Corrective Action Plans

Finding No. 2025-003: Procurement Policies Views of Responsible Officials and Corrective Action The Organization acknowledges incorporation of the procurement standards of the Uniform Guidance to its policies and procedures to ensure compliance with Federal standards, including 2 CFR §200.318(h). The Organization concurs with the prior year (2024-003) and current year renumbered recommendation (2025-003),and highlights its ongoing progressive and corrective implementation of policy and process actions. For context, the Organization’s progressive and corrective actions as of the fiscal year ended (FYE) June 30, 2024 report included the following: A. Financial Policies – May 2025. Completed financial policies related to: implementation of significant accounting policies, internal control environment, cash and banking, cash disbursements and check issuance, payroll processes, procure to pay and revenue recognition policies, processes and procedures. In addition, when applicable, documenting procurement circumstances, processes, decisions and CEO approval was implemented via memo(s) to the procurement file (MTPF). B. Procurement Related Processes – May 2025. Initiated use of MTPF, and process implementation of Request(s) for Professional Services Qualifications, Request(s) for Professional Services, Request(s) for Proposal. C. HRSA Policies – July 2025. Developed HRSA related policies re: implementation of HRSA policies; executive performance evaluation, non-executive performance evaluation, executive compensation, non-executive compensation, timesheets, suspension & debarment procedure, financial management system, legislative mandates, legislative mandates process & procedure and cash management for federal draws and return of funds. D. Board Policy Provision & Awareness – August 2025. Informed the Board about the progress of the Organization’s policy framework, including the above policies. For the year ended June 30, 2025, to the period of the audit report date, the Organization continued the prospective implementation of the above policies and processes, including the following reflective contract review work by the Organization: A. Reviewed all contracts executed between July 1, 2024 to June 30, 2025. B. Discussed with respective program director(s), the application of initiation, consideration, decision, documentation and monitoring phased activities. C. Worked with respective program director(s) to document in memorandum(s) to file (MTF), the basis for decision and documentation on a contract-by-contract basis. D. Initiated work with respective program contract monitors to implement and document consistent Organization wide contract monitoring processes and activities (e.g., contract, term, billing, deliverables, eligible expenditures, data input, frequency). E. Updated procurement processes for emergency disaster recovery and support of community needs, including MTF documentation. Although as of June 30, 2025 the implementation of the resolution was not completed, the implementation continues and is expected to be fully implemented by the next audit report date Finding No. 2025-003: Procurement Policies Contact Person(s) Responsible for Corrective Action: Sheri Daniels, Ed.D., Chief Executive Officer, Marisa Wilson, Director of Administrative Operations, and Sylvia Hussey, Ed.D., Chief of Staff.

Finding 2025-003 No Written Conflict of Interest Policy Finding: The Town does not have a written conflict of interest policy as required by 2 CFR § 200.318(c)(1). Corrective Action The Town of St. Matthews concurs with the finding. The Town recognizes the importance of maintaining formally adopted written standards of conduct governing actual, potential, and perceived conflicts of interest involving employees and governing body members who participate in the selection, award, or administration of contracts supported by federal funds. To address the finding, the Town will develop a written conflict of interest policy that complies with applicable federal requirements, including 2 CFR § 200.318(c)(1). At a minimum, the policy will: 1. Define actual, potential, and perceived conflicts of interest and prohibited conduct; 2. Identify the employees, officials, and governing body members subject to the policy; 3. Require prompt written disclosure of relevant financial interests and other potential conflicts; 4. Establish procedures for reviewing, documenting, and resolving disclosed conflicts; 5. Require affected individuals to refrain from participating in matters in which a conflict exists; 6. Establish appropriate disciplinary or corrective measures for violations; 7. Require periodic written conflict-of-interest acknowledgments and disclosures; and 8. Address the retention of acknowledgments, disclosures, determinations, and related compliance documentation. The proposed policy will be presented to the Town Council for formal consideration and adoption. Following adoption, the Town will distribute the policy to applicable employees and governing body members and provide appropriate training or written guidance regarding their responsibilities. The Town will retain completed acknowledgments, disclosures, and documentation of any conflict determinations in accordance with its applicable record-retention requirements. Management will periodically review the policy and related procedures to help ensure continued compliance with federal award requirements. Responsible Official Town Administrator Anticipated Completion Date December 31, 2026. Current Status The Town currently does not have a written conflict of interest policy.

