Corrective Action Plans

Condition: Suspension and debarment compliance was not verified for two covered transactions. Corrective Action Planned: All Purchase Order requests that are associated with a federal government grant will all have an attached list showing the company is not on the debarment list. We will also update our School Contract language to include specific wording where the Vendor acknowledges the law and forfeits the contract if they are on the debarment list after the contract has been signed. A statement will be added to the contracts that states the following: ‘The Contractor (or use the term in the contract that identifies the vendor instead of Contractor) certifies under the pains and penalties of perjury, that the Contractor is not currently debarred or suspended by the Federal government, or any of its agencies, entities or subdivisions, nor is the Contractor currently debarred or suspended by the Commonwealth Massachusetts or any of its agencies, entities or subdivisions.’ If there is a section in the contract where the vendor certifies to other conditions (i.e. state taxes paid), then this language could be included under that section as another certification requirement. A Google Drive has been created to upload all supporting documents on a yearly basis. Anticipated Completion Date: 2/17/2025 Contact: Noel Velez, Director of Finance and Fiona Maxwell, Procurement Director

Condition: Suspension and debarment compliance was not verified for five covered transactions. Corrective Action Planned: All Purchase Order requests that are associated with a federal government grant will all have an attached list showing the company is not on the debarment list. We will also update our School Contract language to include specific wording where the Vendor acknowledges the law and forfeits the contract if they are on the debarment list after the contract has been signed. A statement will be added to the contracts that states the following: ‘The Contractor (or use the term in the contract that identifies the vendor instead of Contractor) certifies under the pains and penalties of perjury, that the Contractor is not currently debarred or suspended by the Federal government, or any of its agencies, entities or subdivisions, nor is the Contractor currently debarred or suspended by the Commonwealth Massachusetts or any of its agencies, entities or subdivisions.’ If there is a section in the contract where the vendor certifies to other conditions (i.e. state taxes paid), then this language could be included under that section as another certification requirement. A Google Drive has been created to upload all supporting documents on a yearly basis. Anticipated Completion Date: 2/17/2025 Contact: Noel Velez, Director of Finance and Fiona Maxwell, Procurement Director

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 - 2301KSOASS ALN 93.045 – Special Programs for the Aging_Title III, Part C_Nutrition Services – 2301KSOAHD Management’s Response: Procurement began performing suspension and debarment checks on all vendors/contracts funded with grants in 2024. This process was implemented in the summer of 2024 as a result of the 2022 Single Audit Finding. Due to the audit not being completed prior to the completion of 2023, this finding was unknown to management. Upon being aware procurement was not doing the checks, immediate correction was undertaken. Checks are being done and documentation maintained in the purchasing file. The language has been included in bid documents as well. Views of Responsible Officials and Corrective Action: The reason for recurrence is the finding was communicated late in the prior year and due to transition and turnover within the department's staff. Procurement has begun the process of checking SAM.gov for debarment for potential suppliers. Also, departments have been informed of this required step for both suppliers and subrecipients. Downstream, need to evaluate if this language can be added to the contract templates. 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

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

Suspension and Debarment State and Local Fiscal Recovery Funds – Assistance Listing No. 21.027 Recommendation: We recommend that the City review its policies over suspension and debarment review to ensure they are maintaining compliance and controls over verifying or contracting with vendors that are allowable. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We will take actual computer image snips of the search results. Name(s) of the contact person(s) responsible for corrective action: Maryanne Groat Planned completion date for corrective action plan: 9/30/2024

2023-001: Significant Deficiency in Internal Controls and Compliance Finding -Child Nutrition Cluster ALN (10.553, 10.555,10.559): A competitive procurement process, which includes suspension and debarment certifications, was not properly performed by the Town for the purchase of school lunch food product. (Questioned Costs: $453,359) The Town of Clinton/School Department will maintain proper procurement procedures in compliance with Local, State and Federal laws and regulations. State procurement laws (MGL Chapter 30B for Goods and Services and MGL Chapter 149 Construction) are followed however the district is aware of the federal requirements. When there are exemptions from state procurement laws, or when federal regulations are stricter the district will use the strictest rules, under 2 CFR 200.318-327. These procedures have been updated in the Financial Procedures Manual (pages 231-240, under Section II Procurement System). The Town of Clinton/School Department has expanded membership with French River Education Center – Purchasing Cooperative to include several school lunch food products. The Town of Clinton/School Department will utilize two methods to determine if a potential vendor has been suspended or disbarred. Prior to approving a requisition for a contracted service in excess of $25,000 funded by a Federal grant, district will verify Sam.gov and will require the vendor to sign a Vendor Compliance Certification.

