Corrective Action Plans

FINDING 2024-002 (prior finding audit number 2023-001) Finding Subject: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds – Suspension and Debarment Contact Person Responsible for Corrective Action: Mindy Byers, Auditor Contact Phone Number and Email Address: 765-364-6401 mindy.byers@montgomerycounty.in.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: A new policy was adopted after the previous audit to ensure proper language regarding suspension and debarment is included in every contract. Because the contracts are outside of Auditor control, the Auditor is requesting county management to get an amendment for the vendor in question, Indiana American Water. Anticipated Completion Date: 08/31/2025

FINDING 2024-003 Finding Subject: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds – Suspension and Debarment Contact Person Responsible for Corrective Action: Katherine Adamson Contact Phone Number and Email Address: 574-223-2912 auditor@co.fulton.in.us View of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: This grant is fully expended; however the Auditor will work with the County Attorney and Commissioners to create the necessary policies and procedures for the County related to Suspension and Debarment of other grant funds. Anticipated Completion Date: December 31, 2025

Communicate with the Budget Board regarding this finding. We have already introduced to the budget board, a form guideline called "Payne County Grant Administration Plan" to aid in proper documentation, reporting and proper spending of all grant awards, including creating a capital outlay sub account as recommended.

FINDING 2024-001 Finding Subject: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds – Suspension and Debarment Contact Person Responsible for Corrective Action: Joanne Broadwater, Clerk-Treasurer Contact Phone Number and Email Address: (765) 762-2467 / clerk@attica-in.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: We will include an addendum to all future federal contracts to be signed by the contractor, stating “neither the contractor nor its principals are presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from entering into this contract by any federal agency or by any department, agency or political subdivision of the State. The contractor agrees that if after the execution of this agreement, either it or any of its principals are debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from entering into contracts similar to this one that it will immediately notify the City of Attica”. Anticipated Completion Date: September 2nd 2025.

We agree with the finding that internal controls were not sufficient to maintain compliance with federal procurement standards under Title 2, Subtitle A, Chapter II, Part 200, Subpart D, 200.318 to 200.327 for a non-federal entity. However, the funds were expended for the intended purpose of the federal award. The Company is committed to implementing internal controls to ensure procurement related to federal awards follow 2 CFR section 200.318 to 200.327. The Company will update the procurement policy to ensure it complies with the requirements of 2 CFR section 200.318 through 200.327, that includes the written standards of conduct covering conflicts of interest, governing the actions of its employees who select, award and administer procurement contracts. This policy will include procedures to ensure proper procurement for small purchases to ensure sufficient price quotations are obtained from the required number of qualified sources, proper sealed bids or proposals are obtained through public advertising, an appropriate cost or price analysis is performed for procurement actions exceeding the simplified acquisition threshold, documentation is retained, and proper oversight is exercised to demonstrate compliance with 2 CFR section 200.318 through 200.327. While the Company did not perform a check of each vendor against the SAM Exclusions prior to selecting a vendor, the Company has procedures in place to ensure the vendors are approved by Corporate purchasing and in good standing, which limits the risk of conflict of interest between employees and vendors, and contracting with a vendor who is suspended or debarred from federal related contracting. Further, the Company confirmed the vendors that were contracted with were not included on the SAM Exclusions listing. Contact Person Michael Davis, Chief Financial Officer of Southern Regional Hospital Expected completion date: The procurement policy will be updated by September 30, 2025, and training will be provided to all employees who are relevant to the procurement process of federal contracts by December 31, 2025.

