Corrective Action Plans

Finding 2024-003 Contact Person Responsible for Corrective Action Plan: Brenda Layne, Food Service Director Contact Phone Number: 765-289-7323 We concur with the finding. Corrective Action plan: As of 3/1/25. Cindy will look the company up on Sam.gov. and the Food Service Director will look it over and both of us will initial and keep a copy on file. Anticipated Completion Date: March 2025

Finding Reference 2024-06 Corrective Action Plan: The Authority will revise its procurement policies and procedures to ensure that all federally funded projects undergo the appropriate competitive procurement processes. This will include consistent and standard guidelines for project scope determination, bidding process, and documentation requirements. Responsible: Eng. Maria Ayala Rivera, Construction Office Director Planned Implementation Date: December 31, 2025

FINDING 2024-003 Subject: Special Education Cluster (IDEA) - Procurement and Suspension and Debarment Federal Agency: Department of Education Federal Programs: COVID-19 - Special Education Grants to States, COVID-19 - Special Education Preschool Grants Assistance Listings Numbers: 84.027, 84.173 Federal Award Numbers and Years (or Other Identifying Numbers): 22611-042-ARP, 22619-042-ARP Pass-Through Entity: Indiana Department of Education Compliance Requirement: Procurement and Suspension and Debarment Audit Findings: Material Weakness, Modified Opinion INDIANA STATE BOARD OF ACCOUNTS 20 METROPOLITAN SCHOOL DISTRICT OF STEUBEN COUNTY SCHEDULE OF FINDINGS AND QUESTIONED COSTS (Continued) Condition and Context The School Corporation is a member of the Northeast Indiana Special Education Cooperative (Cooperative). During fiscal years 2022-2023 and 2023-2024, the Cooperative operated the special education program and spent the federal money on behalf of all its members. As the grant agreement was between the Indiana Department of Education and each member school, the School Corporation was responsible for ensuring and providing oversight of the Cooperative. The School Corporation did not have internal controls in place to ensure that the Cooperative complied with the procurement and the suspension and debarment requirements. The Cooperative did not have adequate procedures in place to ensure that the requirements for the simplified acquisition threshold and for small purchases were met for each applicable procured good or service or to ensure that vendors were not suspended or debarred prior to entering into a covered transaction. Procurement When the value of the procurement for property or services exceeds the simplified acquisition threshold (SAT), or a lower threshold established by a nonfederal entity, formal procurement methods are required. The SAT is typically set at $250,000. However, Indiana Code 5-22-8 has a more restrictive threshold. Therefore, the SAT threshold is set at $150,000. Formal procurement methods require adherence to documented procedures and formal methods such as sealed bids or proposals. When the purchase value exceeds the micro-purchase threshold but is less than the simplified acquisition threshold, a small purchase occurs. Small purchases require documented full and open competition or a documented rationale for limited competition. For 2022-2023, the Cooperative had one vendor, with disbursements, totaling $379,313, which exceeded the SAT threshold of $150,000. The Cooperative did not obtain sealed bids or competitive proposals nor was there documentation detailing the history of the procurement, which must include the reason for the procurement method used. For 2022-2023, the Cooperative had one vendor with disbursements in the amount of $55,374, which were less than the SAT threshold of $150,000, but exceeded the $50,000 micropurchase threshold and was selected for testing. The Cooperative did not obtain price or rate quotes nor was there documentation detailing the history of the procurement, which must include the reason for the procurement method used. For 2023-2024, three vendors with disbursements, totaling $175,125, were identified as being less than the simplified acquisition threshold of $150,000, but exceeding the $50,000 micropurchase threshold and were selected for testing. The Cooperative did not obtain price or rate quotes for two of the three vendors and there was no documentation detailing the history of the procurement, which must include the reason for the procurement method used. 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 nonprocurement transaction (i.e., grant agreement) that are expected to equal or exceed $25,000. The verification is to be done by checking the SAM exclusions, collecting a certification from that vendor, or adding a clause or condition to the covered transaction with that vendor. INDIANA STATE BOARD OF ACCOUNTS 21 METROPOLITAN SCHOOL DISTRICT OF STEUBEN COUNTY SCHEDULE OF FINDINGS AND QUESTIONED COSTS (Continued) Upon inquiry of the Cooperative in order to review the procedures in place for verifying that a vendor with which it plans to enter into a covered transaction is not suspended, debarred, or otherwise excluded, the Cooperative disclosed there were not any documented internal controls or procedures. Nine covered transactions were identified. The covered transactions, totaling $803,836, were selected for testing. The Cooperative did not verify the suspension and debarment status of the tested vendors prior to payment. The lack of internal controls and noncompliance were systemic throughout the audit period. Criteria 2 CFR 200.303 states in part: "The non-Federal entity must: (a) Establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in 'Standards for Internal Control in the Federal Government' issued by the Comptroller General of the United States or the 'Internal Control Integrated Framework', issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). . . ." 