Corrective Action Plans

Finding 2024-002 Procurement and Suspension and Debarment (Compliance) – 2020 Findings Major Federal Award Programs Condition The City's procurement standards do not include the essential elements as outlined in 2 CFR sections 200.318 through 200.326. Corrective Action Plan The City issued and updated purchasing policy which includes the CFR requirements in early fiscal year 2024-2025. The city has hired adequate staffing which allows the purchasing department to enforce the suspension and debarment process during the procurement process. The City will have a formal process to require checking for Procurement and Suspension and Debarment prior to any contracts being issued. The policy will include but not limited to: 1. Bidding/RFP requirements: Prior to making a grant-related purchase, the procurement office will check the selected vendor on www.sam.gov prior to approving. The procurement office will document the Suspension and Debarment verification by including a screen print of the Exclusions search. 2. Annual check Annually, procurement will run a list of all vendors and employees paid from federal funds. This list will be reviewed against sam.gov, unless set up one month prior to the review. 3. Notification in bid/RFP specifications The procurement office will also make sure to include language in the specification about complying with CFR rules for federal funding. The implementation of this recommendation is monitored by the Procurement Director and Finance Director Michael Gormany or designee.

FINDING 2024-002 Finding Subject: Child Nutrition - Procurement, Suspension, and Debarment Summary of Finding: There were no controls in place to ensure that the School Corporation complied with the small purchase requirements. The School Corporation obtained quotes for the two vendors that qualified for the small purchase threshold, but no oversight performed. There were no controls in place to ensure that the vendors included a suspension and debarment clause or check the Sam.gov website. Contact Person Responsible for Corrective Action: Micah Williams Contact Phone Number and Email Address: 765-832-2426/mwilliams@svcs.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The finance department will work in conjunction with the Food Services Director to ensure that quotes are obtained from vendors that are listed on Sam.gov or have a suspension and debarment clause before making in purchases. There will be an email thread detailing the request, the quotes, and the process for ensuring suspension and debarment. Anticipated Completion Date: Immediate.

Actions taken in response to finding: Esperanza will: 1. Sole source justification - Implement a Summary Approval and Signoff Sheet (SASS) for new contracts that documents, among other things, the justification for sole source purchases. 2. Create a pre-approved vendors list to streamline procurement while ensuring compliance. a. Require justification and periodic review for vendor inclusion 3. Review, on an annual basis, nonpersonnel costs charged to federal grants to ensure compliance. Name(s) of the contact person(s) responsible for corrective action: Ryan Gadia Planned completion date for corrective action plan: June 30, 2025

Finding: While testing the procurement requirement, we 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: Management became aware of the need to perform additional procedures to comply with Uniform Guidance part way through the year ended June 30, 2024 and completed the evaluation once it became known. However, by that time, the vendor was already charged to the grant prior to the completion of the vendor evaluation. UW Health has developed processes and procedures to ensure compliance with the Uniform Guidance and that evaluations are taking place prior to any vendors being charged to the grant. UW Health is also in the process of updating policy to comply with Uniform Guidance. Anticipated completion Date: June 2025 UW Health employees responsible for Corrective Action Plan: James Hood, Director of Procurement Services and Jamie Soyk, Program Director – Financial Reporting

2024-001 (Procurement and Suspension & Debarment) Management Comments and Corrective Action: Due to the growing need to adequately care for the minors at SWK’s shelters coupled with the limitations of access to vendors caused by COVID-19, SWK utilized existing vendor to minimize significant disruptions to operations. The Organization is aware they are operating under contracts that were procured in previous years that may not have all the records maintained. Reprocuring all of these contracts at once would potentially cause disruptions in operations due to the products/services related to those vendors playing an important role in the Organization’s dayto- day operations. In April 2021, the Organization hired new procurement leadership and invested in Full Time Employees (FTEs) to develop a robust procurement department. Due to this procurement revamp, Procurement adopted a hybrid model, and Desktop Protocols were established to provide universal procedures to fulfill policy. Protocols instruct staff on obtaining three quotes and provide tools for selecting the vendor. In addition, quality protocols and tools are currently in development to verify a random sample of procurement transactions and files. The Organization still has several active contracts procured under the old policies that they are working on reprocuring as these contracts’ renewal dates arise, if not earlier. Proposed Implementation Date of Corrective Action: In process and to be completed by December 31, 2025. Person Responsible for Corrective Action: Steven Beckman, CFO 45

The district will establish a system of internal controls with the Cooperative (NISEC) to ensure formal procurement methods are properly followed.

