Corrective Action Plans

February 27, 2025 Finding 2024-001 U.S. Department of Health and Human Services, passed through the Curators of the University of Missouri ALN 93.680 - Medical Student Education PTE Federal Award No: T9952110 Management's Response: Bothwell Regional Health Center will begin performing suspension and debarment checks on all vendors/contracts funded with grants in 2025. This process will be implemented in 2025 pending policy review processes. Bothwell Regional Health Center will start documenting reviews of suspension and debarment checks of vendors receiving Federal funds while onboarding new vendors and monitoring periodically throughout the year. Views of Responsible Officials and Corrective Action: Management agrees with the finding and management will implement a control process to ensure that suspension and debarment checks are performed on vendors/contracts funded with grants in 2025. Responsible Official: Steven Davis Chief Financial Officer Bothwell Regional Health

The following corrective actions have either been implemented or will be implemented to prevent recurrence: 1. Audit Documentation: For the identified contract, C/CAG obtained and affidavit from the vendor affirming their compliance with suspension and debarment requirements at the time of contract. C/CAG also confirmed that the consultant is currently not on the suspension and debarment list. This documentation has been shared with the auditors and added to the project file. 2. Quality Assurance: Staff confirmed that the C/CAG’s other federally funded contracts included the required suspension and debarment requirements. 3. Staff Training: All staff members that work or might work on federally funded activities have completed training on federal procurement requirements, including guidance on suspension and debarment protocols. This training references the necessity of conducting SAM.gov checks and obtaining certifications for all federalized contracts. The specific training was: "Navigating the Uniform Guidance: Procurement Standards," and it was conducted on December 18, 2024. The provider of the training was “Federal Grants Training.” Ten C/CAG staff attended the training, including staff in the following positions: Executive Director, Deputy Director, Stormwater Program Director, Transportation Systems Coordinator, Senior Program Specialist, and Program Specialist. Copied of the completion certificates are available upon request. To ensure ongoing compliance, all future staff working on federally funded activities will also complete training on relevant federal requirements as part of their onboarding or ongoing professional development. 4. Contract Template and Procurement Policy Update: C/CAG is in the process of updating its standard contract template and the Procurement Policy to include suspension and debarment language for all contracts, regardless of funding source. This proactive measure ensures compliance across all contracts, even if funding transitions from non-federal to federal sources. Starting in February 2025, all relevant new contracts will have suspension and debarment language. The new contract template is expected to take effect beginning in April of 2025, and all contracts signed from that time onward will use the updated template. Furthermore, C/CAG will continue to review and update its contracts and policies regularly to ensure compliance with evolving regulations and standards. 5. Verification Procedures: Moving forward, C/CAG will: o Require vendors to provide a certification of compliance with suspension and debarment requirements before executing any agreement. o Conduct SAM.gov checks for all federally funded contracts.

Suspension and Debarment Federal Assistance Listing Number: Special Education Cluster (84.027 and 84.173) Procedures will be updated to include documentation of verification that a vendor has not been suspended or debarred. A record of this verification will be retained. Responsible official: Mark Lindem, Business Manager, mark.lindem@gibraltar.k12.wi.us Anticipated Completion Date: June 30, 2025

2024-007 – Procurement, Suspension and Debarment. Auditor Description of Condition and Effect. During our testing of disbursements, it was noted that the College did not follow their procurement policy for purchases over the micro purchase threshold and there is no procedure in place to determine whether vendors are suspended or debarred. Certain vendors could be used that are considered suspended or debarred by the federal government resulting in noncompliance. Auditor Recommendation. We recommend that the College implement a policy over suspension and debarment review to ensure they are maintaining compliance and controls over verifying or contracting with vendors that are allowable, and to follow their procurement policy when entering into purchases greater than the micro purchase threshold. Corrective Action. College to create a procedure that will require a vendor search to determine if vendors are listed as suspended or debarred, or otherwise excluded from participating, before engaging with them. In addition, the college will remind employees involved in purchasing that they must follow the college’s threshold regarding amounts of purchases. Responsible Party. Connie Stewart, SR VP & COO will create and implement new policy. Anticipated Completion Date. As soon as practicable but no later than February 28, 2025.

Type of Finding : Significant Deficiency Over Compliance with Procurement and Suspension Debarment Delta County Joint School District No. 50J had the following regarding internal controls in Nutritional Services: The District did not properly procure one vendor within the Child Nutritional Cluster that incurred questioned costs in excess of the $25,000 threshold, based on 2 CFR 200.516. Delta County Joint School District No. 50J concurs with finding 2024-001 and will implement the following corrective steps: Additional procedures have been put in place, and documentation will be maintained for purchases to satisfy Procurement and Debarment requirements.