Condition The Institute does not have a written procurement policy. Additionally, the Institute does not perform suspension and debarment verification (e.g., checking the System for Award Management (SAM.gov) or equivalent excluded parties list) prior to entering into contracts or agreements with vendors, contractors, or subrecipients. Criteria Organizations that receive federal funding are generally required, under 2 CFR § 200.318–200.327 (Uniform Guidance), to: • Maintain written procurement procedures that conform to applicable federal, state, and local laws; • Ensure procurement transactions are conducted in a manner providing full and open competition; • Verify that contractors and subrecipients are not suspended, debarred, or otherwise excluded from participating in federal programs, per 2 CFR § 200.214 and 2 CFR Part 180. Cause The Institute has not formalized its procurement practices in a written policy and staff is not currently required to check suspension and debarment status as part of the vendor selection or contracting process. Effect Without a written procurement policy, the Institute lacks a consistent, auditable standard for procurement decisions, increasing the risk of non-compliance, favoritism, or inconsistent practices across departments. The absence of suspension and debarment checks creates risk that the Institute could enter into agreements with parties who are legally excluded from receiving federal funds, potentially resulting in disallowed costs, reputational harm, or loss of funding. Recommendation The Institute should develop and formally adopt a written procurement policy that addresses methods of procurement, competition requirements, documentation standards, and conflict-of-interest provisions consistent with 2 CFR § 200.318–200.327. The Institute should also implement a documented procedure requiring suspension and debarment verification (via SAM.gov or equivalent) for all vendors, contractors, and subrecipients prior to contract execution, and retain evidence of this check in procurement files. Management Response Management agrees with the finding and recommendation. The Institute is formalizing its procurement practices in a written procurement policy consistent with applicable Uniform Guidance requirements. The policy addresses procurement methods, competition, documentation, conflicts of interest, and suspension and debarment requirements for procurements in accordance with federal regulations. Action Taken The Institute contracted with Visual Compliance to assist with verifying vendors against all available U.S. debarred and suspended lists before entering into covered contracts or agreements with vendors, contractors, or subrecipients. The Institute has developed and approved a Suspension and Debarment policy and staff are required to check suspension and debarment status as part of the vendor selection or contracting process. The Institute is developing a written procurement policy. Evidence of the verification will be retained with the applicable procurement or agreement documentation.

Finding Reference This corrective action plan relates to audit finding 2025 001 as reported in the schedule of findings and questioned costs. Contact Persons Dwayne Shaw, Executive Director, and Michelle Wright, Office Manager , are responsible for implementing and monitoring the corrective actions, maintaining related policies and procedures, and reporting status to those charged with governance. (207) 483-4336 Management’s Response / Concurrence Management agrees with the finding. The organization acknowledges that it does not currently have written policies and procedures addressing certain required Uniform Guidance compliance areas. Planned Corrective Action Management will develop, approve, and implement written policies and procedures designed to comply with applicable Uniform Guidance requirements, including policies over allowable costs/cost principles, cash management, and procurement, including suspension and debarment. Management will also communicate the new policies to relevant personnel and provide training as needed to support consistent implementation. Anticipated Completion Dates Management will finalize and implement the corrective action plan on or before September 30, 2026.

