Corrective Action Plans

Finding 2023-003: Establish and maintain effective internal control over the Federal award Plan: We have ensured all policies and procedures have been vetted by an attorney and approved by the River View Board of Trustees and the Claremont Learning Partnership Board of Directors. Moving forward, the Executive Director will ensure that all policies and procedures stay current and are reviewed by the Board annually. FY-22 & FY-23 Audits were completed in tandem, all corrections were made as soon as the issue was identified. Expected Implementation Date: RiverView amended the policy on June 17, 2025, CLP amended the policy on July 3, 2025. Contact: Cathy Pellerin Executive Director, Claremont Learning Partnership 169 Main Street; Claremont, NH 03743 603-287-7120

Finding Number 2023-109 Subject Heading (Financial) or AL no. and program name (Federal) ALN: Multiple Federal Program name: Multiple Planned Corrective Action The finding states two ongoing concerns: “1) there are no policies and procedures in place for the people on [the pilot program] Statewide Contracts [as is required by 2 CFR § 200.317], and 2) these vendors are not being vetted to ensure state agencies are getting contracts that are reasonable per 2 CFR 200.404.” On the first issue, Section 200.317 of Title 2 of the Code of Federal Regulations requires states to “follow the same policies and procedures it uses for procurements with non– Federal funds” when “conducting procurement transactions under a Federal award.” 2 CFR § 200.317. Our publicly available CPO training explains the process for purchasing off Statewide Contracts (See Attachment 1 and 2). Also, we provided agencies with procedures related to the pilot program to give guidance on ordering off those specific Statewide Contracts (See Attachment 3). Additionally, OMES reiterates that Recipients of federal funds are ultimately charged with ensuring and documenting compliance with specific requirements under the federal award. However, in an attempt to assist agencies in understanding requirements of spending federal dollars, OMES issued a Procurement Information Memorandum and a new contract attachment to be utilized by agencies. (See Attachments 4 and 5). Therefore, OMES disagrees that we do not have the required policies and procedures in place to comply with Section 200.317. On the second issue, Section 200.404 of Title 2 of the Code of Federal Regulations explains, “A cost is reasonable if it does not exceed an amount that a prudent person would incur under the circumstances prevailing when the decision was made to incur the cost.” All our Statewide Contracts are evaluated on specific criteria, including pricing. If a bidder’s pricing appears to be unreasonable, they do not receive an award. Additionally, in Attachment 3 it is demonstrated that when an agency ordered from the pilot program Statewide Contracts, the Information Services Division (“ISD”) of OMES works with the agency and the supplier to develop a Scope of Work (“SOW”). The SOW is comprised of detailed deliverables and pricing for the relevant goods and/or services. ISD stakeholders are subject matter experts in the relevant work and ensure that all pricing on SOWs is fair, competitive and reasonable. Therefore, OMES also disagrees with the assertion that the vendors on contract are not vetted to ensure that state agencies are getting reasonable costs on their contract. OMES further reiterates that we believe the relevant solicitations were conducted pursuant to the requirements of the Statewide Contract pilot programs and meet competitive bidding requirements. The Statewide Contract pilot programs utilized the same initial procedures as all other Statewide Contracts prescribed in statute. Vendors are required to agree to standard state terms and submit competitive pricing for the goods and/or services within scope of the solicitation. OMES identifies evaluators for every solicitation to conduct an evaluation process relevant to the particular scope of services and to negotiate price when choosing responsive and responsible suppliers. In conclusion, OMES respectfully disagrees with the concerns of the State Auditor’s Office and invites any member of the State Auditor’s team to meet with OMES personnel to further clarify our processes and standards for ensuring fair and competitive procurement practices. Anticipated Completion Date Sine Die Responsible Contact Person

2023-003 Documented Procurement Policy Contact Person - Erin Metcalf, Finance Director Description of Corrective Action - The organization has implemented a new procurement policy that is compliant with state and federal regulations. Completion Date - June 30, 2025 Root Cause - Historically, the organization had very minimal procurement activity; that combined with rapid growth of the organization resulted in outdated policies.