Recommendation: The City should review and enhance controls and procedures to ensure that it follows the applicable procurement policy and Federal suspension and debarment regulations for all goods and services charged to the program. Explanation: There is no disagreement with the audit finding. Action taken in response to finding: The City of Harrington, Delaware will review the State’s procurement process to satisfy the compliance requirements for the program. The City of Harrington, Delaware will also put procedures in place to check and review each bidder as part of the Federal suspension and debarment policies. Name(s) of the contact person(s) responsible for corrective action: Norman Barlow, City Manager Amanda Marlow, Assistant City Manager Planned completion date for corrective action plan: Procurement training and monitoring, ongoing Suspension and debarment training and monitoring, ongoing

Recommendation: The City should review and enhance controls and procedures to ensure that it follows the applicable procurement policy and Federal suspension and debarment regulations for all goods and services charged to the program. Explanation: There is no disagreement with the audit finding. Action taken in response to finding: The City of Harrington, Delaware will review the State’s procurement process to satisfy the compliance requirements for the program. The City of Harrington, Delaware will also put procedures in place to check and review each bidder as part of the Federal suspension and debarment policies. Name(s) of the contact person(s) responsible for corrective action: Norman Barlow, City Manager Amanda Marlow, Assistant City Manager Planned completion date for corrective action plan: Procurement training and monitoring, ongoing Suspension and debarment training and monitoring, ongoing

Recommendation: The City should review and enhance controls and procedures to ensure that it follows the applicable procurement policy and Federal suspension and debarment regulations for all goods and services charged to the program. Explanation: There is no disagreement with the audit finding. Action taken in response to finding: The City of Harrington, Delaware will review the State’s procurement process to satisfy the compliance requirements for the program. The City of Harrington, Delaware will also put procedures in place to check and review each bidder as part of the Federal suspension and debarment policies. Name(s) of the contact person(s) responsible for corrective action: Norman Barlow, City Manager Amanda Marlow, Assistant City Manager Planned completion date for corrective action plan: Procurement training and monitoring, ongoing Suspension and debarment training and monitoring, ongoing

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. Name of the contact person responsible for corrective action: Keith Flores, CFO Planned completion date for corrective action plan: End of 2024

Views of Auditee and Planned Corrective Actions: Starting in April 2024, GMHA incorporated the Certificate Regarding Debarment, Suspension, Ineligibility, and Voluntary Exclusion for Covered Contracts and Grants in all of its Invitation for Bids and Request for Proposals. Proposed Completion Date: Completed. Name of Contact Person: Yukari Hechanova, Chief Financial Officer

Views of Responsible Officials and Action Taken: We agree with the finding and recommendation and have implemented a verification step in our vendor approval and onboarding process which requires all vendors to be run through the SAM website and debarment search. We also require an annual verification to be performed for all vendors.

Finding 2023-001 Grantor: Department of Health and Human Services Federal Program: Various Assistance Listing #: Various Title: Suspension and Debarment Award Year: Fiscal year 2023 1/1/2023 – 12/31/2023 Award Number: None Corrective Action Plan and Anticipate Completion Date Nationwide Children’s Hospital (the Corporation) uses a third-party to perform its suspension and debarment checks on a monthly basis. However, we noted the following matters: • The Corporation did not retain the monthly supporting documentation related to the monthly suspension and debarment check. The suspension and debarment checks performed at year-end were retained. o Management Response: In September 2023, E&Y rendered the same finding and recommendation for the 2022 calendar year audit. The finding has already been remediated. Upon finalization of the remediation details from the September 2023 finding, Management implemented remediation in Q4 2023 to address this finding. • The Corporation does not have a process to reconcile the vendor list provided to the third-party vendor with the results received from the third-party vendor after the suspension and debarment checks are performed to ensure the listing is complete. o Management Response: In September 2023, E&Y rendered the same finding and recommendation for the 2022 calendar year audit. The finding has already been remediated. Upon finalization of the remediation details from the September 2023 finding, Management implemented remediation to address this finding for the annual screening that was performed in Q1 2024 for year 2023. Management also implemented a monthly reconciliation process as quickly as practicable, beginning with January 2024 data. • The third-party vendor does not have a SOC 1 (System and Organization Controls) Report. The Corporation relied on the results of the suspension and debarment checks performed by the third-party vendor without implementing an internal process to ensure the results provided by the third-party vendor were accurate. o Management Response: In September 2023, E&Y rendered the same finding and recommendation for the 2022 calendar year audit. The finding has already been remediated. Management implemented a process to verify the accuracy of the results produced by the third-party vendor. Management implemented the remediation to address the finding in the first quarter of 2024 for 4th quarter 2023 results. Responsible Person: Kathleen Dunn, JD – VP and Chief Compliance Officer Completion Date: January 31, 2024 • In addition, the Corporation performs a suspension and debarment check of all new vendors prior to activating them in the procurement system. The Corporation did not consistently maintain supporting documentation to support the vendor was checked for suspension and debarment before the “new”-vendor was set up in the procurement system. o Management Response In September 2023, E&Y rendered the same finding and recommendation for the 2022 calendar year audit. The finding has already been remediated. Management implemented an audit process to ensure that screening documentation is maintained. This audit process flagged 2 of these 3 deficient documentation results, and documentation was subsequently uploaded to the file. The third vendor was an insurance company, which prior to mid-2023 was not screened at the time of setup based on vendor type. As of mid-2023, all vendors regardless of vendor type, are being screened at setup. Responsible Person: Mary Beth Colatruglio, CPA – Director of Accounting Completion Date: January 31, 2024