Significant Deficiency in Internal Control over Compliance, Other Matters Description of Finding The Town does not have a written conflict of interest policy in place as required by Uniform Guidance §200.318 procurement standards. Statement of Concurrence or Nonconcurrence Management concurs with the finding. Corrective Action Management will establish written conflict of interest policies to ensure the Town is in compliance with procurement requirements of Uniform Guidance. Name of Contact Person Caitlyn Choiniere, Finance Director Projected Completion Date 7/1/2026

2025-002 Coronavirus State and Local Fiscal Recovery Fund, ALN #21.027 Condition: During our audit, we noted the Organization had not adopted formal written procurement policies and procedures governing purchases made with Federal award funds. Specifically, the Organization had not documented procurement methods, purchasing thresholds, quotation requirements, sole-source procurement requirements, or procedures for ensuring compliance with applicable Federal procurement standards. Although testing of procurement transactions selected for examination did not identify instances of noncompliance with Uniform Guidance procurement requirements, the Organization's procurement practices were based on informal procedures. Auditor's Recommendation: We recommend that management develop and formally adopt written procurement policies consistent with Uniform Guidance. At a minimum, such policies should address procurement methods and thresholds, competitive bidding and quotation requirements, sole-source procurement documentation, conflict-of-interest standards, contractor responsibility determinations, suspension and debarment considerations, and procurement record retention requirements. Action Taken: We have documented and adopted our Procurement Policy in accordance with Uniform Guidance. A copy of this policy will be provided upon request. Anticipated Completion Date: December 31, 2026

Type of Finding: Material weakness in internal controls over compliance relating to suspension and debarment checks and maintenance of documentation puts CCS at risk of noncompliance with the standards of Procurement. Views of Responsible Officials: Management accepts this finding. Performing timely suspension and debarment checks avoids any potential issues with using federal funds for unallowable vendors. Maintaining documentation and performing proper procurement steps is vital to ensure compliance with agency policy. Corrective Action: Management is in the process of setting agency-wide procurement procedures that will align with our current policy. This includes completing a suspension and debarment check on all new vendors. Management is in the process of finding a third-party vendor to assist with annual suspension and debarment checks.

Historic South acknowledges this finding is the same as reported in 2024. Although the corrective actions identified in the prior year’s audit were implemented, they were not fully in place during most of the period covered by the current audit. As a result, the transactions tested during the 2025 audit occurred before the corrective measures became effective. Corrective measures implemented include policies and procedures designed to strengthen its procurement and contracting processes. These include: 1. Requiring the solicitation of multiple bids for all construction work in excess of $10,000 2. Establishing criteria for awarding all construction work 3. Implementing formal contracting processes for all construction work Management believes these corrective actions address the deficiencies identified and expects them to be fully effective for construction activities occurring after implementation.

Prior to purchases being made, the Child Nutrition Program Supervisor will check for suspension and debarment of vendors. The accounts payable accountant will also review for suspension and debarment prior to payment being made. Evidence of review will be maintained in an appropriately labeled file each year.

Prior to purchases being made, the Child Nutrition Program Supervisor will check for suspension and debarment of vendors. The accounts payable accountant will also review for suspension and debarment prior to the payment being made. Evidence of review will be maintained in an appropriately labeled file each year. See response to finding 2025-018 above.

Programs: ALN 66.458 Clean Water State Revolving Fund and ALN 66.468 Drinking Water State Revolving Fund Condition: The City's procurement procedures do not conform to Uniform Guidance requirements. Actions Planned in Response to Finding: The City will update procurement procedures to conform with Minnesota statutes and Uniform Guidance. Officer Responsible for Ensuring CAP: Kimberly Block, Clerk/Treasurer Planned Completion Date: 12/31/2026