We agree with the finding that internal controls were not sufficient to maintain compliance with federal procurement standards under Title 2, Subtitle A, Chapter II, Part 200, Subpart D, 200.318 to 200.327 for a non-federal entity. However, the funds were expended for the intended purpose of the federal award. The Company is committed to implementing internal controls to ensure procurement related to federal awards follow 2 CFR section 200.318 to 200.327. The Company will update the procurement policy to ensure it complies with the requirements of 2 CFR section 200.318 through 200.327, that includes the written standards of conduct covering conflicts of interest, governing the actions of its employees who select, award and administer procurement contracts. This policy will include procedures to ensure proper procurement for small purchases to ensure sufficient price quotations are obtained from the required number of qualified sources, proper sealed bids or proposals are obtained through public advertising, an appropriate cost or price analysis is performed for procurement actions exceeding the simplified acquisition threshold, documentation is retained, and proper oversight is exercised to demonstrate compliance with 2 CFR section 200.318 through 200.327. While the Company did not perform a check of each vendor against the SAM Exclusions prior to selecting a vendor, the Company has procedures in place to ensure the vendors are approved by Corporate purchasing and in good standing, which limits the risk of conflict of interest between employees and vendors, and contracting with a vendor who is suspended or debarred from federal related contracting. Further, the Company confirmed the vendors that were contracted with were not included on the SAM Exclusions listing. Contact Person Michael Davis, Chief Financial Officer of Southern Regional Hospital Expected completion date: The procurement policy will be updated by September 30, 2025, and training will be provided to all employees who are relevant to the procurement process of federal contracts by December 31, 2025.

Finding 2024-001 Suspension & Debarment - Management concurs with the finding. The Town will design and implement polcies and procedures regrding verification of enetity suspension and deparment. Contact person - Brian Sullivan. Project Completion Date 9/30/2025

2024-002 Procurement Policy Recommendation: We recommend that management amend and formally update the procurement policy to address the following critical areas: Vendor acceptance and debarment testing, definition and procedures for the Simplified Acquisition Threshold, domestic preference for procurements, procedures for handling procurement issues and policy governance and version control. Action Taken: To improve clarity, accountability, and regulatory compliance, the Finance Department will work with the Fiscal Sponsorship Department to develop The Praxis Project's procurement policy going forward. We will ensure the updated policy includes the following: · We will formalize procedures to confirm vendor eligibility, including consistent use of the SAM.gov exclusions list prior to entering contracts, and ensure documentation is retained for audit purposes. · The updated policy will outline specific steps for procurement activities at various thresholds, particularly mid-range purchases, with requirements for obtaining multiple quotes and documenting price comparisons. · In alignment with Federal guidelines, the revised policy will include a provision supporting preference for U.S .- made products and materials when feasible. · New sections will be added to address how the Organization will manage vendor selection reviews, disputes, and issue resolution to promote fairness and consistency in the procurement process. · To ensure transparency and version control, the policy will include the date of each revision and a process for periodic review. The Fiscal Sponsorship Department will implement the updated policy, coordinate training for programmatic staff, and monitor compliance with the updated procedures. We expect the revised procurement policy to be finalized and implemented by July 31, 2025. If the Cognizant or Oversight Agency for Audit has questions regarding this plan, please call Susan Pagel, CPA at 503-701-7173. Sincerely yours, Xavier Morales Executive Director

Condition: Suspension and debarment compliance was not verified for three covered transactions. Corrective Action Plan: The Town will implement the following: • Have the Grant Coordinator review and understand compliance with the Town’s Federal Grant Awards Policy. • Have the Grant Coordinator in conjunction with the compliance accountant develop a standard reporting checklist to be used by all staff preparing or reviewing Federal project submissions. • Implement a two-level review process requiring: o Department-level preparation with supporting documentation. o Grant Coordinator final review and approval before submission of Federal reports. • Require quarterly reconciliations between project expenditures and Federal reporting to ensure accuracy. Anticipated Completion Dates: o By September 30, 2025: Grant Coordinator training completed, and checklist distributed. o Ongoing: Reports will be reviewed and certified quarterly by the Grant Coordinator prior to submission. Contact Information: Donna Cotterell, Grant Coordinator