U.S. Department of the Treasury, Passed through Lancaster County, Nebraska COVID-19 Coronavirus State and Local Fiscal Recovery Funds, AL #21.027 Procurement, Suspension, and Debarment: Noncompliance and Material Weakness in Internal Control over Compliance Finding Summary: The Organization does not have a formalized procurement policy that conforms to applicable standards under Uniform Guidance. Additionally, the Organization did not follow procurement policies when obtaining bids for contracts. Responsible Individuals: Natalya Young, Executive Director Corrective Action Plan: Procedures will be developed to ensure proper procurement transactions in accordance with the Uniform Guidance. Additionally, the Organization will follow procurement policies when obtaining bids for contracts. Anticipated Completion Date: June 2025

The City of Bardstown places a high priority on fiar and equitable purchasing practices. The General Bidding Statue (KRS 424.260) governs purchases made during the normal course of business. The City acknowledges the need to adopt a written purchasing policy to set qualifications and procedures when federal funds are being utilized. A purchasing policy is currently being drafted to adopt procurement standards found in 2 CFR 200.317 through 200.326. This policy will be presented to council and adopted prior to February 28, 2025.

Management's Response: The College will strengthen its policies and procedures over procurement to ensure all procurement threshold requirements are identified and all vendors are properly procured. Anticipated Completion Date: February 28, 2025

FINDING 2024-002 Subject: Child Nutrition Cluster - Internal Controls Federal Agency: Department of Agriculture Federal Program: School Breakfast Program, National School Lunch Program Assistance Listing Number: 10.553, 10.555 Federal Award Numbers and Years (or Other Identifying Numbers): FY 22-23, FY 23-24 FINDING 2024-002 (Continued) Pass-Through Entity: Indiana Department of Education Compliance Requirement: Procurement and Suspension and Debarment Audit Finding: Material Weakness Condition: An effective internal control system was not in place at the School Corporation to ensure compliance with requirements related to the Child Nutrition Cluster and Procurement and Suspension and Debarment compliance requirements. Context: Procurement The School Corporation participates in the Food2School Child Nutrition Cooperative which procures vendors for food purchases and other supplies on behalf of its members. During the audit period, the School Corporation purchased supplies and equipment from vendors not procured by the Cooperative. One vendor with aggregate annual purchases of $118,390 and $68,859 for fiscal year 2023 and fiscal year 2024, respectively, exceeded the small purchase threshold ($50,000 - $150,000) and was not subject to the School Corporation’s procurement policy to solicit multiple quotes and to document the method and rationale for procurement. Suspension and Debarment For three vendors tested which were not procured by the Cooperative and had aggregate annual disbursements exceeding the federal suspension and debarment threshold of $25,000, the School Corporation did not perform suspension and debarment checks to confirm the vendors were not suspended or debarred before entering into the contract or disbursing federal funds. Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Management will implement a procurement checklist that is reviewed after the purchasing process has been completed to ensure compliance with purchasing requirements for federal awards. Sam.gov will be checked for each vendor with aggregate purchases above $25,000. Responsible Party and Timeline for Completion: Shane Hacker, Assistant Superintendent of Operations; Corey Ebert, Director of Finance; Jordan Ryan, Director of Nutrition Services Anticipated Completion Date: February 1, 2025.

Management's Response: Management concurs with the above finding and will ensure that the restricted accountant and purchasing agent receive further training on federal grant purchasing requirements to ensure all purchasing rules are met. Additional approval levels will also be put in place to safeguard required federal purchasing limits. Implementation will be completed by June 2025.

