Corrective Action Plans

Finding 2023-001 – Procurement and Suspension and Debarment Federal Grantor: U.S. Department of Education Pass-through Grantor: Pennsylvania Department of Education Program: Early Intervention (Philadelphia), Early Intervention (Chester) Assistance Listing #: 84.027, 84.173 Title: Special Education Cluster (IDEA) Audit Period: 07/01/2022 – 06/30/2023 Passthrough Numbers: 232-210026, 231-210026, 232-210035, 231-210035 Recommendation: We recommend Elwyn enforce its existing policy and procedures to ensure compliance with procurement requirements. Elwyn should provide targeted training to members of the organization involved in procurement processes on its existing policy and procedures to ensure understanding of the Organization’s requirements for documentation of procurement methods. Additionally, Elwyn should ensure all procurement decisions are contemporaneously documented with the information necessary to conclude on appropriateness of the procurement with respect to the procurement policy and requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The purchasing department will conduct an annual training with organizational leadership regarding the Elwyn’s procurement policy. This training will help to reinforce the existing procurement documentation requirements. In addition, the purchasing department will create and distribute a purchasing checklist and tracking form that will be utilized for new procurements and renewals. This form will help to ensure that the procurement method and rationale are appropriately documented and approved by organizational personnel. The completed form will be submitted to the purchasing department for electronic storage and retention. Name of contact person responsible for corrective action: David Bowers, Vice President of Finance and Corporate Controller Email: David.bowers@elwyn.org Phone: 610-891-2028 Planned completion date for corrective action plan: June 30, 2024

Polk County acknowledges the finding stated in the audit and is in the process of developing a corrective action plan. To address the finding the County will increase its monitoring of procurement procedures related to federal award purchases. Increased monitoring will include additional reviews and discussions by County staff (Finance Director/Administrative Officer/County Counsel) during the initial stages to be certain we meet all federal requirements.

December 14, 2023 Donovan CPAs 9292 N. Meridian Street, Suite 150 Indianapolis, IN 46260 To Whom It May Concern, Liberty Grove Schools will take the following corrective action to address the FY2023 Single Audit Report finding: We will take corrective action to ensure our procurement policy is updated and in line with the audit requirements of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements forFederal Awards (“Uniform Guidance”), specifically 2023-001. In addition, Morrise Harbour, Founder & Executive Director of Liberty Grove Schools, will ensure this updated procurement policy is implemented and approved by our Board of Directors. Sincerely, Morrise Harbour Founder & Executive Director

Finding, #2023-001 and #2023-002· Material Weakness - Other Matters, Government Auditing Standards; Major Federal Award Finding - Procurement and Suspension and Debarment Corrective Action Plan: We recognize the carry over nature of these findings in that the contract with the vendor that triggered the finding began in fiscal year 2022 and the work was not completed until fiscal year 2023. Revise the current procurement policy to include federal regulations 2 CFR Section 200.317-200-326 per the thresholds in CFR 200.320. The revised policy will be reviewed with managers responsible for procurement that could potentially exceed these thresholds. Our procurement procedure will be revised to clearly specify the requirements for Small Purchase Procedures for purchases between the micro-purchase threshold and the simplified acquisition threshold per federal government regulations.

Finding number: 2023-003; Finding: While testing the procurement requirement, we were able to test compensating controls, but noted that internal controls were not properly designed over the procurement requirement. Prior to receiving federal funding beginning in August 2022, the program conducted a request for proposal (RFP) process and began contracting with a vendor. When federal funding was obtained, the vendor was not reevaluated in accordance with the Uniform Guidance to ensure the procurement requirements were being met. In addition, we noted UW Health – Madison’s procurement policy documents do not include all of the information that is required by the Uniform Guidance. Correction actions taken or planned: UW Health will develop processes and procedures to ensure compliance with the Uniform Guidance. Vendors will be reevaluated for compliance with the Uniform Guidance prior to being charged to any grant. Anticipated completion Date: June 2024; UW Health employees responsible for Corrective Action Plan: James Hood, Director of Procurement Services, and Sara Schiek, Manager of Procurement Services

Recommendation: JTCHS should review federal procurement guidelines and revise its procurement policy to be in compliance with the federal procurement guidelines. Responsible Official’s Response: Management will review adopt a procurement policy in accordance with the Uniform Guidance. Planned Implementation Date of Corrective Action Plan: Management has started revising its policy and expects to have a revised procurement policy during fiscal year ending January 31, 2024.