Finding 2023-007: Significant Deficiency, Procurement and Noncompliance Finding – Procurement – Internal Control over Procurement Finding: SPED/Grant Administration did not adhere to the Danbury Public Schools “Bids and Purchases-Competitive” procurement policies, that were compliant with Federal Part 3 compliance guidelines. The DPS had a procurement policy in place that was consistent with the standards of the aforementioned compliance sections; however, the City did not follow their own procurement policy requiring two quotes for a micro-purchase expenditure, three quotes for a small purchase expenditure and advertising for bids publicly for the large >$5,000 purchase expenditures. They only obtained one quote for each expenditure for micro and small purchases, and they did not use a public bid process for expenditures over $5,000. Corrective Action Taken or Planned: Danbury Public Schools (DPS) will begin reviewing the procurement policies that are in place in order to ensure they are in accordance with all compliance requirements set forth by any grants that DPS participates in. A memorandum will be issued summarizing procurement policy features. Lastly, training will be conducted with both the department and the finance team to review the policies and ensure understanding.

Program 66.958 Water Infrastructure Finance and Innovation Award No: WIFIA-N18147WI Award Year: 2023 Finding 2023-001: Procurement policy and related contract Repeat finding of 2022-001Waukesha Water utility management has worked closely with WIFIA to craft contracts that include all necessary language prior to releasing RFPs for construction contracts. WIFIA was presented all service contracts to review prior to reimbursements received in fiscal year 2023. The finance department is working to update the procurement policy to ensure necessary federal language is included. The finance department will also work with service contractors to execute contract addendums

FINDING 2023-006 Finding Subject: Child Nutrition Cluster – Procurement, Suspension and Debarment Summary of Finding: A School Nutrition Cooperative (Co-ops, Education Service Center, Group Purchasing Organization, etc.) that would like to be classified as a School Food Authority (SFA) Cooperative must complete a questionnaire and submit it to the Indiana Department of Education (IDOE). Once a questionnaire is received IDOE will review the answers to determine a Cooperative’s classification. Only Cooperatives that submit the questionnaire and receive a SFA-only Cooperative classification from IDOE in writing will be considered a SFA only Cooperative for the purposes of the procurement process and procurement reviews. INDIANA STATE BOARD OF ACCOUNTS 41 􀀃 “Meeting􀀃students􀀃where􀀃they􀀃are􀀃and􀀃leading􀀃them􀀃forward…every􀀃student,􀀃every􀀃day”􀀃 When the value of goods or services exceeds the simplified acquisition threshold, the proper purchasing method would be the bidding process, unless the purchase meets certain other qualifications. Federal regulations allow for informal procurement methods when the value of the procurement for goods or services does not exceed the simplified acquisition threshold, which is customarily set at $250,000. However, Indiana Code 5-22-8 has a more restrictive threshold of $150,000 or less for when small purchase procedures may be used. 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 $10,000 or under, and small purchase procedures for those purchases above the micro-purchase threshold, but below the simplified acquisition threshold. Micro-purchases may be awarded without soliciting competitive price rate quotations. If small purchase procedures are used, then price or rate quotations must be obtained from an adequate number of qualified sources. If it is determined a single source provider can be used for a small purchase, documentation must be retained supporting the determination. The School Corporation could not provide supporting documentation that an adequate number of price or rate quotations was obtained to ensure full and open competition for two vendors procured under the small purchase threshold. Contact Person Responsible for Corrective Action: Drew Cooper, Business Manager Contact Phone Number and Email Address: 765-425-7889 dcooper@shenandoah.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The procurement method used to purchase equipment costing over $10,000 will be documented and archived with the purchase order. Anticipated Completion Date: July 31, 2024

COVID-19 Coronavirus State and Local Fiscal Recovery Funds —Assistance Listing No. 21.027 Recommendation: We recommend the District design controls to ensure an adequate review process is in place to review potential contractors to determine compliance with the Uniform Guidance procurement rules and procedures. Procedures for approval of the vendor contracts, and verification documents to ensure the vendor was not on the suspended or debarred vendor list maintained by the General Services Administration, should be reviewed and retained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The District’s policies will be updated and approved if needed to confirm to federal guidance. Name(s) of the contact person(s) responsible for corrective action: Ron McEachern, General Manager, or Delia Stoor, Accounting Manager Planned completion date for corrective action plan: September 30, 2024

Finding: 2023-004 Significant Deficiency in Internal Control over Compliance U.S. Department of Treasury Federal Financial Assistance Listing 21.027 Coronavirus State and Local Fiscal Recovery Funds Procurement, Suspension & Debarment Finding Summary: We selected 4 procurements during our review of overall grant activity for the year ended June 30, 2023. We noted the following in our testing: 1 of the 4 procurements tested was not purchased prior to publishing bids within the local newspaper as required by the County’s Procurement Policy. Responsible Individuals: Dana Aschenbrenner, Finance Director Corrective Action Plan: The County will be more diligent in following their procurement policy. The Finance Department and Grants Team will provide training and guidance to ensure all the other County Departments/Offices are aware of the requirements. Additionally, the upcoming move to a new financial system will lend itself to policy updates and business process updates to ensure this will be less likely to happen. Anticipated Completion Date: Ongoing