Federal Agency Name: Department of Housing and Urban Development Continuum of Care, Federal Financial Assistance Listing 14.267, Affects all grant awards included under Federal Financial Assistance Listing 14.267 on the Schedule Finding Summary: Catholic Charities has documented procurement procedures that conform to applicable federal standards regarding testing vendors for suspension and debarment; however, the procedures were not followed for four vendors selected for testing. Corrective Action Plan: Procurement, suspension and debarment procedures were largely decentralized across the agency. In response, the organization has an internal, cross-functional compliance team that has reviewed and is developing process changes to ensure appropriate systems are developed and documentation is maintained for purchasing related to federal programs. Responsible Individuals: Chief Legal Officer, Controller Anticipated Completion Date: June 30, 2025

Procurement, Suspension and Debarment Significant Deficiency in Internal Control over Compliance Finding Summary: In our testing of procurement, suspension and debarment it was identified that the District did not go out for quotes on one contract over the mircro purchase threshold. Responsible Individuals: Beth Slette, Superintendent Corrective Action Plan: The District will ensure all contracts comply with their procurement policy and the procurement standards as identified in 2 CFR sections 200.317 through 200.327. Anticipated Completion Date: June 30, 2025

In the future, we intend to advertise for a longer period of time and if needed re-advertise for a second job walk. We will note each company that attends and if they did or did not chose to bid the job. The documentation of each bid and the board approval for the awarded bid will now be maintained at both the Construction, Maintenance, and Operations Department and the District Office to lessen the loss of documentation due to employee turnover.

January 5, 2024 To: Nigro & Nigro PC Regarding Audit Finding 2024-001 Procurement (5000) Assistance Listing #10.533, 10.55- U.S Department of Agriculture, California Department of Education, Child Nutrition Cluster We agree with the auditor's comments and the following actions will be taken to ensure the district is compliant with Code of Federal Regulations, CFR 200.320. 1) Implement a district system to track all formal bids, informal bids and RFQ's by contract year 2) Documents will include key information such as bid solicitation dates, contract dates and renewal dates for all Nutrition Services bids, RFPs, RFQs and micro-purchases. 3) The Director of NUtrition Services will review all contracts at the beginning of each school year. These steps along with training key personnel will make sure we are in compliance with Code of Federal Regulations, CFR 200.320 Michelle Cagle Director, Fiscal Services

MATERIAL WEAKNESS 2024-002 Child Nutrition Cluster – Assistance Listing Number 10.553 and 10.555 Procurement Recommendation: We recommend that the Organization establish and maintain effective internal controls over procurement requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: One City Schools adopted a procurement policy in November 2023 that, if followed, resolves this finding. A new primary food vendor was selected in summer of 2024, and the selection did adhere to the new procurement policy. This policy and all procedures were edited to be comprehensive of all uniform grant requirements through the development and adoption of the Federal Funds Procedural Manual. Name(s) of the contact person(s) responsible for corrective action: Janel Vertz, Finance Director Planned completion date for corrective action plan: January 2025

December 18, 2024 Donovan CPAs 9292 N. Meridian Street, Suite 150 Indianapolis, IN 46260 Subject: Response to Uniform Guidance Audit Finding for FY23-24 Finding 2024-001 Procurement Significant Deficiency Federal Program: Charter Schools Program Assistance Listing Numbers: 84.282A Springville Community Academy (SCA) plans to develop a written procurement policy that incorporates the Federal regulations and procurement standards identified in §200.317 through 200.327. I, Corbin Dietrich, will work with the Board of Directors of SCA and our consultants with Indiana Charters to develop the appropriate procurement policies and procedures. We plan to draft and approve the required policies at the board meeting in January 2025. Sincerely, Corbin Dietrich, Treasurer

2024‐001 Procurement and Suspension and Debarment Person Responsible for Corrective Action: Lark Reynolds, Business Administrator Correction Action Planned: (1) The District management will review procurement policies with staff. (2) Timely action will be taken to solicit bids for contracts that exceeds District thresholds. (3) To ensure full and open competition takes place, management will routinely review spending reports. Anticipate Completion Date: November 30, 2024