Finding No.: 2022-029 AL Program: 21.027 - Coronavirus State and Local Fiscal Recovery Funds Area: Procurement and Suspension and Debarment Questioned Costs: $12,244,415 Contact Peron(s): Tracy B. Norita, Secretary of Finance / Geraldine Cruz, Procurement Services Director Corrective Action Plan: Condition 1&3: The Procurement Services Division agrees with this finding. The Division will revise CNMI’s procurement regulations to ensure alignment with federal procurement standards as outlined in 2 CFR Part 200, particularly the small purchase threshold requirements and competitive procurement procedures. Proposed Completion Date: Policy updates drafted by December 31, 2025 and adopted by March 31, 2026. Condition 2&5: The Procurement Services Division agrees with this finding. To address the lack of consistent verification of vendor eligibility under federal debarment and suspension requirements (2 CFR §180.300), a policy will be implemented requiring all agencies to submit debarment verification documentation at the time of vendor selection. Acceptable documentation may include (1) a printout or screenshot from the SAM.gov Exclusions database, confirming that the vendor is not debarred or suspended, (2) a signed certification from the vendor attesting to their eligibility, or (3) a signed contract clause or provision that explicitly states the vendor is not excluded from federal transactions and complies with applicable debarment regulations. Procurement procedures and standard forms will be revised to include debarment verification as a mandatory step prior to any purchase approval involving federal funds. Procurement Services will ensure that debarment verification documents are maintained in the official procurement file for each transaction involving federal funds. Proposed Completion Date: October 1, 2025 Condition 4&6: The Procurement Services Division respectfully disagrees with this finding. Due to internal scheduling constraints and the compressed timeline required to complete the FY22 audit, the requested documents were not submitted by the specified deadline, resulting in this finding. However, the Division maintains all relevant supporting documentation and is prepared to provide it upon request from the Grantor. Proposed Completion Date: Ongoing

Finding No.: 2022-017 AL Program: 15.875 - Economic, Social, and Political Development of the Territories Area: Procurement and Suspension and Debarment Questioned Costs: $770,427 Contact Person(s): Epiphanio Cabrera, Jr., Grants Administrator, OGM-SC / Gerladine Cruz, Procurement Services Director / Nerissa B. Karakaya, CIP COTR Corrective Action Plan: Condition 1 (G. Cruz): The Procurement Services Division agrees with this finding. The Division will revise CNMI’s procurement regulations to ensure alignment with federal procurement standards as outlined in 2 CFR Part 200, particularly the small purchase threshold requirements and competitive procurement procedures. Proposed Completion Date: Policy updates drafted by December 31, 2025 and adopted by March 31, 2026. Condition 2 (G. Cruz): The Procurement Services Division agrees with this finding. To address the lack of consistent verification of vendor eligibility under federal debarment and suspension requirements (2 CFR §180.300), a policy will be implemented requiring all agencies to submit debarment verification documentation at the time of vendor selection. Acceptable documentation may include (1) a printout or screenshot from the SAM.gov Exclusions database, confirming that the vendor is not debarred or suspended, (2) a signed certification from the vendor attesting to their eligibility, or (3) a signed contract clause or provision that explicitly states the vendor is not excluded from federal transactions and complies with applicable debarment regulations. Procurement procedures and standard forms will be revised to include debarment verification as a mandatory step prior to any purchase approval involving federal funds. Procurement Services will ensure that debarment verification documents are maintained in the official procurement file for each transaction involving federal funds. Proposed Completion Date: June 30, 2026 Condition 3(a) (E. Cabrera): The Office of Grant Management (OGM) respectfully disagrees with this finding. Due to internal scheduling constraints and the compressed timeline required to complete the FY22 audit, the requested documents were not submitted by the specified deadline, resulting in this finding. However, OGM maintain all relevant supporting documentation and is prepared to provide it upon request from the Grantor. For Project Code 2701210042, a purchase order (PO 22202856) totaling $48,000 was executed in accordance with procurement requirements, supported by the solicitation and evaluation of three independent quotations to ensure competitiveness and compliance with applicable procurement regulations. For Project Code 1901210064, a purchase order (PO 22216403) totaling $22,881 was processed following the initial Invitation to Bid (ITB21-OGM/RDCCA-046). After the originally awarded contractor defaulted, procurement guidance was sought, resulting in direction to obtain and evaluate three independent quotations before issuing a purchase order. This approach ensured continued adherence to competitive procurement standards while addressing the unforeseen contractor default and maintaining project continuity. Proposed Completion Date: Ongoing Condition 3(b) (N. Karakaya): Capital Improvement Program agrees with this finding. CIP acknowledges the need to maintain sufficient and appropriate audit evidence demonstrating compliance with federal procurement standards. We recognize that our current recordkeeping for bid submissions and ITB publication can be improved to ensure that auditors can readily verify compliance. Corrective Actions: 1. Standardize Procurement Documentation Checklist • Develop a Bid Documentation Checklist that must be completed and signed for each procurement action. • Checklist will confirm inclusion of: - Copy of ITB and required documents - Copy of any addendums issued by Procurement Services - Proof of ITB publication (e.g., newspaper ad tear sheets, online postings with date/time stamps, screenshots). - Bid opening records (bid tabulation sheet, attendance log, time-stamped submissions). - Copies of all bids received, with date/time of receipt. - Documentation of evaluation committee scoring and award recommendation. 2. Centralized Digital Repository • Establish a secure electronic folder in the organization’s shared drive or document management system for every procurement project. • Require that all supporting documents—bid advertisements, bid submissions, evaluation forms, and award notifications—be uploaded within five business days after bid opening. 3. Policy and Procedure Update • Revise the Procurement Manual to incorporate the checklist and digital repository requirements. • Reference 2 CFR 200.508(d) explicitly, ensuring staff understand the federal mandate for “sufficient and appropriate audit evidence.” 4. Staff Training and Awareness • Conduct a mandatory training session for all staff involved in procurement on proper documentation and the use of the checklist and repository. • Provide annual refresher training to maintain compliance 5. Monitoring & Verification • The CIP staff will conduct a semi-annual review of procurement files to verify that all required evidence is consistently documented and readily accessible for future audits. Proposed Completion Date: December 31, 2025