Suspension and Debarment State and Local Fiscal Recovery Funds – Assistance Listing No. 21.027 Recommendation: We recommend that the City review its policies over suspension and debarment review to ensure they are maintaining compliance and controls over verifying or contracting with vendors that are allowable. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We will take actual computer image snips of the search results. Name(s) of the contact person(s) responsible for corrective action: Maryanne Groat Planned completion date for corrective action plan: 9/30/2024

FINDING 2023-005 Finding Subject: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds – Procurement and Suspension and Debarment Summary of Finding: Procurement - Policy The County had not established a purchasing policy that would reflect applicable state laws and regulations including procedures to avoid acquisition of unnecessary or duplicative items, procedures to ensure that all solicitations incorporate a clear and accurate description of the technical requirements for the material, product, or service to be procured and did not maintain written standards of conduct covering conflicts of interest and governing actions of its employees engaged in the selection, award, and administration of contracts. Procurement – Small Purchases The County had one vendor that was identified as being less than the simplified acquisition threshold of $150,000 but exceeding the $50,000 micro-purchase threshold. The one vendor was selected for testing. For the one vendor, the County did not obtain price or rate quotes nor was there documentation detailing the history of procurement, which must include the reason for the procurement method used. Suspension and Debarment One covered transaction paid with SLFRF grant funds was identified during the audit period. The covered transaction totaled $66,000 with $46,752 paid in the audit period. Upon review, the County had not performed procedures to ensure the vendor was not suspended or debarred, or otherwise excluded or disqualified, from participation in federal assistance programs or activities at any time during the audit period Contact Person Responsible for Corrective Action: Bryan Lewis Contact Phone Number and Email Address: 574-223-4764 and blewis@co.fulton.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The County will work on establishing a purchasing policy which will address federal procurement requirements. Before entering into contracts we will ensure the procurement procedures in the policy are followed and obtain quotes for vendors that meet the small purchase threshold as well as verify the suspension and debarment status. The Commissioners and Auditor’s office will work together to ensure requirements are met before payment is processed. Anticipated Completion Date: No later than December 31, 2024

FINDING 2023-003 Subject: COVID 19 - Coronavirus State and Local Fiscal Recovery Funds - Suspension and Debarment Summary of Finding: The ineffective internal controls resulting in a failure of having processes and procedures in place to prohibit from contracting with or making subawards under covered transactions to parties that are suspended and debarred or whose principals are suspended or debarred. Contact Person Responsible for Corrective Action: Kristinia L. Hammack, Perry County Auditor Contact Phone Number: (812) 547-6427 Views of Responsible Official: We concur with the audit finding. Description of Corrective Action Plan: Currently, the County requires all new vendors to complete a “Vendor Registration Form”. A new step that Procurement implemented as of September 30, 2024 will be verification of vendor’s status on sam.gov and attaching the screenshot to the LOW system. Procurement will update their vendor policy to specifically include this step. The Auditor’s Office will check incoming contracts from departments to ensure proper documentation is attached that verifies the vendor has been checked through sam.gov and in.gov. Once the contract has been approved by the Commissioners, the Auditor’s office will then upload the contract and supporting documents into Gateway. Anticipated Completion Date: September 30, 2024

