Corrective Action Plans

The District Cafeteria Manager, Melanie Pardini, corrected this procedure for fiscal year 2025-26 and has the process in place going forward for each fiscal year.

Condition: The School District's internal controls did not effectively identify the required formal solicitation. The School District did not utilize the appropriate competitive procurement methods and did not retain suspended or debarred verification documentation. Planned Corrective Action: The School District will ensure that the proper procurement methods are adhered to, prior to executing future contracts. This includes also reviewing to ensure that vendors are not suspended or debarred, prior to awarding the contract. To accomplish this, the School District will use their grant budget process as a control for identifying the population of applicable expenditures that will be subject to procurement compliance requirements for federal programs. Contact person responsible for corrective action: Kyle Jen, Chief Financial and Operations Officer Anticipated Completion Date: 6/30/2026

Finding 2025-001 Lack of Internal Control Over Procurement Name of Contact: Rayna Bowdre Corrective Action: The District will ensure all procurements follow Board polices relating to bids and procurement, including written documentation for sole source and procurements and exemptions. Proposed Completion Date: December 31, 2025.

Condition: The School District's internal controls did not effectively identify all of the required components necessary in formal solicitation documents for food service/cost reimbursable contracts and when using a third party entity (e.g., consortium) and did not utilize competitive procurement methods. Planned Corrective Action: The School District is revising its food service procurement documents to explicitly include all required contract provisions under the Uniform Guidance. The School District is also incorporating recent interpretations and guidance from the U.S. Department of Agriculture (USDA), as communicated through MDE, particularly regarding cooperative purchasing and pricing structures for federal compliance. These actions are intended to strengthen the procurement controls to ensure all future food service contracts meet the compliance requirements of the Uniform Guidance and USDA regulations. Contact person responsible for corrective action: Danielle Jacobs, Director of Business Services Anticipated Completion Date: 8/15/2025

We acknowledge the audit finding and agree that, for the two vendors identified, documentation of suspension and debarment verification was not completed or retained in accordance with proper internal controls for our federal programs. This was an oversight in our procurement documentation process and not an intentional omission. Neither vendor had any exclusions based on the SAM.gov database record. Since becoming aware of this issue, the organization is in the midst of implementing the following corrective actions to strengthen compliance with suspension and debarment requirements: (1) Revised Procurement Procedures- We will update our written procurement policies and procedures to explicitly require and document suspension and debarment checks prior to the execution of any contract using federal funds. This includes checking the federal SAM.gov database or obtaining a signed certification from the vendor, as permitted. (2) Standardized Documentation- We will create a standardized checklist that must be completed and filed in the procurement record for each vendor before payment of federal funds. This form documents the date, verification method, and staff member responsible. (3) Staff Training- All staff involved in procurement and accounts payable will complete training on federal procurement requirements, including suspension and debarment verification. This training will be repeated annually and upon onboarding of new staff. (4) Internal Control Review- A secondary review step has been added. Before any payment of federal funds is processed, our finance team will verify that the suspension and debarment check is on file. This dual review adds an additional layer of assurance.

We agree with auditor's comments, and the following actions have or will be taken to ensure the procurement of goods and services for the nutrition services department follows all applicable steps according to Title 2, Code of Federal Regulations (2 CFR) sections 200.317 -200.327; Title 7, Code of Federal Regulations (7 CFR), parts 210 and 220; and all applicable state and local rules: 1. During the school year 2024/2025, changes were made to staff to allow for additional oversight. A Procurement Specialist reporting directly to the Director of Purchasing was added to staff in lieu of a Buyer that had previously reported to the Director of Nutrition Services. This move allowed for an additional step to ensure proper procurement is happening. 2. All purchasing methods, including Micropurchase, Simplified Acquisition, and Formal, will be followed in accordance with all applicable regulations, in line with RUSD's written procurement procedures. 3. Any noncompetitive procurement will only occur if the conditions outlined in applicable regulations are met and sufficient evidence and documentation is received and retained, including participating in performing due diligence to ascertain whether a single source document is accurate from any given vendor. 4. In addition documented annual training will take place for all staff involved in the procurement process. This procedure includes a review and annual update of procurement procedures, if applicable, and an acknowledgement of the nutrition services code of conduct in regards to purchasing. Please reach out to us with any questions.