Finding No.: 2022-010 AL Program: 10.539 - CNMI Nutrition Assistance Program Area: Procurement and Suspension and Debarment Questioned Costs: Unknown Contact Person(s): Margaret Aldan, NAP Administrator / Geraldine Cruz, Procurement Services Director Corrective Action Plan: Condition 1 (G. Cruz): The Procurement Services Division agrees with this finding on behalf of CNMI NAP. The Division will revise CNMI’s procurement regulations to ensure alignment with federal procurement standards as outlined in 2 CFR Part 200, particularly the small purchase threshold requirements and competitive procurement procedures. Proposed Completion Date: Policy updates drafted by December 31, 2025 and adopted by March 31, 2026. Condition 2 (M. Aldan): The CNMI NAP agrees with this audit finding and that vendors were not being vetted using SAMS.gov. CNMI NAP has created and implemented an internal Standard Operating Procedure (SOP) to address this issue to ensure compliance. The SOP went into effect August 2025. A copy of the SOP can be provided upon request. Proposed Completion Date: Completed

The Government concurs with the auditor's findings and recommendations. The Government has since updated its procurement laws and has issued revised procurement manuals, along with issuing position-specific Standard Operating Procedures. Processes for enforcing Internal controls and adherence to procurement laws have been established and are regularly reinforced.

I believe this has to do with the sewer project. I was thrown into the middle of this. I don’t believe proper records were started or kept by the former Fiscal Officer. I only have what happened since I was here.

The Board of County Commissioners, with the cooperation and participation of all elected officials, reviews, develops and implements policies and procedures to create a strong internal control environment. The Board of County Commissioners will work with all elected officials, the third-party administrator, and federal, state and local partners to develop policies, procedures, and internal controls designed to accurately track grants, including the application process, verification, oversight, and reporting of grant requirements. The Board of County Commissioners will work with the third-party administrator to ensure proper grant administration.

Finding Reference Number: MW2022-006 Statement of Concurrence or Nonconcurrence: CUAHSI agrees with the finding and recommendation. CUAHSI Corrective Action: Action by CUAHSI impacting audit year 2022: Vendor status for 2022 recipients was retroactively evaluated by CUAHSI staff and certified by management during calendar year 2024. Records were organized and filed in a secure, centralized document management system. Corrective actions to processes and responsibilities impacting subsequent years: CUAHSI considers this finding closed, as current practices comply with established policies and procedures. Name of Contact Person: • Maureen S. Ako, Director of Finance • Telephone: (339)221-5400 • Email: msabino@cuahsi.org Projected Completion Date: NA; is complete

Procurement documentations were provided on May 19, 2025. The MOF management designated three audit focal points to coordinate effectively with external auditors in regards to timely submissions of required supporting documents.

