Corrective Action Plans

MATERIAL WEAKNESS IN INTERNAL CONTROL OVER COMPLIANCE AND MATERIAL NONCOMPLIANCE – U.S. DEPARTMENT OF AGRICULTURE, PASSED THROUGH MINNESOTA DEPARTMENT OF EDUCATION, CHILD NUTRITION CLUSTER – FEDERAL ALN 10.553, 10.555, AND 10.559 2024-002 Internal Control Over Compliance and Material Noncompliance With Federal Procurement, Suspension, and Debarment Requirements Finding Summary 2 CFR § 180 and 2 CFR § 200.318-327 requires the District to establish and maintain effective internal control over compliance with requirements applicable to federal program expenditures, including procurement, suspension, and debarment requirements applicable to the child nutrition cluster federal program. During our audit, we noted the District did not have sufficient controls in place resulting in material noncompliance within its child nutrition cluster federal program to ensure compliance with federal procurement requirements related to methods of procurement and to assure that it was not contracting for goods or services with parties that are suspended or debarred, or whose principals are suspended or debarred from participating in contracts involving the expenditures of federal program funds. Corrective Action Plan Actions Planned – The District is in the process of reviewing and updating its policies and procedures relating to procurement, suspension, and debarment for its federal programs to ensure compliance with the Uniform Guidance in the future. The review of procedures will also include steps to assure that district personnel are following the requirements of the Uniform Guidance related to methods of procurement and maintaining appropriate documentation. Official Responsible – Kathleen Heider, Finance Director. Planned Completion Date – June 30, 2025. Disagreement With or Explanation of Finding – The District is in agreement with this finding. Plan to Monitor – Kathleen Heider, Finance Director, will assure appropriate internal controls and procedures are updated and in place to ensure compliance with procurement, suspension, and debarment requirements.

Primo Center for Women and Children has immediately implemented an update to the existing procurement procedure to ensure complete records are maintained for all procurement activities, including quotes from other qualified sources and documentation of the bid selection process. The agency considers the Plan fully implemented and complete as of December 31, 2024.

Views of Responsible Officials The Health Department agrees with this finding. Corrective Action Plan The Health Department will establish a robust system of controls to ensure it complies with its procurement policy when entering into covered transactions. Name of Responsible Individual Teresa Anderson, Health Director Anticipated Completion Date January 31, 2025

CORONAVIRUS STATE AND LOCAL FISCAL RECOVERY FUNDS, ASSISTANCE LISTING No. 21.027, PROCUREMENT AND SUSPENSION AND DEBARMENT Name of contact person: County Commissioners Corrective Action: Roosevelt County will follow the procedure of verifying contractors through SAM or GSA Websites when using SLFRF funds. Proposed Completion Date: Immediately.

We will develop a formal procurement plan for federal expenditures which will include the specific processes for selecting vendors including documentation retention of the selection process. The policy will also include the process to be followed for verification of vendor suspension or debarment. At the time of the policy’s adoption by the Division, the document will be shared with all corps officers and program administrators throughout the Division. The Divisional Contract Compliance Manager will be responsible for identifying grants to which the policy would apply and to assist with retaining the documentation.

Susquehanna Township School District respectfully submits the following corrective action plan for the year ended June 30, 2024. The finding from the schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the numbers assigned in the schedule: A. Compliance Findings Finding 2024-001: Procurement Federal Agency: U.S. Department of Education Pass-through agency: Pennsylvania Department of Education Assistance Listing Number: 84.425 Education Stabilization Fund; 84.027 IDEA Recommendation: The Subrecipient must implement procedures to fully comply with Uniform Guidance Procurement requirements. View of Responsible Officials and Corrective Action Planned: The District will require all payments to have either a purchase order or request for payment form completed. The Accounts Payable Coordinator is responsible for ensuring the form is signed for all disbursements. For the particular item cited by our monitors the Superintendent and Business Manager signed off on the invoice instead of a request for payment form. The District Accountant / Business Office Manager discussed with the Accounts Payable Coordinator that going forward this is insufficient. All payments must have either a purchase order or request for payment form. The District Accountant / Business Office Manager reviews backup documentation for check disbursements. During their review if any payments are discovered to be missing a purchase order or request for payment form, he will notify the Accounts Payable Coordinator to complete the form. This is effective immediately. The District has also reviewed the applicable Uniform Guidance Procurement requirements and has developed an electronic procurement process that all staff member making the purchase with federal funds, must complete a form prior to the procurement being made. Then the Business Manager approves the form. There is a box to check if the procurement is a sole source. If this is checked the Business Manager will require justification. This process was presented by the Business Office to Leadership Personnel on 5/9/24 and is effective now. Person Responsible: Oslwen C. Anderson, Jr., Business Manager OCA Completion Date: June 30, 2024