Emergency Solutions Grant – Assistance Listing No. 14.231 Recommendation: We recommend that management implement formal procurement policies requiring periodic reassessment of vendors used in federally funded programs, particularly when new grant awards are received or grant periods change. This should include evaluating whether the original procurement method remains appropriate, performing updated cost or price analyses as necessary, and conducting and documenting periodic suspension and debarment checks (e.g., SAM verification). Additionally, management should establish oversight controls to ensure procurement compliance and vendor eligibility are maintained throughout the lifecycle of vendor relationships in accordance with 2 CFR §200.318–200.320 and §200.214. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Avivo is in the process of updating its procurement policy and processes to include annual reviews of ongoing vendor contracts that will assess the appropriateness of the original procurement conditions and determine if updates or new analyses are required. Reviews will be signed off by the staff with contracting authority at the time of review; and if warranted, the appropriate staff will undertake new cost analyses, complete the documentation, and save in a shared repository that relevant departments will have access to. Program leadership is working with the appropriate administrative departments to develop the necessary processes for periodic review and the collection/storage of documentation around the periodic review process. The Accounting department has added a system-wide debarment check of all active vendors in the 3rd quarter of each year and will add any new vendors to this schedule regardless of when they were originally added to the vendor payment system. This ensures that all vendors are re-checked for debarment and suspension at minimum of one time annually. Name(s) of the contact person(s) responsible for corrective action: Kelly Matter Planned completion date for corrective action plan: 12/31/2026

Finding Reference Number: 2025-003 – Internal Control over Compliance in Relation to Procurement Suspension and Debarment Description of Finding: This is a new finding. Upon review of the town’s Bid Ordinance and Charter, a policy could not be found that determines whether a vendor for goods and services was either suspended or debarred from receiving or participating in federal awards, which is required as part of the 2025 Uniform Guidance related to Federal Programs. Additionally, it could not be determined whether any suspension or debarment review had been made and documented. Statement of Concurrence or Nonconcurrence: Concur. Corrective Action: The town will update the Town Bid Ordinance to include the policy that mandates that before any contract or purchase order is awarded using federal funds, staff must verify the vendor’s eligibility status via the federal System for Award Management (SAM.gov). The Town will also update its Policy and Procedures manual to require a printed or digital SAM.gov search certificate to be attached to the procurement file as auditable evidence of the verification. Projected Completion Date: December 31, 2026

Finding 2025-003 Procurement, Suspension and Debarment Programs: ALN 66.458 Clean Water State Revolving Fund Condition: The City’s procurement procedures do not conform to Uniform Guidance requirements. Corrective Action Planned: The City will update procurement procedures to conform with Minnesota statutes and Uniform Guidance. Officer Responsible for Ensuring CAP: Stacy Kass, Clerk/Treasurer Planned Completion Date: 12/31/2026 49

Finding 2025-002 Procurement, Suspension and Debarment Material Weakness in Internal Control Over Compliance and Instance of Material Noncompliance Assistance Listing 21.029 Wabash currently maintains the process of procurement standards and internal controls. While we previously managed contractor selections through established internal practices, we recognize the requirement for a comprehensive written procurement policy that explicitly outlines selection criteria and mandatory debarment verification procedures. To remediate the identified material weakness, Wabash implemented a formal Procurement Policy and Procedure June 30, 2026. This document mandates: • Standardized Selection Criteria: Clear guidelines for the evaluation and selection of contractors to ensure transparency and competition. • Debarment Verification: A required protocol for verifying and documenting that contractors are not excluded or debarred via the System for Award Management (SAM). • Oversight: The Network Operations will be responsible for the implementation and ongoing monitoring of these controls to ensure full regulatory compliance. These measures will ensure that all future procurement activities meet federal requirements and organizational standards for financial integrity. Contact person(s): Jason Griffy, Network Operations Manager Justin Gephart, Chief Operating Officer