Finding Number: 2022-006 Condition: Policies and procedures in place over procurement, suspension, and debarment are not in conformance with Uniform Guidance. Additionally, the Organization did not procure in accordance with the regulations, including maintaining records sufficient to detail the history of each procurement transaction nor did they comply with suspension and debarment rules. Planned Corrective Action: Management will implement written policies and procedures over procurement, suspension, and disabarment that conform with Uniform Guidance Contact person responsible for corrective action: Chief Financial Officer Anticipated Completion Date: 06/30/2025

Assistance Listing Number 21.027 Noncompliance Over Procurement and Suspension/Debarment - Major Federal Program - Coronavirus State and Local Fiscal Recovery Funds Muskogee County has hired an internal grant administrator to assist in keeping the county compliant with all local, state, and federal requirements. Efforts will be made going forward to ensure that all grant funds are properly expended. This includes that all expenditures are properly documented and that all vendors are ferderally eligible to perform services

AIRS management has started the process of creating new and updated policies and procedures related to financial reporting, activities, including written procurement standards, written standards of conflict of interest and others as required under Uniform Guidance

Finding 2022-005: Procurement Federal Program: Research and Development Cluster (Education and Human Resources) Assistance Listing Number and Title: 47.076 STEM Education Name of Federal Agency, Pass Through Entity (when applicable), Award Number and Year: National Science Foundation: 1431638 (9/1/2014 – 8/31/2022), 1500529 (9/1/2015 – 8/31/2022), 1624185 (9/16/2016 – 8/31/2022), 1640791 (9/15/2016 – 8/31/2022), 1720869 (5/15/2017 – 4/30/2022), 1726113 (8/1/2017 – 9/30/2023), 1821462 (7/1/2018 – 6/30/2024), 1940925 (1/15/2020 – 12/31/2023), 1907950 (7/1/2019 – 6/30/2024), 2015205 (4/1/2020 – 3/31/2022), 2021059 (10/1/2020 – 9/30/2024), 2141745 (5/1/2022 – 4/30/2027), 2212807 (7/1/2022 – 6/30/2026) Federal Program: Research and Development Cluster (Mathematical and Physical Sciences) Assistance Listing Number and Title: 47.049 Mathematical and Physical Sciences Name of Federal Agency, Pass Through Entity, Award Number and Year: National Science Foundation: 1821372 (10/1/2018 – 9/30/2024 pass through entity American Physical Society), 1834530 (9/1/2018 – 8/31/2025 pass through entity American Physical Society), 1938815 (8/1/2020 – 7/31/2024) Federal Program: Research and Development Cluster (Science) Assistance Listing Number and Title: 43.001 Science Name of Federal Agency, Pass Through Entity: National Aeronautics and Space Administration: NNX16AR36A (8/24/2016 – 8/23/2021 pass through entity Temple University of the Commonwealth System of Higher Education), 80NSSC21K1560 (6/28/2021 – 6/27/2022 pass through entity Temple University of the Commonwealth System of Higher Education), 80NSSC22K1071 (5/23/2022 – 5/22/2023) Condition: AAPT did not consistently adhere to written policies with respect to the procurement process, as bids/quotes were not obtainable or the conclusion for selection was not documented. Views of Responsible Officials and Planned Corrective Actions: Management will update current policies and procedures and review and enforce the polices. Management will be responsible for proper documentation and confirmation that all policies and procedures are followed. Management will confirm that all agreements, mou’s and contracts are property, reviewed signed and documented. Management will require all departments to document all procurements for goods and services with written cost and price analysis based on AAPT's dollar thresholds. Anticipated Completion Date: November 2024 Responsible Official: Dr. Beth Cunningham CEO, Michael Brosnan CFO

Corrective Action: Management of the Institute did not provide any planned corrective actions for this finding. Person Responsible: Management of the Institute did not identify an individual responsible for corrective action for this finding. Completion Date: Management of the Institute has not established a completion date for corrective action for this finding.

November 17, 2022 To: U.S. Department of Agriculture, Passed-through Commonwealth of Massachusetts, Department of Elementary and Secondary Education (DESE). From: Mystic Valley Regional Charter School (MVRCS) respectfully submits the following corrective action plan for the year ended June 30, 2022. Name and address of independent public accounting firm: AAFCPAs, Inc. 50 Washington St, Westborough MA 01581 Audit period: June 30, 2022 The findings from the June 30, 2022 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS-FEDERAL AWARD PROGRAMS AUDITS SIGNIFICANT DEFICIENCY U.S. Department of Agriculture (Passed-through Commonwealth of Massachusetts, Department of Elementary and Secondary Education): 2022-001 Child Nutrition Cluster: CFDA No. 10.55 Written Procurement Policy Recommendation: MVRCS should revise their written procurement policy to comply with current standards under the Uniform Guidance. Actions taken: MVRCS is updating it's procurement policy and will submit to it's Board at the next meeting for review and approval. If there are any questions regarding this plan, please call Rick Veilleux at 781-974-5671. Sincerely yours, Richveller Rick Veilleux, Assistant Superintendent-Finance & Operations]