Management will update written procurement policy that conforms with the Uniform Guidance and implement procedures and control processes to retain documentation supporting compliance with major federal program compliance requirements regarding suspension and debarment. Our HUD program currently checks certificates of occupancy through the City of Rochester and Towns to ensure that the properties do not have violations. Moving forward, we will also check new landlords and or contractors through the central contractor registry to be following federal requirements regarding suspension and debarment.

Finding 2024-240: The Division is not following Idaho Administrative Rules for Purchasing as required by federal requirements. Related to Prior Finding: N/A Agency’s view: Agree 4.1 Corrective Action Plan: Policy Alignment: Review and revise internal procurement policies and procedures to align with IDAPA 38.05.01, 2 CFR 200.317, and 2 CFR 200.303 requirements. 4.2 Training and Awareness: Provide training to all staff to ensure understanding of: 4.2.1 Purchasing thresholds and categories (small, informal, and formal purchases). 4.2.2 Documentation and approval requirements. 4.2.3 Process and documentation requirements for purchases requiring exemptions. 4.3 Internal Control Strengthening: Develop and implement internal control mechanisms to ensure compliance with State and Federal purchasing requirements. 4.4 Monitoring and Accountability: Establish a quality assurance and compliance monitoring process to perform monitoring of procurement transactions to verify compliance with Division policies and procedures. Anticipated Corrective Action Date: 06/30/2026 Responsible for Corrective Action: Contracts and Vendor Relations Officer, To be Hired Position Oversight: MiKayla Monaghan, Internal Operations and Stakeholder Relations Manager

Finding 2024-203: The Commission is not following Idaho Administrative Rules for Purchasing as required for compliance with the requirements applicable to the Rehabilitation Services-Vocational Rehabilitation Grants to States program. Related to Prior Finding: N/A Agency’s view: Agree Corrective Action Plan: ICBVI acknowledges the failure to document compliance with state procurement policies for select vendors. Policy Clarification: ICBVI will ensure future purchases above the threshold are fully documented in accordance with state requirements. Procedural Update: A procurement checklist and documentation template will be added to internal controls to support purchases subject to state policy. We have a training setup with DOP on 12/18/25 to help with correcting this deficiency. Upon completion of this training, we will conduct comprehensive internal training for all ICBVI staff to ensure consistent understanding and compliance with state procurement requirements. Anticipated Corrective Action Date: 12-31-25 Responsible for Corrective Action: Angela Starr, Office Services Supervisor, 208-639-8374, astarr@icbvi.idaho.gov

In our audit findings there was noted $555,000 in bids awarded were not properly advertised. There was an advertisement for a pre-bid meeting for the projects. The projects were the removal of blockages on Rough River with money received from NRCS for that purpose. The intention was for the ad to say the projects were open and that bids were to be received by a certain date. The ad was improperly ran but not intentionally. We will double check all items going to bid. If an item is sent by any department it will be double checked at the Judge Executive's office. If it originates here it will be double checked by the treasurer's office.

FINDING 2024-001 Finding Subject: Water and Waste Disposal Systems for Rural Communities - Procurement and Suspension and Debarment Contact Person Responsible for Corrective Action: K. Rochelle Seneff Contact Phone Number and Email Address: (812)649-2242 ct@rockportin.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Procurement As Clerk-Treasurer, I will educate all parties involved on the requirements that were found to be unfulfilled through this Federal Audit. For the duration of any federally funded projects, a discussion will be held during a public board meeting, detailing the rationale behind the City's decision to work with the vendors selected for small purchases and simplified acquisitions. This will be done to verify that all vendors, even when bids are not required, were retained through appropriate methods. A procurement policy that outlines the City's procedures and conforms to applicable federal, state, and local laws will be developed and taken to the Common Council for approval. Suspension and Debarment All vendors who participate in the project will receive a Suspension and Debarment Certificate provided by the City that must be signed by a representative of the vendor and filed with the vendor's contract or in the project folder. Anticipated Completion Date: December 23, 2025

Finding 2024-011 – Procurement and Suspension and Debarment (Material Weakness) Finding: The Organization did not have sufficient controls to ensure that the procurement requirement was met due to staff turnover. Management Response: Management agrees. Corrective action plan: •All procurements now require documentation of vendor eligibility verification (SAM.gov) and compliance with competitive bidding rules. Responsible Party: CFO Completion Date/Status: Expected to be Implemented by end of 2025; ongoing review.