COVID-19- Coronavirus State and Local Relief Funds (CSLRF)-Assistance Listing No. 21 .027 Suspension and Debarment Recommendation: The Town should review and enhance controls and procedures to ensure that it follows procurement policy for all goods and services charged to the program and should ensure that all departments are subject to applicable controls, policies and procedures. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Town will verify vendors are not suspended or debarred from business prior to acquiring goods or services charged to the program. The Town should maintain documentation of procurement suspension/debarment status verifications for its vendors. Name(s) of the contact person(s) responsible for corrective action: Lewis George, Town Administrator Planned completion date for corrective action plan: 01/01/2026

FINDING 2024-004 Contact Person Responsible for Corrective Action: Amy L. Glackman Contact Phone Number: 317-392-6310 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Control procedures will be put into place effective immediately, which will include implementing a federal procurement policy. The Auditor will start checking all vendors paid from grants for suspension, debarred or excluded from being able to enter into contracts. Anticipated Completion Date: August 30, 2025

Effect: The Organization may be paying subcontractors that are suspended or debarred, which would be unallowable costs. However, none of the 4 subcontractors were suspended or debarred as of the date audit procedures were performed. Recommendation: The auditor recommends that the Organization implement policies and procedures to ensure that all subcontractors and subrecipients of covered transactions are properly verified before entering into transactions, and that this be documented as a control each time it is performed. 1. Explanation of Disagreement with Audit Findings: There is no disagreement with the audit findings. 2. Action Planned in Response to Finding: The Organization has implemented procedures to verify that subcontractors with goods or services transactions expected to exceed $25,000 are verified before entering into transactions, which will be documented each time. 3. Official Responsible for Ensuring CAP: Kari Jo Lawrence, Chief Executive Officer and Jernon Kelly, Chief Financial Officer are responsible for ensuring corrective action of this deficiency. 4. Planned Completion Date for CAP: December 31, 2025.

Finding 2024-004 – Procurement (repeat finding): Type: Material Weakness in Internal Control/Noncompliance. Condition: The CMHSP did not follow the formal procurement methods outlined in 2 CFR 200.320 prior to entering into contracts for services under the grant. Also, the CMHSP did not verify that the vendors were not suspended, debarred, or otherwise excluded or disqualified in accordance with 2 CFR requirements prior to entering into a contract for services under the grant. Corrective Action: Current Finance staff will ensure that procurement measures are followed and that vendors are not suspended or debarred or disqualified. Contact Person: Kevin Hartley, CFO Completion date: October 1, 2024

Federal Agency Name: Department of Treasury Pass-Through Entity: State of Iowa Department of Management Federal Financial Assistance Listing #21.029 Program Name: Coronavirus Capital Projects Fund Finding Summary: Testing of the federal program identified the following • The Cooperative’s formally documented procurement policy was missing one required element as it relates to the methods of procurement. • One instance where the Cooperative followed a bid process, however, the documentation was not retained to support the selection. Additionally, the contract with the vendor was missing required contract provisions in accordance with Uniform Guidance • One instance where the Cooperative did not follow the procurement process as detailed in the procurement policy and did not have any formal documentation or contract in place with the vendor. • Two instances where the Cooperative entered into a contract with a vendor over $25,000 and there was no review performed to ensure the vendor was not suspended or debarred. Corrective Action Plan: The Cooperative has taken several steps to remedy the findings of the 2024 single audit: • In April 2025, the Board of Directors approved a revised procurement policy that includes the missing method of procurement. • Existing contracts have been amended to include required contract provision in accordance with Uniform Guidance. Any new contract will include those provisions. • All current contractors have been reviewed to ensure the vendors are not suspended or debarred. All searches have been printed and retained. Any new contractors will be reviewed prior to their selection as a vendor. • The reasoning for utilizing single-source vendors has been formally documented and signed off on by management. • All bid processes are now formally documented, including cost comparisons between vendors. Responsible Individuals: Jeremy Richert, CEO and Kelly Gibbs, CFO Anticipated Completion Date: July 2025

2024-006 Lack of Documentation for Supsension and Debarment Verification Views of Responsible Officials and Planned Corrective Actions: Management acknowledges the finding. A process for documenting SAM.gov suspension and debarments will be implemented.