Federal Program: Coronavirus State and Local Fiscal Recovery Funds (CSLFRF) Assistance Listing Number: 21.027 Compliance Requirement: Procurement - Suspension and Debarment Type: Significant Deficiency in Internal Control over Compliance, Other Matters Condition/Context: During our audit, we noted a deficiency related to suspension and debarment verification and documentation. Specifically, for the procurement transactions tested, Worcester County, Maryland did not document verification that the vendor was not suspended or debarred prior to contract execution. In addition, the County does not have a formally documented suspension and debarment policy. While management indicated that suspension and debarment checks may be performed in practice, the absence of written policies and procedures resulted in inconsistent application and documentation of this required compliance procedure. Uniform Guidance requires non-federal entities to ensure that vendors and contractors receiving federal funds are not suspended or debarred from participating in federally funded programs. Effective compliance with this requirement is supported by documented policies and procedures that require verification (e.g., review of the System for Award Management (SAM.gov)) prior to entering into contracts. Recommendation: The County should develop and formally document a suspension and debarment policy that requires verification and documentation of vendor eligibility (e.g., SAM.gov review) for all contracts supported by Federal awards prior to execution of the contract. Management should also consider implementing standardized checklists or review controls to promote consistent compliance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Worcester County plans to update the County purchasing, financial and grant policies ensure debarment and suspension compliance by implementing procedures aligned with the U.S. Office of Management and Budget Uniform Guidance (primarily 2 CFR Part 200) and the governmentwide debarment rules in 2 CFR Part 180, as adopted by the awarding agency. The corrective action includes implementing a written procurement policy which states that the county will not contract with or issue subawards to parties that are suspended or debarred when federal funds are involved. The Grant/Budget Office will maintain open communication with Procurement regarding federally funded grant projects that will be advertised for bid. After bids are received and before the evaluation committee reviews or recommends an award, the Grant/Budget Office will search the System for Award Management (SAM.gov) exclusion database for each vendor that submitted a bid. A PDF or screenshot of the SAM search for each vendor will be retained in a grant and procurement file. All other federal grants under procurement threshold will need county departments to reach out to the Grant/Budget office before choosing vendors. Departments will need to list their potential vendors for the federal grant and email to the Grant/Budget office for debarment verification before moving forward with expending federal grant funding. A PDF or screenshot of the SAM search for each vendor will be sent to the department and a copy kept by Grants/Budget office as well. Name(s) of the contact person(s) responsible for corrective action: Kimberly Reynolds, Budget Officer kreynolds@worcestermd.gov Planned completion date for corrective action plan: Fiscal Year 2027

The EPI Center conducted a comprehensive review of all contractors subject to testing and verified, through alternative procedures, that none were suspended or debarred (e.g., verification through SAM.gov and documented vendor validation processes). As a result, all costs associated with these contracts were determined to be allowable, reasonable, and allocable to the federal award. Accordingly, management concluded that the finding relates to procurement policy implementation, documentation, and compliance processes rather than the allowability, allocability, or eligibility of the expenditures tested.

Management agrees with the finding and will develop and implement written procurement procedures consistent with Uniform Guidance requirements.

Finding 2025-002 – Policies and Procedures Require Review and Update – ALN 14.871 Housing Choice Voucher Program, ALN 14.850 Low Rent Public Housing, ALN 14.872 Capital Fund Program – Significant Deficiency Corrective Action Plan: Strengthening Board governance, ethical expectations, policy ownership, accountability, and delegated authority. Initial Deliverables • Code of Ethics; • Conflict-of-Interest Policy; • Whistleblower and Reporting Policy; • Delegation of Authority Matrix; • Spending and Approval Authority Matrix; • Signature Authority Matrix; • Policy Development and Review Policy; • Board Governance Framework; • Annual policy acknowledgment process; and • Governance training plan. Standardize the Housing Authority’s major operating processes and reduce reliance on undocumented institutional knowledge. Initial Deliverables • Standard Operating Procedure framework; • Priority SOP inventory; • Housing Choice Voucher processing SOPs; • Public housing occupancy and recertification SOPs; • Waiting-list administration SOPs; • Inspection scheduling and tracking procedures; • Intake and communication procedures; • Position-responsibility matrix; • Updated job descriptions; • Workload assessment; • Staff onboarding procedures; and • Cross-training plan. Improve financial accuracy, safeguarding of assets, segregation of duties, reconciliations, reporting, and management review. Initial Deliverables • Financial Policies and Procedures Manual; • Accounts-payable controls; • Check-run and payment-review procedures; • Payroll approval procedures; • Cash-handling procedures; • Laundry-revenue procedures; • Bank and general-ledger reconciliation procedures; • Monthly and annual financial-review checklist; • Audit-adjustment reconciliation procedures; • Fixed-asset and nonexpendable-equipment inventory procedures; • Capitalization policy update; • Investment policy update; • Creative Housing financial-accounting review; • Inter-entity transaction policy; • Corrective-action plan for questioned costs; • Financial close calendar; • CFO and Executive Director review responsibilities; and • Board financial dashboard. Person Responsible: Jennifer Oberlin, Executive Director, with oversight and approval by the Board of Commissioners, where applicable. Anticipated Completion Date: • Phase 1: Target Date of completion: November 30, 2026 o Implementation and Communication about the Red Flags Ethics Hotline o Identification and creation of needed policies and structural tools o Updating of current policies as needed • Phase 2: Target Date of Completion: April 30, 2027 o Training on new policies/expectations and accountability standards.