Program: Continuum of Care, Emergency Solutions Grant Program Federal Financial Assistance Listing No.:14.267, 14.231 Federal Agency: U.S. Department of Housing and Urban Development Pass-through: Sacramento Steps Forward, Sacramento County Department of Human Assistance Award Year: 2023 Compliance Requirement: Procurement, Suspension and Debarment Grant Award Number: CA0955L9T032108, CA0955L9T032209, CA0143L9T032114, CA0143L9T032215, CA1303L9T032107, CA1303L9T032208, DHA-NM-03-23, DHA-NM-03-24 Finding Summary: The Organization’s procurement policy did not include all the required elements as outlined in the Uniform Guidance. Additionally, the Organization did not retain documentation to support the procedures performed to ensure compliance with suspension and debarment requirements. Repeat Finding from Prior Years: Yes, Finding 2022-003 Management’s Response: We concur. Views of Responsible Officials and Corrective Action: • Management will update 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: Bryan Wagner, CFO Projected Implementation Date: December 31, 2024

Corrective Action Plan Finding 2023-002 Criteria: Recipients of federal awards must follow the procurement standards set out at 2 CFR section 200.317 through 200.326. They must use their own documented procurement procedures, which reflect applicable State laws and regulations, provided that the procedures conform to applicable Federal law and the procurement requirements identified in 2 CFR part 200. Recipients “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” 2 CFR section 200.318(i). Auditor Recommendation: We recommend the Academy ensure it 1) maintains documentation of the history of procurement and 2) monitors compliance with documentation requirements. Auditee Response/ Corrective Action Plan: The Academy will review its procurement policies and internal controls and ensure timely action is taken when noncompliance is identified. Person Responsible: Tim Stay, CEO Timeline: All future contract solicitations will follow the required procurement standards.

Finding 2022-07 Failure to Create and Implement a Suitable Procurement Policy Condition: The Organization created and implemented a procurement policy to govern its federal expenditures. The procurement policy implemented by the Organization failed to include several key elements, including clearly establishing and governing the various expenditure purchasing thresholds, documenting a sufficient bid process for competitive bid proposals, and standards of conduct covering conflict of interest for employees involved in the bid evaluation process. Further, while the policy was in place, the Organization failed to implement the elements of the policy into its procurement process. As part of audit procedures, 12 transactions were included in the testing population and all 12 were tested. Of the testing group, the auditor identified 4 transactions that required competitive bid procedures for which the Organization failed to conduct. The Organization also failed to document its rationale to limit competition for all items tested. Corrective Actions Taken or Planned: - VOICES will revise and implement a formal Procurement Policy that fully aligns with Uniform Guidance and federal regulations. The updated policy will include: + Clear Purchasing Thresholds: Establish thresholds for micro-purchases, small purchases, and formal procurements (e.g., competitive bidding for purchases exceeding $10,000 or other appropriate limits) - Implement a structured bid process that requires: + Multiple bids for purchases exceeding established thresholds. + Documentation of vendor selection rationale, including why competition was limited, if applicable. - Conduct mandatory training for all staff involved in procurement. - Require all vendors and contractors to be checked against the System for Award Management (SAM.gov) to confirm eligibility and compliance with federal procurement requirements.

All management will be educated on the procurement policy as well as the information noted from the CFR sections indicated in the findings by the Director of Finance. The Director of Finance will research and provide education to the Executive Leadership related to this finding during the Executive Leadership meeting. All Grants and cooperative agreements must be filed with the fiscal department. All expenditure must be approved prior to purchase / payment with sign off from Executive Director or Director of Finance.

U.S Department of Treasury COVID 19 – Coronavirus State and Local Fisal Recovery Funds – 21.027 Management’s Response: The amount of the expense with this vendor was below $5,000 for three separate invoices and events. The Unified Government’s purchasing policy does not require competitive quotes for purchases under $5,000. However, we understand that we should be viewing these expenses in the aggregate not as individual transactions. We will work with the department to ensure these are competitively procured going forward. Views of Responsible Officials and Corrective Action: Departments have been informed of the procurement requirements and the procurement policy will be adhered to on a go forward basis. Management will ensure this is addressed by December 31, 2025. Responsible Official: Dr. Shelley Kneuvean Chief Financial Officer Unified Government of Wyandotte County & Kansas City KS

The Program will develop an internal procurement policy with reference to the appropriate Federal, State, and local laws, regulations, and standards. The documented policy will be used when initiating and approving purchases under Federal grant programs. Individual(s) Responsible Sherry Bradley Completion Date The plan was implemented.