2 CFR 200.320 states in part: "The non-Federal entity must have and use documented procurement procedures, consistent with the standards of this section and §§ 200.317, 200.318, and 200.319 for any of the following methods of procurement used for the acquisition of property or services required under a Federal award or sub-award. (a) Informal procurement methods. When the value of the procurement for property or services under a Federal award does not exceed the simplified acquisition threshold (SAT), as defined in § 200.1, or a lower threshold established by a non-Federal entity, formal procurement methods are not required. The non-Federal entity may use informal procurement methods to expedite the completion of its transactions and minimize the associated administrative burden and cost. The informal methods used for procurement of property or services at or below the SAT include: . . . (2) Small purchases– (i) Small purchase procedures. The acquisition of property or services, the aggregate dollar amount of which is higher than the micro-purchase threshold but does not exceed the simplified acquisition threshold. If small purchase procedures are used, price or rate quotations must be obtained from an adequate number of qualified sources as determined appropriate by the non-Federal entity. . . . INDIANA STATE BOARD OF ACCOUNTS 22 METROPOLITAN SCHOOL DISTRICT OF STEUBEN COUNTY SCHEDULE OF FINDINGS AND QUESTIONED COSTS (Continued) (b) Formal Procurement Methods. When the value of the procurement for property or services under a Federal financial assistance award exceeds the SAT, or a lower threshold established by a non-Federal entity, formal procurement methods are required. Formal procurement methods require following documented procedures. Formal procurement methods also require public advertising unless a non-competitive procurement can be used in accordance with § 200.319 or paragraph (c) of this section. The following formal methods of procurement are used for procurement of property or services above the simplified acquisition threshold or a value below the simplified acquisition threshold the non-Federal entity determines to be appropriate: . . . (1) Sealed bids. A procurement method in which bids are publicly solicited and a firm fixed-price contract (lump sum or unit price) is awarded to the responsible bidder whose bid, conforming with all the material terms and conditions of the invitation for bids, is the lowest in price. The sealed bids method is the preferred method for procuring construction, if the conditions. . . . (2) Proposals. A procurement method in which either a fixed price or cost-reimbursement type contract is awarded. Proposals are generally used when conditions are not appropriate for the use of sealed bids. . . ." 2 CFR 180.300 states: "When you enter into a covered transaction with another person at the next lower tier, you must verify that the person with whom you intend to do business is not excluded or disqualified. You do this by: (a) Checking the SAM Exclusions; or (b) Collecting a certification from that person; or (c) Adding a clause or condition to the covered transaction with that person." Cause The Cooperative noted that the ARP portion of the Special Education grant was new for 2022-2023 and 2023-2024. The ARP funding gave opportunity for types of expenditures that do not typically get expensed using special education funding. The transactions noted within the Condition and Context were from the ARP portion of the grant, which provided property or services that exceeded the micro-purchase threshold. Management of the Cooperative was unaware of the procurement requirements when property or services exceed the micro-purchase threshold. In addition, management of the Cooperative was unaware of the suspension and debarment requirements when a covered transaction is expected to equal or exceed $25,000. Effect Without the proper implementation of an effectively designed system of internal controls, including policies and procedures that provide segregation of duties and additional oversight as needed, the internal control system cannot be capable of effectively preventing, or detecting and correcting, material noncompliance. Without following the required methods for procurement, the Cooperative could be overpaying for services. Unverified vendors to whom payments equal to or in excess of $25,000 could be suspended, debarred, or otherwise excluded. INDIANA STATE BOARD OF ACCOUNTS 23 METROPOLITAN SCHOOL DISTRICT OF STEUBEN COUNTY SCHEDULE OF FINDINGS AND QUESTIONED COSTS (Continued) Noncompliance with the provisions of federal statutes, regulations, and terms and conditions of the federal award could result in the reduction of future federal funding to the Cooperative. Questioned Costs There were no questioned costs identified. Recommendation We recommended that the Cooperative's management design and implement a system of internal controls related to procurement and suspension and debarment procedures to ensure procurement requirements are met and to ensure entities are neither suspended nor debarred or otherwise excluded or disqualified prior to entering into any covered transactions. Views of Responsible Officials For the views of responsible officials, refer to the Corrective Action Plan that is part of this report.