Bear River Association of Governments (BRAG) will update internal policies to assign a member of the management team to check the federal system for suspension or disbarment for any checks written to vendors over $25,000 related to BRAG grants that involve federal funding.

Finding 2024-001: Suspension and Debarment – Material Weakness in Internal Control Over Compliance Condition: We noted that, although CAFB has a written process for checking suspension and debarment, CAFB did not have documentation of a suspension and debarment check on procurements greater than $25,000 that we selected for testing in three major programs. Views of Responsible Officials and Planned Corrective Actions: The Organization's ability to perform the current manual control for suspension and debarment was impacted by the sustained high level of activity. In December 2024, the Organization developed and implemented a Robotic Process Automation (RPA) tool designed to identify new vendors added to the accounts payable system. This tool then searches sam.gov for these vendors and sends an email with the results. Utilizing artificial intelligence, the tool also creates a service ticket for any suspect vendors that require manual research. Anticipated Completion Date: December 2024

Condition: The City could not provide evidence that it complied with 2 CFR 200.214, which states that nonfederal entities are subject to the non-procurement debarment and suspension regulations implementing Executive Orders 12549 and 12689, as well as 2 CFR part 180. Planned Corrective Action: The city will ensure that all future contracts awarded under this program are in compliance and will have contractors sign to verify that they are in compliance. Contact person responsible for corrective action: Lisa Griggs Anticipated Completion Date: June 30, 2025

CORONAVIRUS STATE AND LOCAL FISCAL RECOVERY FUNDS, ASSISTANCE LISTING No. 21.027, PROCUREMENT AND SUSPENSION AND DEBARMENT Name of contact person: County Commissioners Corrective Action: Roosevelt County will follow the procedure of verifying contractors through SAM or GSA Websites when using SLFRF funds. Proposed Completion Date: Immediately.

Condition: We noted during testing that the City did not maintain sufficient documentation to ensure that subrecipients and contractors were not suspended, debarred, or otherwise excluded pursuant to 2 CFR Section 180.300 prior to entering into a contract or agreement with the third party. Planned Corrective Action: The City of Port Huron will implement a new process for approval of all invoices related to ARPA grant expenses. This includes a check for suspension and debarment prior to any invoices approval and appropriate documentation. Contact person responsible for corrective action: Lee Ward, Director of Finance. Anticipated Completion Date: December 31, 2024.

Finding Number: 2024-002 Condition: The Authority could not provide evidence that it performed a check to verify all subrecipients were not suspended or debarred. Planned Corrective Action: SMART is in agreement with this finding. SMART has reviewed and corrected procedures around our suspension and debarment reviews to include all subrecipient award programs. The Manager of Capital Grant Programs will review all subrecipients in new grant awards, and work with the Manager of Transit Asset Management to ensure we have documented our review of subrecipient suspension and debarment. Contact person responsible for corrective action: Ryan Byrne, VP of Finance and CFO Anticipated Completion Date: 12/31/2024

NONCOMPLIANCE WITH PROCUREMENT AND SUSPENSION AND DEBARMENT REQUIREMENTS, CORONAVIRUS STATE AND LOCAL FISCAL RECOVERY FUNDS; AL No. 21.027; GRANT No. Direct allocation and AM-23-0287 Name of contact person: Kelly Strecker Corrective Action: The City commits to ensuring that a procurement policy be put in place that will allow it to comply with procurement standards outlined in the Uniform Guidance. Proposed Completion Date: Immediately

MATERIAL WEAKNESS 2024-003 Child Nutrition Cluster – Assistance Listing Number 10.553 and 10.555 Suspension and Debarment Recommendation: We recommend that the Organization establish and maintain effective internal controls over suspension and debarment requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: One City Schools adopted a procurement policy in November 2023 with a $150,000 threshold for suspension and debarment. With the development of the Federal Funds Procedural Manual, that policy will be amended to the $25,000 threshold identified by the grant guidance. The procedural manual also stipulates a suspension and debarment process that adheres to grant guidance. Name(s) of the contact person(s) responsible for corrective action: Janel Vertz, Finance Director Planned completion date for corrective action plan: January 2025

