Corrective Action Plans

Federal Agency: U.S. Department of Labor Assistance Listing No. 17.270 Type of Finding: ● Material Weakness in Internal Control Over Compliance – Suspension and Debarment ● Other Matter Recommendation: The Organization should strengthen controls and adherence over their policy and the UG and DOL guidelines and ensure a control is in place for verifying vendors are not suspended, debarred, or otherwise excluded per UG guidelines prior to use of the vendor. The Organization should ensure these policies are followed for all applicable vendors and that documentation related to these controls are maintained and documented. Views of Responsible Officials: Management agrees with the audit finding. Effective immediately, the Organization will update the Procurement and Vendor Management Policy to explicitly require suspension and debarment checks for all applicable vendors in accordance with 2 CFR 200.214 and 2 CFR Part 180. The Organization is implementing a standardized vendor verification form and will require procurement staff to document SAM.gov checks prior to contracting with any vendor. In addition, all staff involved in procurement will be trained on the updated requirements and documentation procedures. The CEO will perform quarterly monitoring to ensure compliance with federal procurement standards and internal policy. These corrective actions will strengthen internal controls and ensure compliance with federal regulations. Contact information for this finding: If the U.S. Department of Labor has questions regarding this schedule, please call Brandi Janke at (816) 520-4404. Completion Date: September 2025

Finding 2024-002 Finding Subject: COVID-19 Coronavirus State and Local Fiscal Recovery Funds Contact Person Responsible for Corrective Action: Cindy Poore Contact Phone Number and Email Address: 317-733-2809, cpoore@zionsville-in.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The Town will begin checking the EPLS system for all vendors receiving federal dollars. This will be part of the new purchasing policy that is being created for the Town. The Finance and Records Dept. will work with the Department Head receiving federal dollars to check the chosen vendor’s suspension and debarment status prior to proceeding with the project. Documentation verifying the check will be saved for audit purposes. Anticipated Completion Date: We will immediately begin checking the EPLS system for vendors receiving federal dollars. The new purchasing policy should be completed by September 2025.

Views of Responsible Officials and Planned Corrective Actions: Management agrees in review of this finding and going forward, Federal independent contractor agreement for Federal awards includes the following clause Re. Debarment and Suspension: Debarment and Suspension (Executive Orders 12549 and 12689). A contract award (see 2 CFR 180.220) must not be made to parties listed on the governmentwide exclusions in the System for Award Management (SAM), in accordance with the OMB guidelines at 2 CFR 180 that implement Executive Orders 12549 (3 CFR part 1986 Comp., p. 189) and 12689 (3 CFR part 1989 Comp., p. 235), “Debarment and Suspension.” SAM Exclusions contains the names of parties debarred, suspended, or otherwise excluded by agencies, as well as parties declared ineligible under statutory or regulatory authority other than Executive Order 12549. The Contractor represents that neither it, nor any of its principals or senior managers, are currently suspended or debarred or otherwise ineligible for award of a grant, contract, or cooperative agreement from the federal government, nor have they been proposed for suspension or debarment. Contractor agrees to notify Recipient immediately if at any point during the performance of work under this Agreement, it is proposed for suspension or debarment by any federal agency. The Excluded Parties List System has recently been consolidated within the System for Award Management at https://www.sam.gov/portal/public/SAM/. In additional action, management has updated its contract and procurement review procedures to include staff certifying selected vendors are not on the SAM.gov excluded parties list. Staff must also provide Finance a screenshot as backup. This item is listed on the Procurement Form as described under the Planned Corrective Actions on finding 2024-001.