The District will ensure that there are at least 2 quotes obtained for any purchase over the $10,000 threshold using federal monies. The District will also verify that the vendor being used is not suspended or debarred by checking the SAM exclusions and requiring the vendor to provide a certificate of verification.

VIEWS OF RESPONSIBLE OFFICIALS Management agrees with the audit finding. The Puerto Rico Department of Education (PRDE) acknowledges that the requested procurement documentation was not fully available at the time of the auditors’ review. However, management made every effort to gather and reconstruct the information for all the selected transactions, and the complete documentation will be available. Furthermore, the PRDE is taking actions to improve the accessibility and organization of procurement files to ensure that all documentation is readily available for review in a timely manner. Internal controls over document retention and filing procedures are being reinforced to prevent recurrence of this situation. It is important to note that the procurement processes followed by the PRDE comply with the applicable requirements established under the Code of Federal Regulations (2 CFR Part 200 – Uniform Guidance). Management remains committed to strengthening its internal controls, ensuring full compliance with federal and state requirements, and maintaining complete and timely documentation to support all procurement activities. IMPLEMENTATION DATE Current Fiscal Year. RESPONSIBLE PERSON María de los A. Lizardi Valdés Office of Federal Affairs Director Edgar Delgado Serrano Office of Federal Affairs Associate Director

We will incorporate oversight of procurement for the agency to our Accounts Payagble Manager’s job duties and in addition revise our protocols and procedures to adhere to procurement standards found in 2 CFR 200.317-200.326 of the Uniform Guidance. The protocols and procedures will include the following methods of procurement: o Micro-purchases (≤ $10,000): Award without competitive quotations if the price is reasonable; distribute purchases equitably among qualified suppliers. o Small purchases ($10,000–$250,000): Obtain price or rate quotations from at least two qualified sources; document quotes and selection rationale. o Sealed bids (≥ $250,000): Publicly solicit bids; award to the lowest responsible bidder. o Competitive proposals (≥ $250,000): Use when sealed bids are not appropriate; publicize RFPs and evaluate proposals based on predetermined factors o Non-competitive proposals (sole source): Use only when justified (e.g., single source, emergency, federal authorization, inadequate competition). o Maintain Oversight of Contractors to ensure contractors perform according to contract terms. o Record Keeping including: Rationale for method used, selection of contract, selection and rejection of contractor o Training - Provide training to all staff responsible for procurement on the updated policy and procedures.

Finding Number 2024-002: Uniform Guidance Compliant Procurement Policy (Significant Deficiency, Instance of Noncompliance – Procurement and Suspension and Debarment) Program: Continuum of Care Program Assistance Listing Number: 14.267 Response and Corrective Action Plan: Management agrees with the finding that the agency did not have policies for Procurement or Suspension and Debarment. The agency intends to adopt a procurement policy and procedures that meets the general procurement standards in 2 CFR section 200.318(a) and the State of California. The agency is also creating policies and procedures to ensure vendors are not suspended or debarred from work on federally funded projects. Anticipated Completion Date: by October 31, 2025 Responsible Person: Wanda Lassiter, Controller

Outdoor Recreation Acquisition, Development, and Planning Assistance Listing No. 15.916 Recommendation: City personnel should familiarize themselves with the documentation requirements of the CFR related to procurement. City policies and procedures should be modified to help ensure documentation is maintained on all compliance requirements. The written policies should be expanded to clearly address all five procurement methods allowed under Uniform Guidance. The city should also adopt a written conflict of interest policy. We also recommend that the City review and update policies and procedures to help ensure that all federal grants with covered transactions have vendors reviewed for suspension and debarment status prior to entering into the transaction and that documentation of the status is maintained with the procurement history of each transaction that it is required for. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The City will adopt a formal conflict of interest policy. The City contracted for bidding and construction management, we will do better in familiarizing ourselves with policies and procedures for federal grants. Name(s) of the contact person(s) responsible for corrective action: Amanda L. Bartz, Clerk/Treasurer 715-453-4040, abartz@tomahawkwi.gov Planned completion date for corrective action plan: 12/31/2026