Corporación La Fondita de Jesús Corrective Action Plan December 27, 2024 Finding number: 2024-001 Federal program: 14.267 Continuum of Care Category: Compliance/internal control Condition: An immediate family member of the Executive Director was promoted to Director of Services, and the safeguard measures established in the Conflict-of-Interest policy and the new organizational protocol were not followed. The following instances were noted: • The Employment Agreement was signed exclusively by the Executive Director and the Director of Services. • The Reasonable Accommodation of the Supervisory Role of the Director of Services Agreement was signed exclusively by the Executive Director and the Director of Services. In addition, another immediate family member of the Director of Services was hired as a professional contractor. At the time of the recruitment, the document establishing the relationship was not signed. Subsequently, the referred document was signed, but it did not specify the existing conflicts between the Director of Services and the Executive Director. Views of responsible officials: Management agrees with the audit findings and is committed to addressing the issues identified to ensure compliance with CFR 200.318, our Conflict-of- Interest policy, and new organizational protocols. We would like to bring to your attention that effective on November 30, 2024, the Executive Director resigned from his position with Corporacion La Fondita de Jesus. We will review and revise our Conflict-of-Interest policy and protocols to ensure they are comprehensive and clear. This includes detailing the steps to be followed when hiring or promoting individuals with familial relationships within the organization. We will establish an independent review and approval process for all employment and promotion agreements involving immediate family members of senior management. This process will include an additional review by a member of the executive committee of the Board of Directors to ensure objectivity and compliance with policies. We will review all contracts to ensure that they comply with the conflict-of-interest clause. Names of the contact persons responsible for the corrective action plan: Geraldine Bayron, Interim Executive Director, and Javier Fraguela, Board of Directors Anticipated completion date: March 31, 2025

Management will review their current procurement policies and make any necessary changes to update the policies to be compliant with 2 CFR Sections 200.138 – 300.327. We anticipate that the corrective action will be completed within 12 months.

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

Management concurs with this finding. Management has taken steps to review and revise its procurement policies to comply with state and local laws, the standards of the CFO, as well as current operating procedures. The fining relates to contracts that were originally procured prior to the change in policies, with only renewals in the financial statement periods. Going forward, Management will document basis for procurement for renewals of contracts that originated prior to the new policies and procedures implementation.

Child Nutrition Cluster – Assistance Listing No. 10.553, 10.555, 10.559, and 10.582 Recommendation: We recommend that the Board enhance controls and procedures to ensure that it follows its procurement policies for all goods and services charged to the program. Documentation should be readily available for audit. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Purchasing procedures and thresholds were discussed at a leadership meeting of the Department of Food and Nutrition Services. Specifically, the need for at least two quotes for purchases between $15,000 and $50,000 was reiterated. On an ongoing basis, expenditures by vendor will be reviewed to ensure compliance with the procurement policy. Name of the contact person responsible for corrective action: Jaime Hetzler, Director of Food and Nutrition Services Planned completion date for corrective action plan: For immediate implementation and ongoing.

Criteria: According to 2CFR 200.318(i) the recipient or subrecipient must maintain records sufficient to detail the history of each procurement transaction. The records must include the rationale for the procurement method, contract type selection, contractor selection or rejection, and the basis for the contract price. Condition: The School did not maintain records for a food vendor that met the simplified acquisition threshold for the year. Cause: The School's procurement policies do not address the frequency of which vendors should be evaluated. In addition, the policies also do not address records retention. Potential Effect: The procurement may not have been proper under the grant requirements. Recommendation: We recommend that the School follow federal procurement guidelines for each of the different purchase thresholds for each vendor. We further recommend that the School retain any documentation created related to the procurement selection and vetting process. Action: As of the date of this exit conference, we will adopt the above recommendations, securing and retaining the appropriate documentation of vendor selection and retention.