Identifying Number: 2024-001 Audit Finding: Accounting for Pharmacy 340B Drug Pricing Program Transactions. While testing the 340B Program, revenue and accounts receivable, we identified the following errors: • The Organization overstated 340B Program accounts receivable and revenue by double-counting a 340B Program transaction in the amount of $213,887. • The Organization understated 340B Program accounts receivable and revenue by $45,038 by not properly recording a transaction with a pharmacy. • The Organization overstated 340B Program revenue and professional services expense by $1,111,252 by posting an incorrect adjustment to true-up revenue and expense for dispensing, processing and administrative fees associated with the 340B Program. Corrective Action Taken: The Controller will utilize program data reports to perform reconciliations periodically. The reconciliations will be reviewed by the VP of Finance and stored. Additionally, the Revenue Cycle Manager and the VP of Finance will assist and monitor TPA’s setup and conditions for proper program management. This will be implemented by June 30, 2025. Identifying Number: 2024-002 Audit Finding: Inadequate Internal Controls Over Payroll Transactions. In May 2024, the Organization failed to restrict the modification of payroll reports subsequent to approval. There was no final check performed to ensure that the final submitted payroll report agreed with the approved version. Corrective Action Taken: By June 2024, the Finance Director created additional checks and balances to ensure integrity of payroll. The Director will provide a trend analysis of payroll data for each payroll for the approval process. The analysis will show changes in employee pay and trends. We will also compare the final payroll totals with the website verification after submission to ensure the totals reviewed match what was submitted. Identifying Number: 2024-003 Audit Finding: While testing the procurement requirement for micro purchases, we noted there was one sample selection for which the Organization did not have documentation to support whether the procurement method used was appropriate. Corrective Action Taken: By June 30, 2025, the Operations team and the Accounts Payable Coordinator will maintain a centralized database of vendor contracts, bids, and other information regarding purchases. To ensure continuity through changes in personnel, Tapestry will store the data on the shared drives, allowing for a repository to persist over time. Purchases, contracts, and associated back up will be monitored by both Operations and Finance teams and will be assisted by Office Managers who may perform some ordering.

Information on the federal program: Subject: Child Nutrition Cluster - Internal Controls Federal Agency: Department of Agriculture Federal Program: School Breakfast Program, National School Lunch Program, Summer Food Service Program for Children Assistance Listing Number: 10.553, 10.555, 10.559 Federal Award Numbers and Years (or Other Identifying Numbers): FY2023, FY2024 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 compliance requirements. Context: For one of the two small purchase method procurements sampled for testing, we noted that the School Corporation did not obtain quotes from an adequate number of qualified sources. The sample item amount disbursed was $126,265 in FY23 and $59,748 in FY24 for food service equipment. The School Corporation was unable to provide support for the number of quotes obtained and a signed contract. The School Corporation was also not able to provide support that a suspension and debarment check was performed on the vendor. Corrective Action Plan: The School Corporation will implement internal control procedures to ensure the School Corporation is following their procurement policy to comply with state and federal requirements pertaining to procurement and suspension and debarment. The School Corporation will ensure that suspension and debarment checks are performed on vendors before entering into a contract and support will be maintained to show that the School Corporation followed policy and met state and federal compliance requirements. Person responsible for implementation and projected implementation date: The Food Services Director, Treasurer and Superintendent will oversee the implementation of the corrective action plan. The corrective action plan will be implemented immediately.