Finding No.: 2024-002 For procurements using federal funds, GMHA is permitted to use a Simplified Acquisition Threshold up to the federal limit, which is currently set at $250,000 or $7.5 million for commercial goods. The Code of Federal Regulations (CFR) permits a non-federal entity to use a SAT up to the federal limits, without having to follow threshold limitations imposed by state or local law. The set of criteria employed by the Ernst & Young is incomplete, and fails to give proper deference to the legal opinions of licensed attorneys. In determining to follow the federal SAT, GMHA considered the guidance of a memorandum from the Office of the Attorney General indicating substantively the same legal analysis as follows. See Memorandum from Deputy Attorney General, Solicitor Division to Chief Deputy Attorney General, Federal Simplified Acquisition Threshold and Micro-purchase Threshold, Ref: AG 22-0410 (Sept. 14, 2022). When presented with this memorandum, the auditors refused to accept its instructions stating: “We were unable to follow why the Attorney General considered the definition of a non-Federal entity in applying the requirements of §§ 200.318 through 200.327. In reviewing the aforementioned sections, there was no reference to non-Federal entities.” This statement evidences the auditors’ fundamental misunderstanding of the law. The auditors based their analysis on an amended version of the CFR, which became effective only January 2025. According the definitions in the Code of Federal Regulations in effect during the relevant 2023-2024 audit period, Guam is both a “State” and a “Non-Federal entity.” Guam Memorial Hospital Authority also falls within the definition of “Hospital” and “subrecipient.” As relevant here, 2 CFR 200.1 states: State means any State of the United States, the District of Columbia, the Commonwealth of Puerto Rico, U.S. Virgin Islands, Guam, American Samoa, the Commonwealth of the Northern Mariana Islands, and any agency or instrumentality thereof exclusive of local governments. Non-Federal entity (NFE) means a State, local government, Indian Tribe, Institution of Higher Education (IHE), or nonprofit organization that carries out a Federal award as a recipient or subrecipient. Hospital means a facility licensed as a hospital under the law of any State or a facility operated as a hospital by the United States, a State, or a subdivision of a State. Subrecipient means an entity, usually but not limited to non-Federal entities, that receives a subaward from a pass-through entity to carry out part of a Federal award; but does not include an individual that is a beneficiary of such award. A subrecipient may also be a recipient of other Federal awards directly from a Federal awarding agency. As a Non-Federal entity, GMHA also is required to abide by the definition of “simplified acquisition threshold.” According to 2 CFR 200.1: Simplified acquisition threshold means the dollar amount below which a non-Federal entity may purchase property or services using small purchase methods (see § 200.320). Non-Federal entities adopt small purchase procedures in order to expedite the purchase of items at or below the simplified acquisition threshold. The simplified acquisition threshold for procurement activities administered under Federal awards is set by the FAR at 48 CFR part 2, subpart 2.1. The non-Federal entity is responsible for determining an appropriate simplified acquisition threshold based on internal controls, an evaluation of risk, and its documented procurement procedures. However, in no circumstances can this threshold exceed the dollar value established in the FAR (48 CFR part 2, subpart 2.1) for the simplified acquisition threshold. Recipients should determine if local government laws on purchasing apply. (emphasis added). This definition applies to purchasing by all non-federal entities—including GMHA. Title 2 CFR 200.317 provides: When procuring property and services under a Federal award, a State must follow the same policies and procedures it uses for procurements from its non-Federal funds. The State will comply with §§ 200.321, 200.322, and 200.323 and ensure that every purchase order or other contract includes any clauses required by § 200.327. All other non-Federal entities, including subrecipients of a State, must follow the procurement standards in §§ 200.318 through 200.327. (emphasis added). As a subrecipient of Guam, GMHA would also be required to follow 2 CFR 200.320(a)(2)(ii), which reiterates that: “The non-Federal entity is responsible for determining an appropriate simplified acquisition threshold based on internal controls, an evaluation of risk and its documented procurement procedures which must not exceed the threshold established in the FAR.” The CFR treats the requirement that a state or local entity follow (1) its own “policies and procedures” and (2) its own small purchase “threshold” as separate requirements. The CFR applicable to most federal funds—including ARPA—only requires the hospital to follow the local “policies and procedures.” 2 CFR 200.317. The CFR requires GMHA—as a non-federal entity—to separately make a determination of an appropriate small purchase threshold based on a number of factors specific to GMHA, provided it does not exceed the federal SAT. 2 CFR 200.1; 2 CFR 200.320(a)(2)(ii). Procurement method selection is essentially a two-step process: (1) Make a substantive determination about the monetary cost of a proposed procurement and determine whether it is below or above an applicable threshold. Which side of a threshold a procurement falls on (and some other factors) will determine the method—sole source, RFQ, RFP, IFB—that will be used. (2) After the method is determined, an entity is then pointed to specific policies and procedures applicable to that type of procurement. The relevant factors for determining a recipient-specific SAT include an entity’s “internal controls, an evaluation of risk, and its documented procurement procedures.” 