Corrective Action Plans

2024-002: Written Procurment, Suspension and Debarment Policy Finding Condition - The Town of Dayton did not have written controls in place to ensure that vendors were not suspended or debarred or included in the list of vendors prior to entering into a contract with the Town. The written standard of conduct covering conflicts of interest and governing the performance of its employees and contractors must be documented when engaged in the selection, award and adminstration of Federal grant contracts. Corrective Action Plan - Even though the Town didn't have a formal written policy in place regarding the search for suspended or debarred vendors/contractors, the Town did do the SAM's search before signing agreements with contractors on each of the Federal Grant projects that were in place during the year. A policy was written and signed on September 2, 2024.

Management at the Central Maine Growth Council is aware of its responsibility under 2 CFR 200.516(a) as it relates to the requirements to perform control activities related to suspension and debarment. • All recipients of expenditures under federal grants will be compared to the Office of Inspector General’s Exclusion Database to help ensure they are permitted to receive federal funding. This verification process will be documented and retained. • A written formal procurement policy and conflict of interest policy will be established. Responsible party: Garvan Donegan, Director of Economic Development and Strategic Projects (207) 680-7300 Anticipated completion date: December 31, 2024.

October 17, 2024 Cognizant or Oversight Agency for Audit: Department of Elementary and Secondary Education (DESE) Worcester Cuftural Academy Charter Public School respectfully submits the following corrective action plan for the year ended June 30, 2024 Name and address of independent public accounting firm: AAFCPAs, Inc. 50 Washington Street Westborough, MA, 01581 Audit period: July 1, 2023 through June 30,2024. The findings from the October 17, 2024 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS - FINANCIAL STATEMENT AUDIT FINDINGS SIGNIFICANT DEFICIENCY 2024-001 Massachusetts Teachers’ Retirement System (MERS) Enrollment. Recommendation: Management should ensue that proper controls are in place and operating effectively to ensure that that all MTRS eligible employees are fully enrolled within thirty days of their start date. We recommend management add enrollment of MTRS for eligible employees to its onboarding checklist. Action Token: We concur with the recommendation, and it was implemented effective September 1, 2024. 2024-002 Massachusetts Teachers’ Retirement Board (MTRB) Remittances Recommendation: Management should ensure that proper controls are in place and operating effectively to ensure all MTRS payroll withholdings are remitted timely. We recommend management add MTRB remittances to its monthly closing checklist. Action Token: We concur with the recommendation, and it was implemented effective September 1, 2024. 2024-003 Written Procurement Policy Recommendation: Management revise their poiicy to comply with current standards under the Uniform Guidance. Action Token: We concur with the recommendation, and it will be implemented effective January 1, 2025. If the Department of Elementary and Secondary Education (DESE) has questions regarding this plan, please call Erika Browning, 508-347-0252. Sincerely yours, Signature: Title: Tina Krasnecky, VP of Finance

Finding 2024-003 – Child Nutrition Cluster – Procurement Contact Person Responsible for Corrective Action: Marsha Bohannon, Controller Contact Phone Number: (317) 867-8000 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: We will contact our educational service center and see if they are able to either do an RFI or RFP for food service equipment maintenance or we will otherwise request three quotes for small purchases. We are currently under a contract with SmartCare for food service equipment maintenance until the end of this current school year. Anticipated Completion Date: July 1, 2025

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

As of November 1, 2024, the District will have implemented a process to determine the eligibility of potential vendors to participate in Federal assistance programs or activities prior to disbursing funds.

The District will review the requirements of 2 CFR Section 200.213 and ensure that procurement procedures are being followed and perform a review of the eligibility of potential vendors to ensure they are eligible to participate in Federal assistance programs.

Management’s Response and Planned Corrective Actions: 1. The name of the contact person(s) responsible for the corrective action a. Kathleen Broadhurst, Sr. Director of Finance/ShelterCare 2. The corrective action planned: a. Internal control document and procedure that is consistent with the compliance requirement for: i. CFR §200.318, General procurement standards identify all requirements which the offerors must fulfill and all other factors to be used in evaluating bids or proposals i. §200.319, Competition requirements will be met with documented procurement actions using strategic sourcing, shared services, and other similar procurement arrangements ii. §200.320 Methods of procurement to be followed. 3. The anticipated completion date: a. New processes will be implemented by 11/1/2024.

Reference Number: 2023-05 Finding Type: Significant Deficiency in Internal Control Over Compliance Description of Finding: The Organization did not follow required procurement procedures for subrecipient transactions. Though a procurement policy exists for the Organization, there was no enforcement of this policy for the federal program. Failure to follow a formal procurement policy causes the Organization to be out of compliance with Uniform Guidance and/or grant requirements and increases the likelihood of disallowance of costs. Statement of Concurrence: Management agrees with the finding, however the subrecipient was formally designated budget for the federal program by the pass-through grantor which is why a formal procurement process was not followed. The subrecipient received the same allocated federal funds for the same services provided in the prior year. Corrective Action: The Organization will review internal policies and procedures and ensure that it follows procurement practice for subrecipients under 2 CFR Sections 200.318 – 200.326. Completion Date: March 31, 2026 Name of Contact Person: Maureen Thomas Chief Financial Officer 917-405-7185 maureen@frfive.org