FINDING 2024-005 Subject: Special Education Cluster (IDEA) - Procurement and Suspension and Debarment Federal Agency: Department of Education Federal Program: Special Education Grants to States Assistance Listing Number: 84.027 Federal Award Numbers and Years (or Other Identifying Numbers): H027A210084, H027A220084, H027A230084 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Procurement and Suspension and Debarment Audit Finding: Material Weakness Condition: An effective internal control system was not in place at the School District to ensure compliance with requirements related to the Special Education Cluster and Procurement and Suspension and Debarment compliance requirements. Context: During the audit period, the School District purchased Special Education contracted services from one specialist with aggregate payments for each fiscal year which were within the small purchases threshold ($10,000 - $150,000) under Federal and State procurement regulations. The School District did not solicit multiple quotes for services, document the method and rationale for procurement, and did not perform a check to confirm the service provider was not suspended or debarred before entering into the contract and disbursing federal funds. FINDING 2024-005 (Continued) Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Management will implement a procurement checklist that is reviewed management to ensure compliance with the School's purchasing policy for federal awards. Sam.gov will be checked for each vendor being paid from Federal Funds. Responsible Party and Timeline for Completion: Moriah Crane - Treasurer and Andrew Grismore - Grant Coordinator starting immediately.

CORRECTIVE ACTION PLAN OF CURRENT AUDIT FINDINGS June 30, 2024 FINDING 2024-001 Information on the federal program: Subject: Child Nutrition Cluster - Procurement and Suspension and Debarment Federal Agency: Department of Agriculture Federal Program: School Breakfast Program, National School Lunch Program, Summer Food Program, School Summer Food Service Program Assistance Listing Number: 10.553, 10.555, 10.559 Federal Award Numbers and Years (or Other Identifying Numbers): FY 2023, FY 2024 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Procurement and Suspension and Debarment Audit Finding: Material Weakness Condition: An effective internal control system was not in place at the School Corporation to ensure compliance with requirements related to the Child Nutrition Program and Procurement and Suspension and Debarment compliance requirements. Context: Procurement Federal regulations allow for informal procurement methods when the value of the procurement for property or services does not exceed the simplified acquisition threshold, which is set at $250,000 unless a lower, more restrictive threshold is set by a non-Federal entity. As Indiana Code has set a more restrictive threshold of $150,000, informal procurement methods are permitted when the value of the procurement does not exceed $150,000. This informal process allows for methods other than the formal bid process. The informal process is divided between two methods based on thresholds. Micro-purchases, typically for those purchases $50,000 or under, and small purchase procedures for those purchases above the micropurchase threshold, but below the simplified acquisition threshold. The School Corporation's policy states that the small purchase threshold is between $10,000 and $150,000. If small purchase procedures are used, then price or rate quotations must be obtained from an adequate number of qualified sources. For fiscal year 2023, two vendors, totaling $109,657 and $53,441, were selected for testing at the small purchase threshold. The School Corporation did not obtain price or rate quotes nor was there documentation detailing the history of procurement, which must include the reason for the procurement method used. The lack of internal controls and noncompliance was isolated to fiscal year 2023. Suspension and Debarment Prior to entering into subawards and covered transactions with federal award funds, recipients are required to verify that such contractors and subrecipients are not suspended, debarred, or otherwise excluded. "Covered transactions" include but are not limited to contracts for goods and services awarded under a non-procurement transaction (i.e., grant agreement) that are expected to equal or exceed $25,000. The verification is to be done by checking the SAMs exclusions, collecting a certification from that vendor, or adding a clause or condition to the covered transaction with that vendor. During the audit period, there were ten vendors identified which exceeded $25,000 in disbursements on an annual basis. Six vendors were selected for testing. In one instance, the School Corporation's contract with the vendor did not include any suspension and debarment clause and the School Corporation did not verify the vendor's suspension and debarment status prior to payment. The lack of internal controls and noncompliance was isolated to fiscal year 2023. Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Management will ensure that the School Corporation's procurement policy is being followed for all procurement thresholds. Management will perform a periodic check of federal fund disbursements to see if any vendors exceed procurement or suspension and debarment thresholds on an annual basis to ensure compliance with federal and state procurement guidelines. The School Corporation will ensure that all contracts exceeding $25,000 include a suspension and debarment clause and will verify that the vendor is not suspended or debarred prior to entering into the contract. Responsible Party and Timeline for Completion: The Food Service Department has already implemented these changes as the issue was not present in fiscal year 2024.