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

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

Findings and Questioned Costs Related to Federal Awards Finding Number: 2024‐001 Program Name/Assistance Listing Title: Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number: 21.027 Contact Person: Cheryl Burt, Director of Purchasing; Courtney Pina, Executive Director of Finance Anticipated Completion Date: Ongoing Planned Corrective Action: Issue Identified – The District failed to follow Federal, State, and Board policies and regulations governing procurement when procuring a multi‐year professional development support services contract for $111,200. Instead of issuing a formal procurement process, the District used quotes, which did not meet compliance requirements under 2 CFR §§200.318–200.326. Actions Taken to Address the Finding 1. Immediate Remedial Actions o Contract Review: Conducted a thorough review of the contract in question and determined steps to ensure compliance with applicable policies. o Internal Notification: Informed all relevant staff and departments about the compliance violation to prevent similar issues in the future. 2. Policy Review and Alignment o Procurement Policy Review: Conducted a comprehensive review of internal procurement policies to ensure alignment with federal requirements outlined in 2 CFR §§200.318–200.326, as well as applicable state and board requirements. o Threshold Verification: Confirmed that all documented thresholds for procurement types (e.g., formal procurement, quotes) are clearly stated in district policies to ensure consistency and compliance. Actions Planned to Prevent Future Occurrences 1. Training and Awareness o Staff Training: Implement mandatory training for staff involved in procurement processes to ensure familiarity with federal, state, and board regulations. Training sessions will emphasize formal procurement thresholds and the procedures for multi‐year contracts. o Annual Refresher Training: Conduct annual training sessions to maintain staff awareness of procurement requirements and reinforce adherence. 2. Strengthening Internal Controls o Requisition Review: Implement an enhanced approval process requiring multiple levels of review for all procurement transactions exceeding $50,000 to ensure compliance before purchase. o Checklist Requirement: Provide approvers with a compliance checklist verifying adherence to federal, state, and board procurement requirements before approving requisitions. 3. Ongoing Monitoring o Quarterly Audits: Schedule quarterly internal audits of procurement transactions to verify compliance with established policies and identify any gaps early.

Suspension and Debarment, Child Nutrition Cluster Recommendation: We recommend the district implement a process to check for suspension and debarment for all vendors exceeding the threshold for purchases. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: The Food Service Director will be checking for suspension or debarment and keeping track of this on a spreadsheet. Responsible official: Michael VandenBush, Food Service Director Anticipated completion date: 2024-25 Fiscal Year

Finding 2024-002 – Child Nutrition Cluster – Procurement 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 $69,649 in FY23 and $110,313 in FY24 for food service technology support. The School Corporation did properly perform a suspension and debarment check on the vendor. Contact Person Responsible for Corrective Action: Leslie Beach, Director of Food Services Contact Phone Number: 812-542-2245 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: An RFP will be conducted for the technology support. Anticipated Completion Date: Summer 2025

Description of Finding: The City’s procurement standards do not include the essential elements as outlined in 2 CFR sections 200.318 through 200.326. Statement of Concurrence or Nonconcurrence: Management agrees with this finding. Corrective Action: Management has implemented a revised procurement policy which complies with Uniform Guidance. However, it was not in place until June 2024. Name of Contact Person: Jared Schmitt, Chief Financial Officer Projected Completion Date: June 30, 2025

Description of Finding: The Board of Education failed to solicit quotations related to a contract paid under the grant, in noncompliance with federal/local policy. Statement of Concurrence or Nonconcurrence: Management agrees with this finding. Corrective Action: Management will review existing processes and contracts to ensure procurements are taking place in compliance with local policies and federal guidance. Name of Contact Person: Lunda Asmani, Chief Financial Officer, Board of Education Projected Completion Date: June 30, 2025