2 CFR 200.1; 2 CFR 200.320(a)(2)(ii). For a portion of the relevant procurement period, the CFR also stated: “When applicable, a lower simplified acquisition threshold used by the non-Federal entity must be authorized or not prohibited under State, local, or tribal laws or regulations.” This section was amended effective approximately October 1, 2024. Now, it no longer requires the recipient or sub-recipient to ascertain whether this entity-specific threshold is “authorized or not prohibited under State, local, or tribal laws or regulations.” But even under the prior version, the entity only needed to consider the authorization or lack of prohibition under state or local law if it was adopting a “lower simplified acquisition threshold” than the federal SAT. 2 CFR 200.320(a)(2)(ii) (effective until Sept. 30, 2024) (emphasis added). GMHA determined that the federal SAT levels were appropriate, and—in any event—local law does not prohibit GMHA from adopting the federal SAT when using federal funds. GMHA’s use of the federal SAT for procurements using federal funds has been a decades long practice of our materials management, so a suggestion that it is unauthorized would be a finding quite inconsistent with GMHA’s internal controls. Highlighting the distinctness or difference between the “policies and procedures” and “threshold” requirements, is the fact that “simplified acquisition procedures” and “simplified acquisition threshold” are defined separately. See 48 CFR 2.101. And the two requirements are discussed separately in the section of the CFR discussing “informal procurement methods.” 2 CFR 200.320. Additionally, the small purchase “procedures” applicable to federal agencies, FAR Part 13, are contemplated in an entire section that is separate from the rules about the controlling SAT or other threshold. Finally, in other portions of the CFR—such as federal highway funds—the government has specifically instructed state entities to follow both the state or local “procedures” and the state or local “threshold. 23 CFR 172.7(a)(2). When the CFR wants the state government to follow state SATs, it will specifically do so. It has not put that instruction in 2 CFR 200.320. Guam law also specifically directs all persons within the Government of Guam to comply with the applicable federal law and regulations that are in conflict with or are not reflected in the Procurement Code. 5 GCA § 5501. In other words: Guam law requires GMHA to follow the federal rules. Specifically, here, the federal requirement that GMHA determine an appropriate SAT is not reflected in the local laws. GMHA, thus, must comply with the federal requirement that GMHA make a recipient-specific determination of an appropriate SAT. Even the Guam Legislature understands that the law operates in the same manner as the Attorney General’s memorandum. During a legislative hearing on June 25, 2024, Senator Sabina Perez recited the same analysis, recognizing that Guam agencies can use the federal simplified acquisition threshold when expending federal funds. See Guam Legislature, Public Hearing Bill No. 134-39 (COR) at *1:46:00-1:46:31 (June 25, 2025), available at https://www.youtube.com/live/ciXo1EEXJZI. In deciding the federal SAT applies, GMHA was also guided by precedent and guidance issued to other government entities. In 2015, when the Guam Department of Education was under a federal third-party fiduciary, it was still employing the lower local small purchase threshold. GDOE was instructed that this was inappropriate because federal law supersedes Guam law on the SAT. The federal fiduciary—consistent with USDOE instructions—required GDOE to follow the federal SAT. See Letter from John E. Hampford, Alvarez & Marsal, to Jon J.P. Fernandez, Superintendent of Guam Department of Education (Dec. 30, 2015); see also Letter from Jon J.P. Fernandez, Superintendent of Guam Department of Education to Attorney General Leevin T. Camacho and Public Auditor Benjamin J.F. Cruz (July 20, 2020). Thus, other Guam agencies have been instructed by the federal government to use the federal SAT. This is also bolstered by the case law. The Guam Supreme Court has ruled that the CARES Act funding was a federal appropriation for a specific purpose, “outside the control of the Guam Legislature.” See Story-Bernardo v. Gov’t of Guam, 2023 Guam 27 ¶ 46. ARPA funding is substantively similar to CARES Act funds, simply with additional permitted uses. Local law cannot dictate how these federal funds are spent. GMHA also considered case law from Texas federal court where a self-styled “whistleblower” sued the City of Burleson, Texas for allegedly spending in excess of their own SAT. Under Burleson’s own regulations, the local SAT was $10,000, see Rule 5.1, City Council Policy 36, City of Burleson Purchasing Policy (adopted July 2, 2018, revised Oct. 16, 2023). However, the lawsuit alleged that the city was spending in excess of this $10,000 SAT. The federal judge in that court stated: “In addition, the regulations show that “formal purchasing methods are not required” for purchases that are less than the “simplified acquisition threshold.” 2 C.F.R. § 200.1(2021). The simplified acquisition threshold is set at $250,000. 48 C.F.R. § 2.101(2021). However, Mr. Eder's complaint incorrectly alleges “upon information and belief” that the simplified acquisition threshold is $10,000. Doc. No. 37 at 12, ¶27(b). Mr. Eder's apparent misreading of the threshold for formal purchasing is central to his claim under the FCA, and it appears this concern may have arisen from simply misreading the rules, rather than any reasonable dispute under the law.” Eder v. City of Burleson, Civil No. 3:23-CV-00948-K, 2024 WL 4771408 at *5 (N.D. Tex., Nov. 13, 2024). Thus, the federal court recognized that the lower local SAT did not control. The only relevant SAT was the federal one. GMHA’s determination to use the maximum SAT allowed by the federal CFR is thus appropriate. The federal CFR rule requiring a recipient-specific SAT determination supersedes the local thresholds. If the procurement is under the federally-allowed $250,000 SAT, GMHA must still follow the local small purchase procedures. See in part 5 GCA § 5213. The auditors’ view of Guam law appears to be a clear outlier, inconsistent with a plain reading of both federal and Guam law, the opinions of both federal and local courts, the memorandum from the Attorney General’s Office, the understanding of the Guam Legislature, and the reasoned opinion of Hospital Legal Counsel. The auditors’ finding is also inconsistent with decades of GMHA procurement practice. The questioned costs based on this finding should be removed. The auditors’ (1) inability to even reference the relevant definitions from the CFR in effect at the time of the relevant audit period and (2) unwillingness to accept the legal opinions from licensed attorneys, should be a finding on the auditors’ peer review.