Bronx Community Health Network, Inc. (“BCHN”) Corrective Action Plan For the Year Ended December 31, 2023 Health Resources and Services Administration (“HRSA”) Federal Award Finding Finding 2023-003 – Procurement and Suspension and Debarment – Significant Deficiency Description of Finding: BCHN did not perform a timely 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 check sam.gov and the Office of Inspector General, to screen all potential employees, contractors/consultants, and vendors, prior to the commencement of their affiliation with BCHN and maintain evidence of the results. BCHN will also screen all employees, contractors, consultants, and vendors on an annual basis thereafter and maintain evidence of the results. Completion Date: August 26, 2024. Name of Contact Person: James Paine, Ph.D Chief Executive Officer Tel. No.: (646) 678-6711 E-mail: jpaine@bchnhealth.org If HRSA has questions regarding this Corrective Action Plan, please call James Paine at (646) 678-6711. Sincerely yours, _________________________ James Paine, Ph.D. Chef Executive Officer

93.493 Congressional Directives Complete documentation of vendor suspension and disbarment verification was not maintained. While outside vendor verification services were performed monthly, adequate documentation for all vendors is not provided, only vendors with suspension or disbarment issues are identified and communicated to management. Management will coordinate with appropriate departments to review federal provisions for grant procurement and adjust policies and procedures to comply. Management will work with appropriate departments and the outside vendor to identify all grant related vendors and request positive verification monthly. All grant project directors will be educated on the procurement requirements for all federal awards. Contact Person: Jane Hardy – VP Corporate Accounting jane.hardy@childrens.com Expected Completion Date: December 31, 2024

FINDING 2023-002 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Suspension and Debarment Summary of Finding: Of the three covered transaction tested, one did not follow the County’s procedures as outlined above. The one covered transaction, totaling $47,283, did not include the appropriate provisions in the contracts nor did the County require a certification or check the EPLS to ensure the entity was not suspended or debarred prior to making payment. Contact Person Responsible for Corrective Action: Jessica Secrease Contact Phone Number and Email Address: 765-456-2804 Jessica.secrease@howardcountyin.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The County will continue to review any vendors paid with federal grant funding on SAM.gov to see if they are suspended or debarred. This is tracked on a spreadsheet in the Auditor’s Office. One employee reviews the vendor on SAM.gov, and another employee verifies the information. We will ensure this internal control is implemented. Anticipated Completion Date: September 2024

Views of Responsible Officials: Management concurs with and has already implemented the recommendation. See the corrective action plan.

FINDING 2023-05 Finding Subject: COVID-19 Coronavirus State and Local Fiscal Recovery Funds – Procurement and Suspension and Debarment Summary of Finding: No procurement policy is in place and vendors were not confirmed to not be suspended or debarred. 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. The Auditor will start checking all vendors paid from grants for suspension, debarred or excluded from being able to enter into contracts. Additionally, a procurement policy will be put into place. Anticipated Completion Date: August 30, 2024

2023-004 Federal Grants Management – Procurement Policy Recommendation: We recommend County use sam.gov or the ELPS listing to review clients at the beginning of the year or before a transaction is incurred in accordance with the Uniform Guidance requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: Train staff on 1. Sam.gov and ELPS sites 2. Collecting a certification from entity (SBA Form 1624, Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion Lower Tier Covered Transactions) 3. Adding a clause or condition to the covered transaction with entity (2 CFR section 180.300) Name(s) of the contact person(s) responsible for corrective action: Kim Merrill, Finance Manager Planned completion date for corrective action plan: Staff Training – November 2024

The county will implement procedures to ensure when a contractor is paid with federal funds, sam.gov will be utilized to verify the entity has not been suspended or disbarred and such procedure will be documented.

Views of Responsible Officials: The Center will implement internal controls to ensure that all vendors, contractors, and consultants are screened for suspension and debarment prior to entering into any executed contract. A policy will also be formalized and staff trained on new procedures. Name and Title of Responsible Official(s): Vibha Bhatia, Vice President of Finance and Operations Anticipated Completion Date: September 30, 2024

Finding 2023-004 Finding Subject: Covid-19 – Coronavirus State and Local Fiscal Recovery Funds – Procurement and Suspension and Debarment Summary of Findings: The County did not have a Board approved procurement policy that would reflect applicable state laws and regulations including procedures to avoid acquisition of unnecessary or duplicative items and procedures to ensure that all solicitations incorporate a clear and accurate description of the technical requirements for the material, product, or service to be procured. The County had five vendors that qualified for testing under small purchase procurement requirements (vendors paid $10,000-$150,000). Of the two chosen for testing, one was awarded a contract without the County obtaining quotes. The contract awarded was $31,000 for engineering services related to drain construction. Contact Person Responsible for Corrective Action: Debbie Morton-Crum, County Auditor Contact Phone Number: 765-482-2940 Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The process was not clear to the Auditor’s Office or the departments submitting the claims for payment. We are more aware of the correct process and procedures that need to take place and will add those procedures to our Internal Control policy to ensure that the vendor is not suspended or debarred. Anticipated Completion Date: October 2024