Due to going out twice with this RFP during FY23/24 in order to try and receive more sealed bids the contract did not get awarded until July 1, 2024 falling into the FY24/25.

CONDITION: The Western Beaver Area School District contracted with a third-party vendor – Snider Recreation for the purchase and installation of playground equipment. The contract was procured through a cooperative purchasing group. The District 1) was unable to provide documentation from the cooperative purchasing group to verify that the playground procurement contract was competitively procured, such as a bid evaluation and public solicitation and 2) did not obtain the adequate number of price or rate quotations. This is a continuing finding from the 2022-2023 fiscal year. CRITERIA: As specified in 2 CFR 200. 318(i) of the Uniform Guidance, the District 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. In addition, small purchase procedures per 2 CFR 200.320(a)(2)(i) for acquisitions between the micro-purchase threshold (currently $10,000) and the simplified acquisition threshold (current $250,000), price or rate quotations must be obtained from an adequate number of qualified sources as determined appropriate. Per 24 PS 8.807.1, there should be three quotes that are either written or well documented. MANAGEMENT’S CORRECTIVE ACTION PLAN: Management will review and update as necessary, it’s current procurement policies and procedures to ensure compliance with all applicable sections of the Uniform Guidance, in specific, Sections 2 CFR 200.318(i) and 200.320(a)(2)(i) of the Uniform Guidance, as well as 24 PS 8.807.1. In specific, these procedures will include 1) obtaining all relevant information pertaining to procurements involving federal assistance from any cooperative purchasing group and 2) obtaining quotations from three qualified providers where applicable and documenting those results. These two (2) updated procedures will be implemented during the remaining months of the 2024-2025 fiscal year, and all subsequent years, for future purchases where applicable.

Contact Person Mark Bell Director of Finance vcc.m.bell@ontrackroguevalley.org Explanation and Specific Reasons for Disagreement With the Audit Finding or That Corrective Action is not Required (if Applicable) No disagreement. Corrective Action Planned 1. Develop and Implement a Formal Procurement Policy o A written procurement policy will be developed that aligns with 2 CFR 200.317 - 200.327, ensuring compliance with federal, state, and local regulations. 2. Enhance Internal Controls for Procurement Compliance o All procurement transactions will be reviewed and approved by designated personnel to verify compliance before finalizing agreements. o A procurement checklist will be used for each transaction to ensure that required documentation is maintained. 3. Mandatory Suspension and Debarment Verification o The Organization will implement procedures to verify all vendors against the System for Award Management (SAM.gov) database before entering into contracts. o Documentation of suspension and debarment searches will be retained in the procurement files. Anticipated Completion Date September 30, 2025

Finding Number: 2024‐004 Program Name/Assistance Listing Titles: Indian School Equalization; Indian School Student Transportation Assistance Listing Numbers: 15.042, 15.044 Contact Person: Aurelia Tapaha, Business Manager; Stephanie Woody, Business Technician Anticipated Completion Date: July 2025 Planned Corrective Action: The School will revisit financial policies and procedures and strictly comply with procurement processes. There are specific requirements for different amounts of purchases. The School will review requisitions and ask for required documents before processing. Repeat finding due to employee’s not following the procurement processes and business office personnel accepting requisitions without proper documentation attached.

Finding 2024-003: Healthy Start Procurement Compliance and Control Deficiency Grantor: Department of Health and Human Services Program Title: Healthy Start Initiative Award Name: Healthy Start Initiative‐Eliminating Racial/Ethnic Disparities Award Number: H4927805 Assistance Listing Title: Healthy Start Initiative Assistance Listing Number: 93.926 Award Year: April 1, 2023 – August 31, 2024 Passthrough Entity: None Management agrees with the finding and recommendation and will reinforce and provide education regarding the procurement policies and procedures to ensure proper controls over procurement. Formal documentation will be maintained to demonstrate competitive bidding or single source justification completed for vendors used on grant-funded projects, including appropriate approvals prior to entering into transactions. Furthermore, management will collaborate with the procurement team to determine what revisions are necessary to our current grant accounting policy related to competitive bidding or single source justification in order to be in compliance with the Uniform Guidance requirements. Management will remediate this finding by June 30, 2025.