Personnel Responsible for Corrective Action: Dr. Shelley Kneuvean Chief Financial Officer Unified Government of Wyandotte County & Kansas City, Kansas Anticipated Completion Date: July 1, 2025 Views of Responsible Officials and Planned Corrective Action: Unfortunately, due to the late completion of the 2023 Single Audit and the hiring of the grants position in early 2025, many previous findings and contracts were not yet corrected in 2024. In the event of this finding, there were two vendors which had minimal expenditures in 2024 (under $5,000 which does not require competitive bids but in aggregate they exceeded that amount). The procurement department had not been consulted, and debarment checks were not completed when the work began in 2023, and final payments were issued in 2024. In the Grants Manual and training departments have been instructed that these procedures must be complied with for all grants.

FINDING 2024-003 Finding Subject: Water and Waste Disposal Systems for Rural Communities - Procurement Contact Person Responsible for Corrective Action: David M. Kennard Contact Phone Number and Email Address: 812-677-3959 clerk@princetoncity.com Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Management will establish a proper system of internal controls to ensure expenditures made from federal awards use the appropriate procurement method and retain the documentation to support the procurement methods used in order to ensure compliance with the terms and conditions of the federal awards. Anticipated Completion Date: The corrective action plan will go into effect immediately.

Program: Continuum of Care Federal Financial Assistance Listing No.:14.267 Federal Agency: U.S. Department of Housing and Urban Development Pass-through: Sacramento Steps Forward Award Year: 2024 Compliance Requirement: Procurement, Suspension and Debarment Grant Award Number: CA0955L9T032209, CA0955L9T032310, CA0143L9T032215, CA0143L9T032316, CA1303L9T032208, CA1303L9T032309 Finding Summary: The Organization's procurement policy did not include all the required elements as outlined in the Uniform Guidance. Repeat Finding from Prior Years: Yes, Finding 2023-003. Management's Response: We concur. Views of Responsible Officials and Corrective Action: • Management has updated policies and procedures to ensure they confirm to the Uniform Guidance regarding procurement, suspension and debarment (2 CFR 200.317 through 200.327, 2 CFR 180). • Train grant staff on new policies and procedures. Name of Responsible Person: Projected Implementation Date: Bryan Wagner, CFO Date 8-21-2025