Program: Targeted Airshed Grant Program Federal Financial Assistance Listing Number: 66.956 Federal Grantor: Environmental Protection Agency Award Year: 4/15/2021-4/30/2026; 5/1/2022-4/30/2027 Grant Award Number: TA98T10501; TA98T36001 Compliance Requirements: Procurement and Suspension and Debarment Type of Finding: Material Weakness in Internal Control Finding Summary: As a result of our test work, we noted three (3) out of three (3) instances where there was no evidence that the District verified the subrecipient entity was not suspended or debarred or otherwise excluded from participating in the transaction, prior to entering the contract. However, none of the payments in our sample were made to a suspended or debarred party. Repeat Finding from Prior Years: No Management’s Response: We concur. Views of Responsible Officials and Corrective Action: The District will develop procedures outlining the requirement to 1) access the System for Award Management (SAM) exclusion list, 2) collect a certificate from the subrecipient, or 3) add a clause or condition to the subrecipient agreement to verify that an entity that may submit invoices for federal grant-funded activities has not been debarred or suspended prior entering into the agreement with the subrecipient. Name of Responsible Person: Patricia Kepner, Controller Projected Implementation Date: March 31, 2025

We will amend our existing procurement policy to address suspension and debarment for contractors when using federal grant funds to ensure compliance with federal regulations. We will implement a procurement checklist to document and verify contractor eligibility on SAM.gov prior to engaging in contracts utilizing federal funds.

Auditor Description of Condition and Effect. During our single audit testing, it was determined that there was no process in place to verify that vendors with transactions in excess of $25,000 were not suspended or debarred. Certain vendors could be used that are considered suspended or debarred by the federal government resulting in noncompliance. Auditor Recommendation. We recommend that the Organization review its policies over suspension and debarment review to ensure that they are contracting with allowable vendors. Corrective Action. For Federal grants, management will implement a system for verifying that all vendors or subrecipients with transactions exceeding $25,000 are not suspended or debarred by the federal government, ensuring full compliance with federal regulations and minimizing the risk of using prohibited vendors. A mandatory check against the System for Award Management (SAM) database for suspension and debarment status will occur, with a printout or screenshot of the results maintained. Responsible Person. Chris Sargent, President & Executive Officer Anticipated Completion Date. January 31, 2025

Finding Number: 2024-001 Condition: The City could not provide evidence that it performed a check to verify contractors were not suspended or debarred. Planned Corrective Action: Upon notification of the deficiency, a root cause investigation on the actions involved during the Grant procurement were performed to identify cause. The outcome of this investigation will be communicated as educational training within the Finance Department, which includes Purchasing Division, Operating Departmental procurement requestors using federal grant awards and all Accountants. Additionally, management has amended the standard policy for the City to ensure all federal monies are used in accordance with 2 CFR requirements. Contact person responsible for corrective action: Michael Kennedy, Finance Director Corey Jarocki, Deputy Finance Director Anticipated completion date: 11/19/2024

M anagements Response/Corrective Action Plan: The City of Sault Ste. Marie has instituted the following measures to remedy this deficiency to be implemented immediately. 1. Management learned of this deficiency in response to a request for documentation of a check for debarment in connection with the single audit field work in October 2024. Upon further i nquiry, City staff didn't have documentation of this kind. This task slipped through the cracks because a process was not in place to ensure it was completed. 2. In reference to the City's Uniform Guidance Policies, most recently approved by the City Commission on February 5, 2024, page 43, the City will include a suspension/debarment clause in all written contracts in which the vendor will certify that it is not suspended or debarred. Alternatively, the city may request vendor/contractor sign a certification regarding suspension or debarment. Executed certificates and procurement files will be retained by the City Clerk's office. This language was in the policy but was not implemented. 3. A sample certificate is provided on page 51 of the unform guidance policy. This sample certificate, if completed, would have provided evidence but was not implemented. For future contracts, this certificate will be completed prior to the bid award and documentation that it has been completed will be required for future City contracts that are part of a federal grant award. 4. If for any reason this signed certificate is not available prior to the award bid recommendation, City staff will check the vendor's status on Sam.gov and will document the results in the narrative of the memo. This will be required for all contracts related to federal grants. City staff will be provided instructions about how to check the status as by the State of Michigan in the following link... https://www.michigan.gov/msp/-/media/Proiect/Websites/msp/EM HSD/gra nts2/instructions for checking for excluded debarred contractors revised 72020.pdf?rev=0a928fb6b4b54253b2a627f1eb70dcd8&hash=31DC61AC1AB1E38D5A84952C43D27 F82 5. Going forward, City staff will add a note to the narrative of the agenda memo in BoardDocs to state whether the City has a certificate or found that the vendor was not suspended or debarred and provide documentation to be attached to the memo for all bid award recommendations. For example, we might indicate that the vendor/contractor was checked on Sam.gov and the contractor was not suspended or debarred and then follow up with a signed certificate when the contract is signed. Alternatively, a copy of the certificate, if separate from the contract, can be attached to the requisition in the P0 module. 6. This updated process will be shared with all project managers and grant administrators, along with staff in Finance and Clerks offices, so that we can ensure it is completed with each contract and project managers are supported during the busy construction season. 7. When bid award agenda memos route through Finance, they'll be reviewed to ensure this task has been completed and documentation is provided. This corrective action is being implemented as of this date and is expected to fully resolve the deficiency. Thank you for this opportunity for improvement. Sincerely, Kristin M. Collins Finance Director/Treasurer

