Corrective Action Plans

FINDING 2023-005 Finding Subject: Child Nutrition Cluster - Procurement and Suspension and Debarment Summary of Finding: Management had not developed a system of internal controls that would have ensured compliance with the grant agreement and the Procurement and Suspension and Debarment compliance requirement. The failure to establish an effective internal controls system enabled material noncompliance to go undetected. Noncompliance with the grant agreement and the Procurement and Suspension and Debarment compliance requirement could result in the loss of future federal funds to the School Corporation. We recommended that the School Corporation's management establish a system of internal controls to ensure compliance with the Procurement and Suspension and Debarment compliance requirement. Contact Person Responsible for Corrective Action: Andrea Miller Contact Phone Number and Email Address: 765-564-2100, millera@delphi.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The Food Service Director will obtain 3 quotes for any purchase over $10,000 from different vendors, in addition if the purchase is over $50,000 a contract will be awarded. Vendors will be verified by SAM.gov for suspension and disbarment, a record of these searches will be printed and kept in the vendor file. In addition, a vendor list will be provided annually to the school board for approval. Anticipated Completion Date: July 2024

This document serves as the response to the 2022-2023 Financial Audit on behalf of BELIEVE Schools, Inc. We’ve identified and reviewed the finding outlined below: The results of our auditing procedures disclosed one instance of noncompliance which is required to be reported in accordance with Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (“Uniform Guidance”) and which is described in the accompanying schedule of findings and questioned costs as Finding No. 2023- 001. Our opinion on the major federal programs is not modified with respect to these matters. In an effort to address the finding and to ensure the school's alignment with federal compliance standards, the following corrective action plan has been implemented for all purchases made with federal and state program funds: 1. For any procurement or contract ranging from $10,000-$250,000, The Principal, Angel Jackson-Anderson, should seek to acquire as many quotes as possible, aiming for up to five. Prior to finalizing any purchase order, invoice, or commencement of production, the school is mandated to receive and assess three price comparisons from different businesses or organizations. These price comparisons must be logged in the BCCHS Quote Comparison Template and reviewed by the following parties: a. The individual conducting the price comparison b. Building Level Operations Leader c. Executive Director for purchases or contracts exceeding $20,000 2. For any purchase or contract exceeding $250,000, a formal bidding process is required. BELIEVE Schools has adopted resources provided by the Indiana Department of Education: a. Procurement Checklist b. Procurement Plan Template (accessible through DOE) This protocol has been incorporated into the Standard Operating Procedures and School Handbooks, with all relevant stakeholders duly informed on February 16th, 2024.

FINDING 2023-003 Finding Subject: Subject: Child Nutrition Cluster - Procurement Summary of Finding: An adequate number of quotes were not obtained for small purchases. Contact Person Responsible for Corrective Action: Kellie Romer (Corporation Treasurer/Finance Director), Shelley Gardner (Corporation School Food Authority) Contact Phone Number and Email Address: 765-653-9771 Ext. 1010, kromer@greencastle.k12.in.us, 765-653-9771 Ext. 1011, sgardner@greencastle.k12.in.us Views of Responsible Officials: We concur with the finding Description of Corrective Action Plan: The procurement (small and micro purchases) will be verified by a two-person internal control; the food services director and food services assistant, finance director or deputy treasurer. We will also establish a process to address small and micro purchases. This would include acquiring bids for any combined expenditure(s) over a $150,000, acquiring quotes for any small purchase(s) between $10,000 and $150,000, and documenting equitable distribution among vendors concerning any micro purchases under $10,000. All vendor contracts will be approved yearly. All quotes and purchases will be verified by two-person internal control. Anticipated Completion Date: Immediately 2/8/2024

Recommendation: We recommend that the Organization establish and maintain effective internal controls over procurement requirements. Action Taken: All purchases at One City Schools already require a second approver before invoices are paid. At the November 2023 Board meeting, One City Schools adopted new procurement policies that meet the federal requirements including effective internal controls.

Correctice action plan: The procurement policy will be evaluated and followed with reference to the appropriate Federal, State, and local laws, regulations, and standards. All staff charged with initiating and approving purchases under federal grant programs will use the documented policy. Individual(s) responsible: Allison Hayes, Debbie Pinnock, Yolana Adams Completion Date: Plan to be implemented as soon as possible.

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.

Department of Housing and Urban Development and Department of Veterans Affairs Federal Program Name: Emergency Solutions Grant Program and VA Homeless Providers Grant and Per Diem Program Assistance Listing Number: 14.231 and 64.024 Recommendation: We recommend that the Organization adopt a formal and written procurement policy. Additionally, management should develop controls to help ensure procurement procedures are followed and to monitor the amount spent with vendors throughout the year to ensure procurement procedures are initiated when the vendor costs exceed the procurement thresholds. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management has developed and implemented a formal written procurement policy aligned with applicable federal requirements and organizational purchasing practices. The policy includes required procurement methods, thresholds, documentation standards, conflict-of-interest provisions, and approval authority levels. In addition, the Organization has implemented internal monitoring controls to track cumulative vendor spending throughout the fiscal year and to ensure that procurement procedures are properly initiated when vendor costs approach or exceed established procurement thresholds. Staff responsible for purchasing and vendor management have been trained on the updated requirements and documentation expectations. Name(s) of the contact person(s) responsible for corrective action: Ryan Ross, Executive Director Planned completion date for corrective action plan: March 31, 2026

CORRECTIVE ACTION PLAN (Concerning Finding 2022-004) Contact Person Responsible for Corrective Action: Carrie Castonguay, Town Manager Corrective Action: The Treasurer, Town Manager and Select Board will take the following actions to address finding 2022-004 The current Town Manager was appointed by the Select Board on August 14, 2023, and had no knowledge of this material weakness. She is an experienced Manager and has drafted a new Procurement Policy that addresses this deficiency. This policy was approved and implemented by the Select Board at their January 23, 2024 meeting. Anticipated Completion Date: Completed January 23, 2024.