FINDING 2024-002 Finding Subject: COVID-19-Coronavirus State and Local Fiscal Recovery Funds – Suspension and Debarment Summary of Finding: Material weakness, Modified Opinion Due to the U.S. Department of the Treasury's (Treasury) determination that the revenue loss eligible use category does not give rise to subawards, the County was only required to comply with suspension and debarment requirements related to covered transactions. Covered transactions in the amount of $1,236,661 were made during the audit period to three vendors. Of the three vendors used by the County, one vendor contract had included a suspension and debarment clause. For the remaining vendors, the County did not check the ELPS, nor was a certification collected from the vendors, and a clause did not exist in the agreements with the vendors. Although the County had a policy to include a clause in vendor contracts related to covered transactions, no documentation to verify the County's compliance with the suspension and debarment federal requirement was provided for audit. For the two vendors, the County provided Suspension and Debarment Certifications dated 7-14- 25 and 7-17-25. Contact Person Responsible for Corrective Action: Britt Ostler Contact Phone Number and Email Address: 765-659-6330/bostler@clintoncountyin.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The County had their county attorney draw up the Suspension and Debarment Certificate and the Commissioner Assistant presents it when the Commissioner’s hire Contractors for County projects using federal money. It’s now in our office procedures to have the Suspension and Debarment Certificate ready for signature if a grant is using federal monies. It’s also recommended that all officeholders alert the Auditor and Commissioner’s Assistant if the grant is federal. The Auditor is sending an email reminding elected officials and department heads to communicate with the Commissioner’s office as to their federal grants. Contractors will need to sign the clause before they are permitted to start the project. This is more of a communication issue we need to resolve. The two vendors in question did comply and sign the Suspension and Debarment Clause before their checks were picked up. Anticipated Completion Date: July 28, 2025

Corrective Action Plan. Montour County respectfully submits the following corrective action plan for the year ended December 31, 2024. The findings from the Single Audit Report Year Ended December 31, 2024 included in the schedule of findings and questioned costs are discussed below. Finding 2024-001: Procurement, Suspension, and Debarment Epidemiology and Lab Capacity - (ELC) 93.323. Contact Person: Holly Brandon, Chief Clerk. Recommendation: The County should review policies in place over Procurement, Suspension, and Debarment and establish procedures to identify clear roles for the review of vendors prior to a contract. Action: Montour County will update contract language requiring vendors to attest that they are not debarred or suspended, with the inclusion of language that allows for termination of the contract should a vendor's debarment status change. Project managers will be required to utilize SAM.gov to perform a debarment check on vendors. Date for Completion: 2/25/2025.

Condition: The Organization did not maintain documented procedures, consistent with the standards identified in 2 CFR 200.317 through 200.327 of the Uniform Guidance, for procurement transactions under a federal award or subaward. The Organization also did not comply with 2 CFR 200.318 (h) and 200.214 of the Uniform Guidance including verifying that vendors for covered transactions are not debarred, suspended, or otherwise excluded from receiving or participating in Federal awards. There were two vendors with covered transactions charged to the major program. The vendors were not debarred, suspended, or otherwise excluded. However, the Organization did not perform and document the required verification. Recommendation: The Organization should draft and maintain documented procedures, consistent with the standards identified in 2 CFR 200.317 through 200.327 of the Uniform Guidance. Views of Responsible Officials and Planned Corrective Actions: The Organization agrees with the finding and recommendation. The anticipated completion date for the corrective action is October 30, 2025.

Bronx Community Health Network, Inc. (“BCHN”) Corrective Action Plan For the Year Ended December 31, 2024 Health Resources and Services Administration (“HRSA”) Federal Award Finding Finding 2024-002 – Procurement and Suspension and Debarment Description of Finding: BCHN did not perform a check at the System for Award Management Exclusions (sam.gov) to verify whether an employee or a vendor had been suspended or debarred before being hired. Statement of Concurrence: We concur with the finding above. Corrective Action: BCHN will engage an outside vendor to aid in the review of vendors and employees that are excluded or debarred. The outside vendor will check for exclusion or debarment monthly and provide BCHN with a report indicating that the check was done. The outside vendor will alert BCHN if any vendors or employees are flagged. This will help BCHN to ensure that this check is done timely. Completion Date: October 2024. Name of Contact Person: Alicia Tenny Chief Financial Officer Tel. No.: (917) 364-1156 E-mail: atenny@bchnhealth.org If HRSA has questions regarding this Corrective Action Plan, please call Alicia Tenny at (917) 364-1156. Sincerely yours, _________________________ Alicia Tenny Chief Financial Officer

Federal Agency Name: Department of Treasury Pass-Through Entity: State of Iowa Chief Information Officer Federal Financial Assistance Listing #21.027 Program Name: Coronavirus State and Local Fiscal Recovery Funds Finding Summary: Our auditors identified the following during their testing of the federal program: • 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. • Two instances 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. • Three 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: We plan to review our procurement policy with all parties that may enter into contracts for the cooperative to be sure the policy reflects our needs and that procedures are being followed. We will also implement a review process where management signs off on bid selection documentation, including verification that vendors are not suspended or debarred. Responsible Individuals: Hollee McCormick, General Manager and Jason Troendle, Director of Operations and Engineering Anticipated Completion Date: November 2025

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