Finding 2024-002 Procurement ALN: 93.855 Finding: The College did not have effective internal controls and procedures in place to ensure the College maintained records for procurements sufficient to detail the history of procurement, including the rationale for the method of procurement and other required elements. Corrective Action Plan: BCM management agrees that a sole source documentation form was not completed for this procurement. We do believe that this would have been easily justified as a sole source procurement as this vendor had unique capabilities required by the grant. The master service agreement for this procurement was effective September 1, 2019, and the related PO for this scope of work was issued on June 15, 2023. Since this time period, BCM has implemented a new procure to pay system with improved internal controls and approval routings. With this new system, we believe we have already put in place the appropriate corrective actions necessary to prevent this from happening going forward. Person Responsible: Rob Falivene, Vice President, Supply Chain Services, Baylor College of Medicine Expected Completion: March 2025

CORRECTIVE ACTION PLAN March 17, 2025 Health Resources and Services Administration 5600 Fishers Lane Rockville, MD 20857 The Gavin Foundation, Inc. respectively submits the following corrective action plan for the year ended June 30, 2024. CohnReznick LLP 350 Granite Street, Suite 1200 Braintree, MA 02184 Audit Period: June 30, 2024 The finding from the June 30, 2024 schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. FINDING - FEDERAL AWARD PROGRAM AUDIT U.S. Department of Health and Human Services 2024-001 Congressional Directives - Assistance Listing No. 93.493 SIGNIFICANT DEFICIENCY Recommendation Management should establish procedures to ensure contract files include the history of procurements and the documentation is maintained. Action Taken The organization performed procurement procedures, including soliciting bids/proposals from multiple contractors, evaluating them and selecting the contractor based on their procurement procedures. However, as the project was completed we maintained the contracts related to the contractor selected but inadvertently disposed of the documentation related to the procurement process. We have met with employees responsible for completion and filing of the procurement documentation and discussed the importance of not only completing the documentation, but also the importance of its proper filing. We have updated our procedures to ensure procurement history is adequately documented and maintained in the contract files. These actions were implemented (or are anticipated to be implemented) effective March 17, 2025. If the Health Resources and Services Administration has questions regarding this plan, please call Peter Barbuto at (857) 496-7341. Sincerely yours, Peter Barbuto, CEO The Gavin Foundation, Inc.

The Service Center will be sure to follow the federal procurement requirements pursuant to Policy 6325 and verify that appropriate controls and compliance with federal requirements are maintained with documentation supporting the procurement types.

Information on the federal program: Subject: Special Education Cluster (IDEA) – Procurement Federal Agency: Department of Education Federal Program: Special Education Grants to States, Special Education Preschool Grants Assistance Listing Number: 84.027 Federal Award Numbers and Years (or Other Identifying Numbers): H027A220084, H027A230084 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Procurement and Suspension and Debarment Audit Finding: Significant Deficiency Condition: An effective internal control system was not in place at the School Corporation in order to ensure compliance with requirements related to the grant agreement and the Procurement and Suspension and Debarment compliance requirement. 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. 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. Context: The School Corporation did not obtain price or rate quotes for one out of four vendors tested that were less than the simplified acquisition threshold of $150,000 but exceeded the $10,000 micro-purchase threshold. Documentation of vendor contract, bids or the School Corporation's process and rationale for the chosen vendor was not available for audit. Further, the School Corporation could not provide evidence that a suspension and debarment check had been performed on the vendor prior to entering into contract. Corrective Action Plan: The Special Education Director will obtain pricing quotes from the appropriate amount of qualified sources, when cumulative costs are projected to exceed the micro purchase threshold. The Special Education Director will document and communicate the results of this process with the Business Manager and Superintendent. Person responsible for implementation and projected implementation date: The Special Education Director, the Business Manager, and the Superintendent will be responsible for overseeing the implementation of the corrective action plan, which will go into effect immediately.