FEDERAL AWARDS – CORRECTIVE ACTION PLAN REFERENCE # 2022-001 PROCUREMENT SUSPENSION AND DEBARMENT – MATERIAL WEAKNESS- NON-COMPLIANCE Program Name/ALN Emergency Solutions Grant Program (ALN # 14.231) Criteria: As per § 200.318 General procurement standards. (a) The Non-Federal entity must have and use documented procurement procedures, consistent with State, local, and tribal laws and regulations and the standards of this section, for the acquisition of property or services required under a Federal award or subaward. The non-Federal entity's documented procurement procedures must conform to the procurement standards identified in §§ 200.317 through 200.327. (d) The Non-Federal entity must maintain records sufficient to detail the history of procurement. These records will include, but are not necessarily limited to, the following: Rationale for the method of procurement, selection of contract type, contractor selection or rejection, and the basis for the contract price. Condition/Context: Condition: Based on our review of the Procurement compliance requirements, we noted that the Division has written procurement policies and competitive policies as required by CFR § 200.318 General procurement standards. We selected five (5) vendors for procurement Suspension and Debarment compliance testing of total population of 5 vendors subject to procurement and we were not provided with Procurement comparative bids therefore, we were unable: • To verify that the procurement method used was appropriate based on the dollar amount and conditions specified in 2 CFR section 200.320. • To Verify that procurements provide full and open competition (2 CFR section 200.319 and 48 CFR section 52.244-5). Questioned Costs: Cannot be determined Recommendation: We recommend that the Division must: (1) Use documented procurement procedures, consistent with State, and local, laws and regulations and the standards, for the acquisition of property or services required under a federal award or subaward. (2) The Division must maintain records sufficient to detail the history of procurement. These records should include, but are not necessarily limited to, the following: Rationale for the method of procurement, selection of contract type, contractor selection or rejection, and the basis for the contract price. Corrective Action Plan: The Division will work with Territorial Headquarters to document procedures as outlined in the Recommendations above. Step 1 Action Date: Ongoing Final Implementation Date: 12/31/2023 Name and Phone # Of Person Responsible for Implementation: Jeanne Stromberg, Major, Divisional Finance Secretary (916) 563-3710

CORRECTIVE ACTION PLAN (Concerning Finding 2022-001) Contact Person Responsible for Corrective Action: Dana L. Gendreau, Interim County Administrator Corrective Action: The County of Aroostook has initiated corrective action to address Finding 2022-001. Subsequent to the audit period and notice of the finding January 15, 2026, the County developed a comprehensive Federal Grant Procurement Policy that fully complies with the procurement standards of 2 CFR 200.317–327, including clearly defined micro-purchase and small-purchase thresholds and required procurement methods. The revised policy also establishes mandatory procedures for verifying and documenting contractor eligibility through Debarment and Suspension reviews using SAM.gov prior to contract award and requires inclusion of applicable federal contract provisions. The policy will be presented for formal adoption at the next available County Commissioner meeting scheduled for February 18, 2026. Upon adoption, these measures will strengthen internal controls over procurement compliance and reduce the risk of future noncompliance with federal procurement requirements. Anticipated Completion Date: February 18, 2026

The County will make sure that all federal documentation is maintained by each district for inspection and will ensure it is accurately reported on the SEFA.

Recommendation: We recommend the college implement policies and procedures to ensure all procurement documentation is complete and retained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Procurement policies are in place and trainings have been provided for Purchasing and Accounts Payable staff to ensure that all Procurement documentation is included in payment packets. Name of the contact person responsible for corrective action: Clarissa Salhus, Finance Manager, Duane VanderGriend, CFO Planned completion date for corrective action plan: Completed as of January 14, 2026

Chairman of the Board of County Commissioners: These procurement issues originated during the prior County Clerk’s administration, but the current leadership is focused on corrective measures. Together, we are: • developing a SOP to ensure vendor checks for suspension and debarment are conducted on all purchases over $25,000, • establishing written standards of conduct to address conflicts of interest and set clear procurement guidelines, • and enhancing oversight and review to ensure all procurement processes are fully compliant with federal regulations. Our goal is to build a consistent, transparent procurement framework that safeguards both compliance and public trust. County Clerk: I was not the County Clerk in office at this time. To correct this issue, the County plans to develop a SOP to timely and accurately track and report on the SEFA. The SOP will be reviewed, adopted, and monitored by the Board of County Commissioners.

Corrective Action Plan for Finding 2022-003 We are in receipt of the Findings Required to be Reported by Uniform Guidance, regarding procurement, suspension and debarment. Management agrees with the finding. An official procurement policy is drafted and will be adopted by the District in January 2026. A monthly meeting to include representatives of administration and finance will be held to ensure procedures detailed in the procurement policy are being followed going forward. The hospital CFO, Lewis Robbins, will oversee this to ensure that this is accomplished. The Corrective Action Plan will be implemented by September 30, 2026.

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.