Federal Program Name: Mental and Behavioral Health Education and Training Grants Federal Agency: U.S. Department of Health and Human Services Federal Assistant Listing and Title Number: 93.732 Award Year: January 1, 2024 to December 31, 2024 Criteria or Specific Requirement: Procurement, Suspension and Debarment Condition: The District is required to follow their own documented procurement procedures which conform to the Uniform Guidance procurement standards. Correction Action Planned: The first contract in question was for a vendor (Healthsource Solutions) already under contract with Lubbock County Hospital District dba University Medical Center prior to the grant application. The vendor in question had been used since at least 2010, with the most recent contract for the current wellness portal (Wellness +) beginning in 2017. Because of the success of the wellness portal and established relationship with the vendor, University Medical Center included expansion of existing platforms and additional services provided by Healthsource Solutions as a large component of the Methodology/Approach in the proposed activities of the grant narrative submitted. Use of this vendor and its applications were specifically outlined in the grant project narrative and a critical component of meeting grant objectives. The second contract in question was for the Evaluation Group which provided specific services around grant program evaluation. This vendor was included in the original grant application and selected via the grant consultant used during the grant application process. University Medical Center follows the Lubbock County Purchasing Guidelines, which conform to the Uniform Guidance procurement standards. University Medical Center has reviewed the specified requirements of the Office of Management and Budget Uniform Guidance for procurement standards, specifically related to noncompetitive procurement and concurs that formal procurement methods were not used for expansion of new services with this existing vendor or adequate documentation was provided for noncompetitive procurement. In order to ensure compliance with the Uniform Guidance, the University Medical Center will provide training to existing grant Program Managers on Uniform Guidance procurement standards. Additionally, if a new grant is being pursued the grant committee should receive training on Uniform Guidance procurement standards before completing grant applications. On existing or future grants, any potential contracts or purchases over $75,000 should be reviewed by the grant Program Manager (or Grant Committee lead if a Program Manager has yet been assigned) to ensure all procurement guidelines are followed and sufficient documentation is obtained prior to purchase or contract execution. Contact Person (s) Responsible for Corrective Action: Aaron Davis, VP & Chief Experience Officer Anticipated Completion Date: The Corrective Action will be immediately implemented in response to the auditors’ recommendation.

2024 -002 Documentation of Procurement History Corrective Action Plan: The Standard Operating Procedures currently outlines procurement based on Uniform Guidance. Additional procedures will be implemented to ensure compliance with the policy. An internal Procurement Checklist and Pre-Award Review Form prepared by the Chief Operating Officer will be implemented to ensure compliance is documented before federal funds are expended. That document will be reviewed and approved by the President / CEO. All procurements over the simplified acquisition threshold will be reviewed by the Chief Operating Officer for compliance before a purchase order is issued or a quote is approved. All vendors solicited for proposal on procurements over the simplified acquisition threshold will be discussed during board meetings and documented in board meeting minutes. Personnel Responsible for Corrective Action: Alison Elder, CFO Anticipated Completion Date: May 2025

Management has since developed and formally implemented a written procurement policy that meets the standards of 2 CFR 200 Subpart D, including required controls over procurement and suspension and debarment. The policy is effective as of the date of this corrective action plan. Management will review the policy periodically to ensure ongoing compliance with federal requirements.

2024-001. Allowable Costs/Cost Principles United States Department of Housing and Urban Development Continuum of Care Program ALN: 14.267 United States Department of Justice, Passed through New York State, Office of Victims Services Crime Victim Assistance ALN: 16.575 Condition: The Organization did not have written policies referencing the Uniform Guidance requirements. Recommendation: The Organization should update their policies and procedures manual to ensure compliance with the procurement requirements at 2 CFR 200.317-327, and the impact of 24 CFR 578.103(c). Corrective Action: The Organization will update the written policies and procedures to comply with the Uniform Guidance requirements. Responsible Contact Person(s): Louis Bamonte, Director of Finance Brighter Tomorrows, Inc., - P.O. Box 706 – Shirley, New York 11967 Anticipated Completion Date: December 31, 2025.