CONDITION: The School District contracted with MHY Family Services for professional services. The contract exceeded the threshold for competitive procurement. The District was unable to provide documentation to verify that the third-party procurement contract was competitively procured, such as a bid evaluation and public solicitation. In addition, the District did not conduct a cost or price analysis for this procurement, which was in excess of the Simplified Acquisition Threshold of $250,000. CRITERIA: Section 2 CFR 200. 318(i) of the Uniform Guidance specifies that the School District 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. In addition, Section 2 CFR 200.324(a) of the Uniform Guidance requires the performance of a cost or price analysis in connection with every procurement in excess of the Simplified Acquisition Threshold. RECOMMENDATION: I am recommending that the management of the School District review and update as necessary its procurement policies to ensure retention of the appropriate procurement documentation, in all instances, so as to comply with all applicable sections of the Uniform Guidance, specifically, Section 2 CFR 200.318(i) of the Uniform Guidance. In addition, I recommend that the School District conduct a cost or price analysis for all procurement in excess of the Simplified Acquisition Threshold of $250,000 before receiving bids or proposals in accordance with Section 2 CFR 200.324(a) of the Uniform Guidance. MANAGEMENT’S PLANNED CORRECTIVE ACTION: The School District will conduct a cost or price analysis for all contracts over the Simplified Acquisition Threshold of $250,000 before receiving bids and proposals. The timeframe for implementation of this procedure is effective immediately.

CONDITION: During the PDE monitoring review of the ARP ESSER grant program, it was noted that the School District did not document in writing its rationale for the noncompetitive procurement of services provided by J. Martin & Associates. CRITERIA: In accordance with Section 2 CFR 200.318(i) of the Uniform Guidance, the District must maintain records sufficient to detail the history of procurement. These records include but are not limited to the rationale for the method of procurement, selection of contract type, contractor selection or rejection, and the basis for the contract price. Furthermore, Section 2 CFR 200.320(c’) of the Uniform Guidance details five (5) circumstances in which noncompetitive procurement can be used. RECOMMENDATION: I recommend that for all future purchases involving noncompetitive procurement, the School District adhere to Section 2 CFR 200.318(i) and Section 2CFR 200.320(c’) of the Uniform Guidance regarding the proper documentation required for noncompetitive procurement, as well as the District’s Procurement Policy for Federal Programs (#626.5). MANAGEMENT’S PLANNED CORRECTIVE ACTION: The School District’s will maintain procurement records, including why the noncompetitive procurement contract was necessary with appropriate documentation vetted by the District Solicitor. Additionally, the District will conduct an analysis to support that the price paid was reasonable. This analysis is needed to justify procurements that are not competitively bid. The timeframe for implementation is effective immediately.

March 26, 2025 CORRECTIVE ACTION PLAN FISCAL YEAR OF FINDING: June 30, 2024 AUDITOR FINDING: 2024-001 AREA: Procurement and Suspension & Debarment Compliance It was noted that (1) the Organization's documented procurement procedures must conform to the procurement standards identified in 2 CFR 200.317 through 200.327; and (2) in accordance with 2 CFR Part 180, contracts cannot be entered with certain parties that are debarred, suspended, or otherwise excluded from receiving or participating in federal awards. It is recommended for the Organization to comply with the Organization’s internal procurement policies and the Uniform Guidance with respect to obtaining vendor quotes and retain support for a check of suspension and debarment. CLIENT PLANNED ACTION: 1. WellPower will review and align its procurement policy with Uniform Guidance compliance requirements for procurement, suspension & debarment. 2. WellPower will provide the necessary training on Uniform Guidance procurement compliance requirements to its procurement department and other authorized purchasers within the organization 3. WellPower will update its suspension & debarment check procedures and record keeping thereof, to ensure that SAM.gov checks of vendors are obtained prior to contract / purchase order issuance / purchase, and at a minimum annually. All records will be maintained with Procurement. CLIENT RESPONSIBLE PARTIES: Angela Oakley, VP & Chief Financial Officer Wes Williams, VP & Chief Information Officer COMPLETION DATE: May 31, 2025