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

Finding 2024-004 Procurement, Suspension and Debarment Significant Deficiency in Internal Control over Compliance Finding Summary: During the course of the engagement in testing of procurement, suspension and debarment it was identified that the School’s micro-purchase threshold did not satisfy the requirements of 2 CFR sections 200.318 through 200.326. Responsible Individuals: Brandon Lunak, Superintendent Corrective Action Plan: The District will update their procurement policy for federal programs to be in compliance with all areas as identified in 2 CFR sections 200.318 through 200.326. Anticipated Completion Date: June 30, 2025

NONCOMPLIANCE WITH PROCUREMENT AND SUSPENSION AND DEBARMENT REQUIREMENTS, CORONAVIRUS STATE AND LOCAL FISCAL RECOVERY FUNDS; AL No. 21.027; GRANT No. Direct allocation and AM-23-0287 Name of contact person: Kelly Strecker Corrective Action: The City commits to ensuring that a procurement policy be put in place that will allow it to comply with procurement standards outlined in the Uniform Guidance. Proposed Completion Date: Immediately

Finding Number: 2024-001 Program Name/Assistance Listing Title: COVID-19 Coronavirus State and Local Fiscal Recovery Fund Assistance Listing Number: 21.027 Contact Person: Jeremy Bow, Director of Finance Anticipated Completion Date: August 12, 2024 Planned Corrective Action: In May of 2020, amid the urgent health and safety impacts of the global Covid-19 pandemic, Emerge closed its emergency shelter facility in order to transition to the use of a hotel to provide a non-congregate shelter setting for its Participants. In the urgency to make the transition and the uncertainty of the duration of stay, Emerge did not perform a SAM.gov review of the hotel for suspension or debarment, as federal funds were not anticipated to be utilized at the time. In April 2022, Emerge surpassed the $25,000 threshold for federal funds paid to this vendor during a fiscal year. Having previously been operating out of the hotel for nearly 2 years prior, the need for a SAM.gov review was overlooked at that time and was not identified on the audits for either fiscal year 2022 or 2023. When notified of the deficiency on August 12, 2024, during initial field work for the audit of fiscal year 2024, Emerge took same-day action to resolve the previous oversight. On August 12, 2024 Emerge performed the necessary check via SAM.gov and confirmed the vendor hotel was free from suspension or debarment. Concurrently, Emerge revised its Procurement Policy to specifically require compliance with Federal Acquisition Regulation Systems - 2 CFR §180.300 & §180.995. Per Emerge Procurement Policy, revised August 2024: “Any Agency procurement action which will utilize federal or sub-federal funds, in full or in part, shall be done so in compliance with Federal Acquisition Regulation Systems - 48 CFR §2 Subpart 2.1, 2 CFR §200 Subpart D, and 2 CFR §180.300 & §180.995 as required by federal regulation. Compliance with this and all other Federal guidance shall be the shared responsibility of the Chief Executive Officer, Senior Leadership, and the Director of Finance. Copies of these regulations shall be maintained by the Agency for reference.” It is Emerge’s perspective that appropriate action has been taken in order to substantially mitigate the risk of recurrence based on the revisions to its Procurement Policy and the internal reviews of both the revised policy and the audit finding with Senior Leadership.

Material Weakness in Internal Control Over Compliance and Other Matters Recommendation: We recommend the District ensures it retains all documentation for procurement methods used such as retaining all quotes/bids received, as well as formally documenting rationale for all procurement decisions made. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The District will work to revise its procurement procedures and policies to ensure compliance with documentation requirements. Specifically, the District will implement a system to retain all quotes/bids received and formally document rationale for all procurement decisions. Name(s) of the contact person(s) responsible for corrective action: David Brecht, Executive Director of Finance and Operations. Planned completion date for corrective action plan: June 30, 2025

Material Weakness in Internal Control Over Compliance Recommendation: We recommend the District ensures it retains all documentation for procurement methods used such as retaining all quotes/bids received, as well as formally documenting rationale for all procurement decisions made. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The District will work to revise its policies and procedures to ensure that all required documentation, including quotes, bids, and the formal rationale for procurement decisions, is retained in compliance with best practices and applicable regulations. These updates will include clear guidelines for procurement methods, documentation requirements, and accountability measures to ensure compliance moving forward. Name(s) of the contact person(s) responsible for corrective action: David Brecht, Executive Director of Finance and Operations. Planned completion date for corrective action plan: June 30, 2025