23) and/or Ashley Lopes ? Director of Finance Planned completion date for corrective action plan: December 31, 2023

Virgina Department of Education City of Alexandria, Virginia respectfully submits the following corrective action plan for the year ended June 30, 2022. Audit period: Fiscal Year 22, (July 1, 2021-June 30, 2022) The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS?FEDERAL AWARD PROGRAMS AUDITS 2022-001 Child Nutrition Cluster ? Assistance Listing No. 10.553, 10.555, 10.559, 10.582 Recommendation: We recommend that ACPS consistently follow their procurement procedures and enhance procedures to ensure that all required procurement documentation is maintained in the vendor?s procurement file. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Procurement has developed operating procedures on the steps to run debarment reports within electronic Virginia (eVA) https://eva.virginia.gov/ The operating procedures have been made available to the procurement team. This report will be included in the file of each awarded offeror. For contracts that contain Federal Funding, Procurement tried to run a report from SAM https://sam.gov however the report did not contain information on the debarment status. All Offerors or Bidders are required to complete the Certification Regarding Debarment or Suspension form as part of their response to posted solicitations. If Offerors or Bidders do not submit a completed form they are deemed nonresponsive. See attached form Name(s) of the contact person(s) responsible for corrective action: Dyanna McMullen and Kimberly Young Planned completion date for corrective action plan: March 28, 2023 If the Virginia Department of Education has questions regarding this plan, please call Dyanna McMullen at 703-472-4034 or Kimberly Young at 703-244-0419

The Town of Chelmsford, Massachusetts respectfully submits the following corrective action plan for the year ended June 30, 2022. Audit period: July 1, 2021 ? June 30, 2022 The finding from the schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. FINDING?FEDERAL AWARD PROGRAM AUDIT DEPARTMENT OF AGRICULTURE 2022-001 Child Nutrition Cluster ? Assistance Listing Numbers 10.553 and 10.555 Recommendation: We recommend to annually (at a minimum) document the verification that all vendors are not suspended or debarred from participation in Federal assistance programs or activities. Explanation of disagreement with audit finding: There is no disagreement with the audit finding and agrees that the vendors were not suspended or disbarred. Action taken in response to finding: The Chelmsford Public Schools is one of the twelve districts that is part of the Metro North Collaborative (MNC). The MNC executes the competitive bid process for several of the school nutrition products. A certificate of good standing was required in the bid process and the MNC has added the recommended language that the participant certify to the best of its knowledge and belief that it and its principals are not presently debarred, suspended, proposed for disbarment, declared ineligible, or voluntarily excluded from the covered transactions by any Federal department or agency. Chelmsford Public Schools will also assist the MNC with documenting the suspension/debarment verifications at the time of the bid process and bid award with screen shots from the SAM.gov website resource. In addition, the Chelmsford Public Schools has verified that list of vendors is not suspended or disbarred, using the SAM.gov website resource. Name(s) of the contact person(s) responsible for corrective action: The Director of School Nutrition of the Chelmsford Public Schools. Planned completion date for corrective action plan: The spring of 2023 (April ? May timeframe) is when the MNC invites interested vendors to submit bids for the school nutrition products and the bid documents will reflect the recommended language. In January and February of 2023, the Chelmsford Public Schools verified the list of vendors is not suspended or disbarred, using the SAM.gov website resource.