2024-004 Views of Responsible Officials and Planned Corrective Actions: Management agrees with the recommendation and has implemented measures to improve procurement recordkeeping and compliance. A structured procurement folders and subfolders system has been established to maintain all relevant documentation. Management is actively working with consultants to update policies and procedures. Staff is scheduled to complete a structured three-session training through GFOA to enhance their understanding of federal procurement regulations and best practices. The District will continue training and development efforts in public procurement, with a particular focus on federal compliance, strengthening internal controls, improving documentation, and ensuring adherence to regulatory requirements Responsible Party: Director of Finance & Administration and Department Managers Implementation Date: Ongoing; full implementation expected by June 30, 2025

x. Management Response and Corrective Action Plan: The first of the two identified vendors – Maxim/Amergis - is an employment agency with a specialty in staffing providers who work in the healthcare and social services field. NBCC was seeking to hire an RN. Significant documentable effort was invested in hiring an RN with the necessary experience to fill our vacant RN Healthcare Navigator position. After months of being unable to find an appropriate candidate, NBCC sought consultation from the Santa Barbara County Department of Public Health who advised us of the name of the employment agency (Maxim/Amergis) that is used by the Department of Public Health and Department of Behavioral Wellness to staff their RN positions. We reached out to Maxim/Amergis, provided them with the job listing, and reviewed resumes and interviewed candidates until we found an appropriate match. This was a prolonged and involved process where we spent a significant amount of time working to hire the best suited RN for working in the field with the homeless and formerly homeless individuals we serve. We did not perceive this to be a traditional procurement effort and therefore did not create a written analysis of our efforts to identify and hire an RN, nor did we conduct a SAM search on the company given that the company routinely staffs our departments of behavioral and public health. The second identified vendor is Paychex. We believe our efforts to secure a new payroll solution company were very much aligned with Uniform Guidance rules. Our external accounting firm and multiple staff spent more than one year interviewing multiple potential payroll solution providers, including but not limited to, Paychex, ADP, ClickUp, Inova, Credible, and Replicon, among others. We only reviewed two written cost proposals because only two of the researched and consulted companies were able to provide a solution that could potentially meet our government timesheet needs. We conducted multiple meetings with our external accounting firm and internal staff discussing and analyzing the solution options, but a summary of these discussions was not created. In addition, Paychex is a provider to a number of nonprofits we consulted, including a local grantee who was using their service, and who we were advised had developed a system similar to what we needed for our time and activity reporting requirements. We therefore presumed Paychex was not a debarred contractor given that other nonprofits we spoke to who have the same funding were utilizing their services. Moving forward, we recognize we must write a written analysis of our processes and that we should not assume a vendor has not been debarred given their existing customers and will be sure to confirm a company’s standing on SAM. As a further example of our commitment to always remaining current with procurement standards, at the direction of the Executive Director, our Operations Director had previously enrolled in a two-day Procurement Boot Camp training which occurred this week. Our Operations Director will revisit our procurement process as a result of this finding and after attending the procurement training and will make revisions to our procurement process as necessary to ensure future compliance with Uniform Guidance. Any updates will be made to the NBCC Internal Controls Manual and any new processes will be adhered to subsequent to those revisions. xi. Contact Person (s) Responsible for Corrective Action: Kristine Schwarz, Executive Director, kschwarz@sbnbcc.org Brenda Lang, Operations Director, blang@sbnbcc.org Michael Dzierski, Finance Director, mdzierski@sbnbcc.org xii. Anticipated Completion Date: The anticipated completion date is May 31, 2025.

DCHS has reviewed its procedures and will ensure that awards are reported timely and accurately to FSRS and that documenation of compliance will be available for review.

Finding 2024-001 Written Procurement Polley- This finding impacts the procurement and suspension and debarment compliance requirement for the major program, Assistance Listing Number 10.555 National School Lunch Program (Child Nutrition Cluster) funded by the Commonwealth of Massachusetts Department of Elementary and Secondary Education (DESE). Nurtury should revise its procurement policy to comply with Uniform Guidance requirements and implement policies and procedures to search for suspended or debarred vendors on Sam.gov. Fiscal Year 2025. Procurement policy is in accordance with Uniform Guidance requirements. Management and the finance committee of the board will ensure that revised procurement policies are in accordance with Uniform Guidance requirements. Tubi Olatubosun, V.P. of Finance