The Village of Lexington hired, through a bid process, Townley Engineering to design needed water and sewer expansion and upgrades for the purpose of submitting to USDA for Water and waste disposal systems for rural communities grants in 2017. The Village was awarded funding and hos worked closely with USDA representatives as we have moved through the program. A budget for all costs was approved as part of the grant award. All invoices, including all engineering fees, are approved directly by our assigned Area Specialist. The project costs are currently all within budget. The Village of Lexington will ensure that engineering services follow correct procurement procedures in any future grant program it is awarded.

Re: Finding 2024-001: Procurement (50000) Nutrition Services currently uses US Foods for the purchase of various commercial food items throughout the year (candy, chips, soda, bread, hotdogs, popcorn, coffee, hot cocoa, churros, cookies, etc). A vast majority of the purchases are for non-program foods for catering or Snack Bar Sales at Fred Kelly Football Stadium. Occasionally, US Foods is used to purchase specialty items for students with food allergies (i.e. gluten free) and baby food for students that require a pureed diet. Nutrition Services compares prices between US Foods and Smart and Final periodically throughout the year. Smart and Final purchases are made in store and Nutrition Services would have to provide pictures of price tags on the shelf at Smart and Final to show compliance with this request. Nutrition Services requested a price quote for products purchased through US Foods. Unfortunately, the company representative told us their prices are variable based on the market and could change weekly. Nutrition Services would only be able to provide auditors of screenshots ofUS Foods online ordering portal, which would consist of hundreds of pages given the expansive foods available. To correct the finding, Nutrition Services will do the following: 1. Request piggybackable formal bid options from US Foods. To that end, the Nutrition Services and Purchasing directors will seek board approval no later than March 1, 2025. 2. Take necessary steps to increase micropurchase threshold to $50,000. 3. Consider opening a Purchase Order with Sysco Foods to spread the micropurchases to another online retailer, thus mitigating the issue of in-person shopping and price comparisons. 4. Work with Purchasing Department to ensure open Purchase Orders do not exceed $50,000 for any vendor that does not have formal procurement in place. To that end, the Nutrition Services Accounting Technician and the Purchasing Supervisor will review quarterly expenditures for all open purchase orders effective December 1, 2024.

The Purchasing department will develop and maintain written procurement procedures requiring that “small purchases” of equipment or services made under a Federal award or sub-award above the micro purchase threshold require multiple quotes and that these quotes are properly documented as evidence. “Small purchases” are those where the total dollar amount is higher than the micro-purchase threshold but does not exceed the simplified acquisition threshold. Purchasing department staff will be trained on this procedure and the District will adopt a board policy to address this procedure. The contact person is Philippa Townsend and the anticipated completion date is 11-1-2025.

Statement of Concurrence or Nonconcurrence: CUAHSI agrees with the finding and recommendation. CUAHSI Corrective Action: Action by CUAHS! impacting audit year 2023: Vendor status for 2023 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

FINDING 2023-004 Finding Subject: Drinking Water State Revolving Fund (DWSRF) Cluster - Procurement and Suspension and Debarment Contact Person Responsible for Corrective Action: Tyler Pearson, Clerk Treasurer Contact Phone Number and Email Address: 574-739-1416 clerktreasurer@cityoflogansport.org Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: We will develop and implement a formal process for verifying that vendors are not suspended, debarred, or otherwise excluded from receiving federal funds before entering into contracts or transactions that meet or exceed the $25,000 threshold. The City will develop a purchasing policy that reflects the applicable state laws and regulations related to procurement. The City will also maintain proper documentation to support the appropriate procurement method. Anticipated Completion Date: December 31, 2025