Management Response #2023-007: Due to staff shortages and turnover, the company lacked adequate personnel to effectively monitor or document grant activity. Additionally, formal documentation of policies and procedures was insufficient, and supporting documents were not stored in a centralized location, creating challenges in retrieving necessary information. Corrective Action Plan: In response to these issues, the company implemented the following corrective measures starting in mid-2023: • The Corporation established comprehensive, formal policies and procedures that document the current compliance practices. These procedures have been disseminated across the organization and incorporated into training programs to ensure all employees are aligned with the updated standards. • A procedure enhancement has been implemented in the procurement process, which requires the procurement manager to obtain three bids prior to the creation of certain purchase orders. This ensures competitive bidding and transparency in vendor selection. • Once a vendor is selected, the procurement manager will forward the vendor’s details to the compliance department. The compliance team will then verify the vendor's debarment status and federal eligibility to ensure compliance with all regulatory requirements. • A central repository platform has been created to store all vendor bids, price analyses, and related procurement documentation. This ensures that all relevant information is easily accessible and properly organized. • All accounts payable invoices designated for grant funding are now routed for prior approval to the respective grant program manager via the WorkPlace software before any payments are processed. This ensures proper oversight and alignment with grant requirements. These corrective actions aim to strengthen compliance, improve document management, and streamline oversight processes to prevent future issues related to grant monitoring and procurement. Responsible Party: Tamara Barnes, CFO

Assistance listing number and program name: 14.267 Continuum of Care Program Agency: Arizona Department of Housing (DOH) Name of contact person and title: Lori Moreno, DOH Human Resources and Procurement Administrator Anticipated completion date: March 31, 2025 Agency’s Response: Concur The Department will update written policies and procedures related to procurement to incorporate applicable aspects of Federal Regulations 2 CFR §§200.321, 200.322, 200.323, and 200.327. The updated policy will address competition through competitive bids, sole source selections, and retention of procurement documents. In addition, the policy will state the Federal requirements that are to be included in purchase orders and contracts.

Auditor’s Recommendation: The Organization should develop and document procurement procedures that meet state, local, and Uniform Guidance requirements. Internal controls should be designed, implemented, and documented within the procurement procedures to ensure compliance with 2 CFR sections 200.317 through 200.327. At a minimum, the procurement history including rationale for the method, procurement method support, contract selections and rejections, suspension and debarment, and bases for contract prices should be documented. Corrective Action: Implement Policy A10 – “Grant Management Protocols.” Utilize Donor Database for managing subawards. Responsible for Corrective Action: Finance Team (Outsourced accounting firm, Operations Manager, Executive Director) Anticipated Completion Date: December 31 2024

Finding 2023-005: Internal Control Deficiency and Noncompliance Over Procurement Federal Grantor: United States Department of Health and Human Services Assistance Listing No.: 93.048 Summary of Finding: AdviseWell, Inc. did not have internal controls in place throughout the audit period to sufficiently document the history of procurement, including the rationale for the method of procurement, selection of contract type, contractor selection or rejection, and the basis for the contract price or sole source justification if warranted. Additionally, management did not have evidence of internal controls being in place throughout the audit period to document that vendors were not suspended or debarred prior to entering into a procurement transaction. AdviseWell, Inc. did not have or use documented procurements procedures throughout the audit period. Corrective Action Plan: Internal controls were implemented in October 2023 following the 2022-04 finding, to ensure that sufficient documentation of history of procurement, including the rationale for the method of procurement, selection of contract type, contractor selection or rejection of, and the basis for contract price; ensure vendors are not suspended or debarred prior to entering into the procurement process; and document these procurement procedures with an annual review of these with staff. Responsible Party: Sonja Landry, Executive Director Anticipated Completion Date: Completed October 2023