FINDING 2024-002 Information on the federal program: Subject: Child Nutrition Cluster - Internal Controls over Procurement and Suspension and Debarment Federal Agency: Department of Agriculture Federal Program: School Breakfast Program, National School Lunch Program, Supply Chain Assistance Program, Summer Food Service Program Assistance Listing Number: 10.553, 10.555, 10.559 Federal Award Numbers and Years (or Other Identifying Numbers): FY 22-23, FY 23-24 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 compliance requirements. Context: Procurement The School Corporation participates in Unified Purchasing Cooperative of the Ohio River Valley (the “Cooperative”), which procures vendors for food purchases and other supplies on behalf of its members. During the audit period, the School Corporation also purchased food and supplies from vendors not procured by the Cooperative. One vendor with aggregate annual purchases of $38,261 for fiscal year 2024 exceeded the small purchase threshold ($10,000 - $150,000). The School Corporation could not provide documentation showing the bids received from other vendors that were used to compare pricing. Suspension and Debarment For the small purchase vendor noted above that was 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 provide documentation confirming that the vendor was not suspended or debarred before disbursing federal funds during fiscal year 2024. 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: Ginny Shannon, FSD and Gretchen Berger, Corp Treasurer - 6-1-2025

CONDITION: The Beaver County Career and Technical Center contracted with a third-party vendor – Huckstein Mechanical for the purchase of technology equipment. The contracts were procured through a cooperative purchasing group. The Center 1) was unable to provide documentation from the cooperative purchasing group to verify that the technology procurement contracts were competitively procured, such as a bid evaluation and public solicitation and 2) did not obtain the adequate number of price or rate quotations. CRITERIA: As specified in 2 CFR 200. 318(i) of the Uniform Guidance, the Center 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. In addition, small purchase procedures per 2 CFR 200.320(a)(2)(i) for acquisitions between the micro-purchase threshold (currently $10,000) and the simplified acquisition threshold (current $250,000), price or rate quotations must be obtained from an adequate number of qualified sources as determined appropriate. Per 24 PS 8.807.1, there should be three quotes that are either written or well documented.MANAGEMENT’S CORRECTIVE ACTION PLAN: Management will review and update as necessary, it’s current procurement policies and procedures to ensure compliance with all applicable sections of the Uniform Guidance, in specific, Sections 2 CFR 200.318(i) and 200.320(a)(2)(i) of the Uniform Guidance, as well as 24 PS 8.807.1. In specific, these procedures will include 1) obtaining all relevant information pertaining to procurements involving federal assistance from any cooperative purchasing group and 2) obtaining quotations from three qualified providers where applicable and documenting those results. These two (2) updated procedures will be implemented during the remaining months of the 2023-2024 fiscal year, and all subsequent years, for future purchases where applicable.

FINDING 2024-003 Finding Subject: Child Nutrition Cluster – Procurement and Suspension and Debarment Summary of Finding: The School Corporation did not have effective internal controls in place to ensure contracted vendors were not suspended or debarred or otherwise excluded from participation in federal award programs. The School Corporation could not provide evidence of verification for Resolve Tech during the engagement period. Contact Person Responsible for Corrective Action: Teresa Whitesel Contact Phone Number and Email Address: 765-358-4006 twhitesel@wes-del.org Views of Responsible Officials: We concur with the finding Description of Corrective Action Plan: The Corporation Treasurer was not aware of this requirement. This will be completed by the next audit period of FY2025 FY2026

FINDING 2024-005 Subject: Child Nutrition Cluster – Internal Controls over Procurement and Suspension and Debarment 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 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 compliance requirements. Context: Procurement The School Corporation participates in K12’s Leading Indiana Cooperative (KLIC), which procures vendors for food purchases and other supplies on behalf of its members. During the audit period, the School Corporation also purchased food and supplies from vendors not procured by the Cooperative. One vendor with aggregate annual purchases of $62,545 and $49,614 for fiscal year 2023 and 2024, respectively, exceeded the small purchase threshold ($10,000 - $150,000). For the 2023 fiscal year, the School Corporation could not provide documentation showing the bids received from other vendors that were used to compare pricing. As it pertains to the 2024 fiscal year, the School Corporation could not provide any documentation surrounding the procurement of the small purchase vendor. Suspension and Debarment For the small purchase vendor noted above that was 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 provide documentation confirming that the vendor was not suspended or debarred before disbursing federal funds during fiscal year 2024. 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. Responsible Party and Timeline for Completion: Jessica Defossett, Annually in June or as new vendor is needed.