Management at the Central Maine Growth Council is aware of its responsibility under 2 CFR 200.516(a) as it relates to the requirements to perform control activities related to suspension and debarment. • All recipients of expenditures under federal grants will be compared to the Office of Inspector General’s Exclusion Database to help ensure they are permitted to receive federal funding. This verification process will be documented and retained. • A written formal procurement policy and conflict of interest policy will be established. Responsible party: Garvan Donegan, Director of Economic Development and Strategic Projects (207) 680-7300 Anticipated completion date: December 31, 2024.

Program: AL 21.027 - COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Suspension and Debarment Corrective Action Planned: The County has 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: September 30, 2024 Responsible Party: Michaela Arndt, County Clerk

Program: AL 21.027 - COVID-19- Coronavirus State and Local Fiscal Recovery Funds - Suspension and Debarment Corrective Action Planned: 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 debarred and such procedure will be adequately documented. Anticipated Completion Date: August 16,2024 Responsible Party: Dixon County Board of Supervisors: Don Andersen, Deric Anderson, Roger Peterson, Neil Blolun, Lisa Lunz, Terry Nicholson, and Steve Hassler.

Management's Response: KC CARE Agrees Views of Responsible Officials and Corrective Action: This appears to be an isolated incident where the vendor was not entered at the correct time in our contract management database. But, in response to this incident, management created a clearer policy and outlined the timing of entering new vendors into the database and then making sure to do initial exclusion check during procurement process. Responsible Official: Dennis Dunmeyer, COO Anticipated Completion Date: Already implemented.

The City of North Bend acknowledges that a contract utilizing SLFR funds, and awarded to a software vendor, did not include within the contract, a required self-attestation concerning Suspensions and Debarment. The self-attestation was used in lieu of a documented review of the SAM.gov portal for suspensions and debarment. This was an oversight of the contract review process. Other contracts issued during the same period included self-attestation language from 2 CFR 200.317 through 2 CFR 200.327. In 2024 and 2025, the Public Works Deputy Director, Contract Specialist, and Capital Staff Accountant ensure adherence to all applicable local, State, and federal procurement laws and regulations as provided in the Uniform Guidance at 2 CFR 200.214, 2 CFR Part 180, and Treasury’s implementing regulations at 31 CFR Part 19, prohibiting recipients from entering into contracts with suspended or debarred parties. The City of North Bend understands the significance of the finding and immediately took steps to review all subsequent contracts for compliance.

The following is Management’s Response to the Findings Required to be Reported by the Uniform Guidance. This document was prepared by management of the Catholic Charities of the Archdiocese of Oklahoma City (“CCAOKC”). 2023-002 Assistance Listing Number 93.576, Refugee and Entrant Assistance Discretionary Grants, U.S. Department of Health and Human Services, FAIN 90RP0121, Award Year 2023, Passed Through by the United States Conference of Catholic Bishops Criteria or Specific Requirement – Procurement, Suspension, and Debarment – 2 CFR § 200.317–.327; 2 CFR § 200.214 Finding Summary CCAOKC’s procurement documentation procedures were not adequate to meet the requirements of 2 CFR § 200.317–.327; 2 CFR § 200.214 - Procurement, Suspension, and Debarment. Explanation of Agreement/Disagreement: Management concurs with the findings and has updated CCAOKC’s procurement policy. Officials Responsible for Ensuring Corrective Action: David Ashton, Sr Director of Administration; E-mail – dashton@ccaokc.org Alan Lipps, Chief Financial Officer; E-mail – alipps@ccaokc.org Planned Completion for Corrective Action: Corrective action completed in FY 2026 Action in response to finding: Purchasing staff are trained in federal procurement requirements and were provided with a copy of the new policy.

Conditions 1-2: The MOF acknowledges this finding and will address the deficiencies by reinforcing documentation and compliance requirements. Annual refresher training will be provided to current staff, and onboarding will be conducted for new staff to ensure adherence to established procedures. Condition 3: The MOF acknowledges this finding and notes that screening for debarred, suspended, or excluded entities was incorporated into the Grants and Sub-Grants Monitoring Procedures Manual in November 2024. The Ministry further confirms that this requirement will be enforced immediately.