FINDING 2023-004 Finding Subject: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds – Procurement and Suspension and Debarment Summary of Finding: Suspension and Debarment – Allen County did not have documentation that vendors’ suspension and debarment status were verified through either a) checking the Excluded Parties List System (EPLS), b) collecting a certification, or c) adding a clause or condition to the covered transaction agreement. Procurement – Allen County did not ensure purchases between $10,000 and $150,000 had received the adequate number of quotes or documented why an adequate number of quotes was not received. Contact Person Responsible for Corrective Action: Chris Cloud, Chief of Staff Contact Phone Number and Email Address: 260-449-4752 / chris.cloud@allencounty.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: To correct Finding 2023-004 for Suspension and Debarment, the Chief of Staff to the Board of Commissioners will check the EPLS on SAM.gov every time a contract is placed before the Board of Commissioners for signature not containing the appropriate suspension and debarment language or a county department starts a project with a vendor using State and Local Fiscal Recovery Funds (SLFRF). If a vendor is not found in EPLS, a certification will be solicited from the vendor prior to contract signing or purchase of goods or services verifying that they have not been suspended or disbarred. A new verification must be sought for every contract or purchase. Documentation will be kept on file by the Controller to the Board of Commissioners who is responsible for reviewing claims submitted for payment utilizing SLFRF. To correct Finding 2023-004 for Procurement, the Chief of Staff to the Board of Commissioners will instruct departments who may be spending between $10,000-$150,000 of SLFRF that price or rate quotations must be obtained from an adequate number of qualified sources. When departments submit a claim to the Controller of the Board of Commissioners for payment, they must also provide a cover sheet outlining a) rationale for the method of procurement, b) copies of quotes received, and c) a justification for the selected vendor. This information will be reviewed and if everything is in order, the cover sheet will be uploaded, along with the accompanying invoices, in the Workflow payment system as part of the record. Anticipated Completion Date: This CAP will be completed by December 31, 2024

Significant Deficiency and Noncompliance – Procurement Documentation Statement of Condition/Criteria: Delta County is not following its procurement policy and is therefore not meeting the requirements of 2 CFR section 200.318 to use documented procurement procedures. The County does not have controls in place to ensure that written records are maintained sufficient to detail the history of procurement including the rationale for the method of procurement, selection of contract type, contractor selection or rejection, and the basis for the contract price. The County did not maintain documentation to sufficiently support a written price analysis on one procurement tested. The County was unable to provide proposals from nonwinning bidders and/or a price analysis when only one bid was received on two contracts tested. The County does not have formal procedures or controls in place to ensure written documentation of a cost analysis or a contract file are maintained. Planned Corrective Action: County management has started to develop controls to ensure the procurement policy is followed and will continue to develop controls to ensure that complete contract files with a price analysis are maintained. Contact person responsible for corrective action: Ashleigh Young, County Controller/Administrator Anticipated Completion Date: March 2025

CLIENT PLANNED ACTION: When a new federally funded construction project or purchase is in the planning stage that is in the price range of $10,000 to $250,000(a small purchase), the Director of Facilities and/or the Purchasing agent will send out solicitations including specs via letter, email or by phone to multiple vendors. They may also look up vendor pricing on the internet. After the quotes are received, they will forward them to the CFO or Director of Finance who will then evaluate the quotes and decide on a vendor. Before the vendor is notified, the business office staff will check SAM.gov for federal disbarment or suspension. The SAM.gov verification will be saved in the accounting vendor files. Copies of the quotes will also be filed in the accounting office. CLIENT RESPONSIBLE PARTY: Name of Contact Person: David A. Goff, MBA Vice President of Administration and Chief Financial Officer. 4851 Independence Street, Wheat Ridge, CO 80033. 303-432-5164, Davidg@jcmh.org COMPLETION DATE: 9/1/2024

Contact Person LeAnn Littlewolf, Executive Director Corrective Action Plan We are in the process of updating the Organization’s written policies and procedures to include the requirements of the Uniform Guidance. Completion Date Fiscal year end 2024

CORRECTIVE ACTION PLAN (Concerning Finding 2023-007) 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 2023-007 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 drafted, has had approved, and has implemented the new Procurement Policy that addresses this deficiency. Anticipated Completion Date: This was completed January 23, 2024

CORRECTIVE ACTION PLAN (Concerning Finding 2023-004) 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 2023-004 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, had approved and is using the new Procurement Policy that addresses this deficiency. Anticipated Completion Date: This was completed January 23, 2024.

Condition: The Authority did not utilize federal procurement requirements cited above for the tele-health services and SUD Peer Recovery Service contracted service providers utilized for the Certified Community Behavioral Health Clinics project. (no documentation for sole source, no proof that it was advertised, google search was provided from 7/24/24 is not sufficient, board cannot waive federal requirement). Recommendation: The Authority follow federal procurement as required in 2 CFR 200.319(d) for all contracts reimbursed with federal funds. Planned Corrective Action: Going forward the Authority will follow federal procurement as required in 2 CFR 200.319(d) for all contracts reimbursed with federal funds. Contact Person: Anthony Shaver, Chief Financial Officer Anticipated Completion Date: 9/30/2024