Personnel Responsible for Corrective Action – Accounting Manager – Jenny Trout Anticipated Completion Date – 07/10/2025 Corrective Action Plan – Debarment should be checked prior to purchasing or contracting with any entity or agency to ensure the entity or agency has not been Debarred or Suspended by the federal government at the System for Award Management (SAM.gov) website (http://www.sam.gov/). The SAM website must be checked to verify the entity or agency has not been Debarred or Suspended prior to entering into an award with an entity or agency with federal dollars, and annually checked for the life of the Federally Funded award, and documented with a screenshot of the documentation. If at any time the SAM.gov website indicates the subrecipient has active exclusions, no invoices will be paid until the entity or agency is removed from the exclusion listing. The City of Liberty will expand this policy to check every vendor that we enter into contract with prior to contract approval. This will be a joint effort of the Director of each department, our Deputy City Clerk, and our Accounting Manager.

Views of Responsible Officials and Planned Corrective Actions Per the Associate Director of Contract Accounting, the Foundation has taken the following steps to strengthen its suspension and debarment compliance process: 1. Completed an annual suspension and debarment review for all applicable vendors in February 2025, aligned with the start of most Ryan White Part A contracts, which typically begin on March 1. 2. Updated the Foundation’s policy to require suspension and debarment checks both at initial vendor setup and on an annual basis thereafter. The Foundation has also finalized a Debarment Policy, approved by the Finance Policy Committee, which outlines the procedures for identifying and documenting suspended or debarred vendors. This policy is designed to ensure ongoing compliance with federal regulations. Personnel responsible for implementation: Shibu Sam Position of responsible personnel: National Director of Contracts Date of Implementation: February 2025

The Division will formalize and adopt a procurement policy. This will also include a suspension and debarment check of vendors. Anticipated Completion Date: 8/1/25. Responsible Contact Person: Yohannes Gedlu, NW Divisional Finance Director & Julie Luft, NW Social Services Director

Subject: 2024-002 Material Weakness – Procurement and Suspension and Debarment Noncompliance Federal Agency: Department of the Treasury Federal Program: Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number: 21.027 Compliance Requirement: Procurement and Suspension and Debarment Audit Finding: Material Weakness – Procurement and Suspension and Debarment Noncompliance Recommendation: The auditor recommends the City develop and implement formal written procedures to ensure suspension and debarment checks are performed on all CSLFRF transactions and documented appropriately. Planned Corrective Action: The City agreed with the recommendation and plans to implement corrective action plan by December 31, 2025. Staff are in the process of drafting internal policies for adoption by the appropriate boards to address this item as soon as possible for any of our grant funds not managed by a third-party administrator.

The Town is now duly aware of its responsibilities pertaining to this program and will comply with the program requirements for suspension and debarment including evaluation and documentation for program expenditures.

CORRECTIVE ACTION PLAN Pursuant to federal regulations, Uniform Administrative Requirements Section 200.511, the following are the findings as noted in Monroe Community Mental Health Authority’s (MCMHA) Single Audit report for the year ended September 30, 2024, and corrective actions to be completed. Finding: 2024-001 – Procurement, Suspension and Debarment Auditor Description of Condition and Effect: The CMHSP did not document the noncompetitive procurement process pursuant to 2 CFR 200.320 prior to entering into a contract for services under the grant. Also, the CMHSP did not verify that the vendor was not suspended, debarred, or otherwise excluded or disqualified in accordance with 2 CFR requirements prior to entering into a contract for services under the grant. Auditor Recommendation: That the CMHSP review/update policies and procedures to ensure that formal procurement methods are documented, and verification of suspension, debarment, or exclusion is conducted prior to entering into a contract. Corrective Action: Management acknowledges the situation and is developing process and procedure to correct this going forward. Responsible People: Chief Financial Officer and Chief Operating Officer. Anticipated Completion Date: September 30, 2025

Recommendation – We recommend the Association implement a formal policy and procedure to verify all vendors against SAM.gov for covered transactions exceeding $25,000. Staff responsible for federal procurement should be trained, and documentation of vendor status verification should be retained with procurement records. Views of Responsible Officials and Planned Corrective Actions – Procurement Policy was updated and documentation will be maintained to support vendor verification in the future.