Views of Responsible Officials and Planned Corrective Action: Management confirms that the procurement activities themselves were completed only after the appropriate review and approval processes had occurred; however, sufficient supporting documentation evidencing those procedures could not be located during the audit process. This condition occurred during a period of significant staffing transition and turnover, which contributed to inconsistencies in documentation retention and adherence to established federal procurement documentation requirements. Management recognizes that internal controls and compliance procedures must remain effective regardless of personnel changes and accepts responsibility for strengthening these controls to ensure consistent compliance. Upon identification of this issue, management conducted an assessment of the underlying procurement and documentation processes and determined that enhancements were necessary to improve accountability, standardize documentation practices, strengthen supervisory review, and reinforce staff training related to federal procurement requirements. Management emphasizes that the deficiency related to the retention and completeness of procurement documentation, rather than to the execution of the procurement process itself. Management believes the evaluation, selection, and approval activities were conducted in accordance with applicable federal procurement guidelines and standards. Management is currently reviewing procurement policies and procedures to ensure alignment with federal requirements related to quotations, vendor evaluation and selection, approval protocols, and document retention. Additional corrective actions include reinforcing documentation standards, clarifying approval responsibilities, and implementing enhanced monitoring procedures to help prevent recurrence.

In order to avoid this situation happening in the future, instruction will be provided to all personnel emphasizing that every purchase should be made through a purchase order. This will ensure that we follow the BGCPR formal procedure and ensure better internal control is being followed. In addition, we will emphasize that no shipment should be received if such purchase is not in accordance with the specification disclosed in the purchase order. Contact Person: Purchase and procurement personnel Carlos Rivera Paul Barreras Amarilis Rodríguez (PACNA’s Project Manager) Team: Finance Team Anticipated Completion Date: September 30, 2026

BGCPR agrees with the deficiency identified, mostly attributable to employee turnover within the Finance Division. As a result of this, during fiscal year 2026-2027 BGCPR will implement procedures to ensure proper procurement process including the following: a. Review the procurement check list to ensure that all required documentation is included within and ensure revision before a purchase order is issued to the vendor. b. Training to the personnel to guarantee that policy and procedures are implemented as required. c. Enforce standardized procedures to ensure that all approvals are consistently documented and maintained in accordance with policy or grant requirements. Contact Person: Purchase and procurement personnel Carlos Rivera Team: Finance Team Anticipated Completion Date: September 30, 2026