Finding 2022-005: Procurement Federal Programs: Research and Development Cluster: All Grants Condition: AAPT did not consistently adhere to written policies with respect to the procurement process, as bids/quots were not obtainable or the conclusion for the selection was not documented. Views of Responsible Officials and Planned Corrective Actions: Management will update current policies and procedures and review and enforce the polices. Management will be responsible for proper documentation and confirmation that all policies and procedures are followed. Management will confirm that all agreements, mou’s and contracts are property, reviewed signed and documented. Management will require all departments to document all procurements for goods and services with written cost and price analysis based on AAPT's dollar thresholds. Anticipated Completion Date: 04/15/2024

Action Item Title 2022-003 – Procurement Policies and Covered Transactions Compliance Requirement Procurement, Suspension, and Debarment Status (Open: In-process) Condition: General Procurement Standards - Written Policies – The Corporation has an outdated institutional procurement manual approved in 2014 that lacks written policies to ascertain compliance with the provisions of federal statutes, regulations, or the terms and conditions of federal awards regarding procurement, suspension, and debarment requirements. Suspension and Debarment - Covered Transaction – From a population of nineteen disbursements, we selected nine disbursements to ascertain compliance with 2 CFR section 180.220 by examining the procurement documents provided by the Corporation. From that sample, we identified nine instances in which the SAM.gov registration verification process was not performed. Of the nine instances, we found eight suppliers properly registered, but one supplier appears as validated as unique and existing but not registered in SAM.gov. Identified root cause: Lack of understanding of procurement compliance requirements for federal awards. Fiscal year 2023 was the first year for the Corporation to be subjected to a single audit compliance requirement for receiving and expending COVID-19 public health emergency programs Grantee resolution plan: General Procurement Standards - Written Policies – With the implementation of Law No. 73 of 2019, previous processes established by regulation are repealed and rendered ineffective. In addition, the Corporation will adopt procurement policies in compliance with the federal regulations. Suspension and Debarment - Covered Transaction - Currently, the Corporation is verifying and requesting all suppliers with contracts of $25,000 and over with evidence of being active at SAM.gov. Also, the Corporation is verifying if the supplier is suspended or debarred to do business with the Federal government. Completion Date: General Procurement Standards - Written Policies – By June 30, 2025 Suspension and Debarment - Covered Transaction – Corrected in FY2023. Name and Title of contact: Linnette Dávila Alemán- Financial and Budget Assistant Manager Phone: 787-724-4747 ext. 2105 Email: ldavila@cba.pr.gov Jetppeht Pérez de Corcho Morgado – General Manager Phone: 787-724-4747 ext. 2102 Email: jperez@cba.pr.gov

Management Response #2022-010: Due to the staff shortages and turnover in FY2020-2022 the company did not have adequate personnel in place to monitor or document grant activity. Formal documentation of policies and procedures were also deficient. Additionally, documents were not stored centrally, which made it extremely difficult to find supporting documentation. Corrective Action Plan: In mid-2023, the company established policies and procedures that formally document the current compliance practices that are in place for dissemination and training throughout the organization. Detailed in the procedures was a hard stop by the manager of procurement that would require three bids prior to a purchase order being created. Once a vendor is selected, the manager of the procurement will send the vendor information to the compliance department to check for debarments and federal eligibility requirements. Added to the procedures is the creation of a central repository platform to keep all bids and price analysis performed for each vendor. To further enhance compliance, all Accounts Payable invoices that are designated for grant funding are routed for approval to the respective grants program manager prior to payment being made via the WorkPlace software. Responsible Party: Tamara Barnes, CFO

The administration will review the procurement policy in the next management meeting. Division Directors will review the procurement policy with all Program Directors and Managers. Also, see actions for 2022-017

Corrective Action Planned: The City Clerk and Mayor, with help from the Treasurer, will develop and implement documented procurement procedures that conform to the procurement standards relating to Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) 200.317 through 200.327 Name(s) of Contact Person(s) Responsible for Corrective Action: City Clerk, Kami Hoerning. City Treasurer, Karen Kipp. City Mayor, John McGinley. Anticipated Completion Date: Summer 2024