Finding Reference Number: 2024-008 – COVID-19 - Coronavirus State and Local Recovery Funds. Compliance Requirement: Internal Control noncompliance - Procurement, Suspension, and Debarment. Name of Contact Person: Jim Conklin. Views of Responsible Officials: Management acknowledges the finding and understands the need to perform a review of vendors paid using federal grant funds to determine if they are suspended or debarred. Planned Corrective Action: The Organization will provide training to staff involved in procurement to search the federal government website to determine if vendors selected are suspended or debarred. Documentation of this determination will be retained and reviewed by a member of management to evidence internal control over this procedure. Anticipated Completion Date: 6/30/2025.

Finding 2024-003: TCFB was negligent in two areas for one of their purchases: No record of vendor verification that they were not suspended or disbarred and no WSDA prior approval for the purchase which was over $5,000. This was in violation of both their internal procedures and WSDA requirements. The Problem: During testing the auditors noted that one instance of purchasing using WSDA funds was made without WSDA prior approval and proper documentation of suspension and debarment or WSDA prior approval. Established Standard: Organization must verify SAM registration and conduct suspension, and debarment checks prior to entering into any sub-agency agreement, contract, purchase, or equipment repair over $5,000. It is recommended that lead agency verifies, at least annually, that sub agencies and vendors are not suspended or debarred. Information about suspension and debarment checks is to be entered onto a spreadsheet of approved vendors. When the lead agency enters into a covered transaction with another agency or vendor, lead agency must verify that the entity with whom business is transacted is registered with SAM and is not excluded or disqualified. There are two methods for verification: A. Checking SAM.GOV exclusions (this method requires saving a copy of the verification search) B. Collecting a signed certification from the vendor. Actions to be taken: • Updated training of TCFB staff on the Policy/Procedures for procurements using WSDA funding. • Create step-by-step instructions for purchases using WSDA funding. • Effective October 1, 2024 WSDA’s threshold for preapprovals changed to $10,000. We will update our purchasing policy to reflect this change. Action Assignments: • Instruction checklist will be created by lead purchaser. • Lead purchaser will ensure that any purchases follow the Policy/Procedures for procurement. • Lead purchaser will be responsible for documenting SAM registration, Suspension and Debarment check, and WSDA pre-approvals. The documentation will consist of a copy of the exclusions page on SAM.GOV, as well as a spreadsheet of approved vendors with a date of last check. Timeline: • Instruction checklist for purchases using WSDA funds will be created by July 1st, 2025. • A spreadsheet has already been created to capture the information concerning Suspension and Debarment checks. A separate folder contains copies of each entities exclusion page from SAM.GOV. Verify Implementation: • In July 2025 Lead Purchaser will submit to the Executive Director: A. A copy of step-by-step instruction checklist. B. A copy of the spreadsheet with Suspension and Debarment checks C. Copies of exclusion pages from SAM.GOV Finance Dept. will verify invoice have received WSDA prior Approvals

Condition: The Town could not provide evidence that it performed a check to verify its contractors were not suspended or debarred. Planned Corrective Action: 1. Policy Update: The Town will verify that its procurement policies and procedures to explicitly require verification of all vendors and subrecipients against the System for Award Management (SAM) at https://sam.gov prior to award of any federal contract or subaward is being followed. 2. Training: Staff responsible for procurement and grant administration will be trained on: The requirements of 2 CFR 200.214 and 2 CFR Part 180. How to use SAM.gov to verify suspension and debarment status. 3. Documentation Procedures: The Finance Department will implement a checklist that includes required documentation of SAM verification for every covered transaction using federal funds. 4. Monitoring and Review: The Grants Administrator will conduct periodic reviews of federal purchases to ensure compliance with suspension and debarment requirements. Contact person responsible for corrective action: Chris Fiandaca, Finance Director – Town of Parker Anticipated Completion Date: August 1, 2025