Management acknowledges that procurement documentation was not consistently maintained during the audit period. Because the FY2024 audit was completed after the FY2025 fiscal year had ended, management did not have an opportunity to implement the prior-year corrective actions in time to affect the FY2025 audit period. Since the audit period, the Organization has strengthened procurement and compliance oversight by elevating the Director of Programs position to Vice President of Programs in September 2025, launching the Compliance and Risk Management Committee in FY2026, and creating a Compliance & Evaluation Manager position with an anticipated start date in August 2026. Fiscal and program leadership have substantially revised the procurement policy and are developing related procedures and standardized documentation requirements. The policy and procedures will be reviewed by the Compliance and Risk Management Committee in early FY2027 before being submitted for Board approval. The revised materials address competitive quotations and bids, vendor selection, price reasonableness, noncompetitive procurement justifications, conflict-of-interest requirements, debarment verification, and documentation of the procurement history. The FY2027 budget includes 2 CFR Part 200 training for Fiscal, Programs, and Grants staff. Blackbaud Financial Edge, scheduled to go live in FY2027, will further support approval workflows, transaction tracking, role-based access, and document retention. Management is committed to achieving full compliance with Uniform Guidance procurement requirements. Actions Taken • Elevated the Director of Programs position to Vice President of Programs in September 2025. • Launched the Compliance and Risk Management Committee in FY2026. • Created a Compliance & Evaluation Manager position, with an anticipated start date in August 2026. • Strengthened supervisory review and reinforced procurement documentation expectations. • Substantially revised the procurement policy and began developing standardized procedures and documentation requirements. • Scheduled Compliance and Risk Management Committee review of the revised policy and procedures for the fall of 2026. • Included 2 CFR Part 200 training for Fiscal, Programs, and Grants staff in the FY2027 budget. • Initiated implementation of Blackbaud Financial Edge; planned go-live for October 2026.

We agree with the finding that internal controls were not sufficient to maintain compliance with federal procurement standards under Title 2, Subtitle A, Chapter II, Part 200, Subpart D, 200.318 to 200.327 for a non-federal entity. However, the funds were expended for the intended purpose of the federal award. The Company is committed to implementing internal controls to ensure procurement related to federal awards follow 2 CFR section 200.318 to 200.327. The Company implemented the procurement policy it created on September 30, 2025, in response to prior audit findings 2024-001 and 2024-003, which occurred after the end of the federal award year for this program, that addresses this finding. This procurement policy complies with the requirements of 2 CFR section 200.318 through 200.327, that includes the written standards of conduct covering conflicts of interest and governs the actions of its employees who select, award and administer procurement contracts. This policy includes procedures to ensure proper procurement for small purchases to ensure sufficient price quotations are obtained from the required number of qualified sources, proper sealed bids or proposals are obtained through public advertising, an appropriate cost or price analysis is performed for procurement actions exceeding the simplified acquisition threshold, documentation is retained, and proper oversight is exercised in accordance with 2 CFR section 200.318 through 200.327. While the Company did not perform a check of each vendor against the SAM Exclusions prior to selecting a vendor, the Company has procedures in place to ensure the vendors are approved by Corporate purchasing and in good standing, which limits the risk of conflict of interest between employees and vendors, and limits contracting with a vendor who is suspended or debarred from federal related contracting. Further, the Company confirmed the vendors that were contracted with related to this finding were not included on the SAM Exclusions listing. The Company has now filed the Notice of Federal Interest (“NFI”), and provided the NFI to the appropriate HRSA Grants Management Specialist. The Company also updated its procurement policy to ensure that, regardless of the award amount, it files an NFI against the property deed prior to construction of any project in the appropriate public records office of the jurisdiction in which the property is located and provides a copy to the appropriate HRSA Grants Management Specialist. Contact Person: Ela Lena, Chief Executive Officer of Southern Regional Hospital Expected completion date: Provide training to all employees who are relevant to the procurement process of federal contracts by September 30, 2026.

Finding #2025-004 - Reporting; Procurement and Suspension and Debarment; Subrecipient Monitoring; Allowable Costs/Cost Principles Corrective Action Planned: Since the Finance Manager's arrival, a process has been implemented to reconcile quarterly expenditure reports submitted to the State of Michigan against the general ledger; this reconciliation has become clearer and more consistent with each subsequent period. Beginning in September 2025, suspension and debarment checks on SAM.gov are performed for every new vendor and subrecipient - owned by the Executive Director of the Center for Adult College Success for Center vendors and the Finance Manager for TalentFirst vendors, with all checks reviewed by the Finance Manager. Employee wage allocations are now supported by timesheets and documented on the monthly journal accrual e-signature form, which retains the allocation and its approval electronically. Anticipated Completion Date: Already implemented. Responsible Party: Finance Manager, with oversight by the President.