Contact Person: Iftin Hagimohamed; Chief Financial Officer Stephanie Sosa: Finance Manager Explanation and specific reasons for disagreement with the audit finding or that corrective action is not required (if applicable): Management concurs with the finding. Procurement documentation did not consistently evidence compliance with internal policy and 2 CFR §§200.318–200.326. Status: Corrective Action Taken Corrective action planned: Voices of Tomorrow will implement procurement software to automate workflows and approval processes for procurement purchases. Voices of Tomorrow will • Revise and formalize procurement policy to align fully with Uniform Guidance requirements.Implement a standardized procurement documentation checklist requiring evidence of procurement method, cost/price analysis, and approvals. • Require CFO pre-approval for federally funded procurements above established thresholds. • Conduct staff training on federal procurement standards. • Implement quarterly internal procurement compliance reviews. Anticipated completion date: April 2026: Policy revision and training completed within 60 days; quarterly reviews beginning next fiscal quarter.

CORRECTIVE ACTION PLAN FISCAL YEAR OF FINDING: June 30, 2023 AUDITOR FINDING: 2023-006 In accordance with 2 CFR Part 200.318 the recipient or subrecipient must maintain and use documented procedures for procurement transactions under a Federal award or subaward, including for acquisition of property or services. These documented procurement procedures must be consistent with State, local, and tribal laws and regulations and the standards identified in §§ 200.317 through 200.327. The Organization's purchasing policy did not contain elements of federal procurement requirements specified by Uniform Guidance. CLIENT PLANNED ACTION: The Organization will revise the Procurement Policy such that it is consistent with the appropriate regulations and standards and requires documentation of the vendor procurement policy. CLIENT RESPONSIBLE PARTY: Danielle Cordova, Controller COMPLETION DATE: July 1st, 2025

Corrective Action Plan - Subrecipient Monitoring Finding The City acknowledges the audit findings and recognizes the importance of strengthening internal monitoring practices to ensure full alignment with federal requirements. While there may be additional context to consider regarding the specific circumstances, we appreciate the opportunity to clarify those details and outline the corrective actions that have been taken and are planned. Subrecipient #1 – Edmonds College One of the subrecipients noted in the finding is a public higher education institution operating under the State Board for Community and Technical Colleges (SBCTC). The subrecipient administered the Student Emergency Assistance Grant (SEAG) in accordance with state guidelines that emphasize low-barrier, equity-focused access to emergency aid. These guidelines intentionally discourage requiring extensive documentation from students and instead rely on: - Written applications and student interviews - Internal verification using the college's ctclink student system - Program-level data tracking through financial aid systems - Quarterly reporting to the City, which was submitted Due to FERPA protections, the college was limited in the level of personal data it could share externally without student consent. While this model limited the City's ability to independently audit eligibility at the individual level, it is consistent with the state's recognized approach to supporting systemically disadvantaged students and aligns with SEAG Program principles. The City accepted this structure as appropriate during the agreement period. Subrecipient #2 – Washington Kids in Transition For the second subrecipient, the City followed its standard internal audit process, which includes a quarterly review of 10% of submitted invoices to validate eligibility and ensure federal program compliance. After completing the first-quarter audit, the City identified concerns related to the supporting documentation for certain grant disbursements. In response: - The City escalated oversight and required the subrecipient to submit documentation for 100% of invoices from May through July, encompassing both Q2 and Q3. - Concurrently, the City became aware that the subrecipient had not initiated or completed a Single Audit for FY2023. Upon learning that the audit would not be submitted by the federal deadline (September 30), the City immediately ceased all grant funding and closed the program. - Though additional invoices were received in August and September, the City determined that the heightened audit activity from May through July had addressed the prior concerns. Q3 was considered to have been appropriately audited, and no further audit was conducted for the final period. The City has not resumed any partnership with this entity since September 2024. - The subrecipient ultimately declined to obtain the required Single Audit for FY2023 and FY2024. Review of Prior – Year Subrecipient Audit Requirements As part of the City's monitoring efforts for subrecipients from previous fiscal years, the Deputy Director of Finance at the time requested Single Audit reports directly from the two college subrecipients and was ultimately able to obtain the reports through the Federal Audit Clearinghouse (FAC). While the City does not have documentation to confirm this process, it was discussed during internal meetings that the reports had been reviewed, and this task was considered complete at the time. Of the four subrecipients referenced in the audit, the third was a nonprofit organization for which the Deputy Director reviewed publicly available financial records. Based on that review, it was determined the organization did not meet the $750,000 federal expenditure threshold and was therefore not subject to a Single Audit. The fourth subrecipient, the entity that did not complete the required audit, was addressed in the corrective actions outlined above. Planned and Ongoing Corrective Actions To strengthen subrecipient oversight moving forward, the City is implementing the following corrective actions: - Updated Subrecipient Agreements: All future contracts will include specific and detailed language regarding audit thresholds, access to documentation, and monitoring expectations, including reference to Uniform Guidance requirements. - Audit Verification Procedures: The City will implement a documented protocol for tracking and verifying Single Audits for any subrecipient receiving $750,000 or more in federal funds. - Monitoring Documentation: The City will maintain written records of all monitoring activities, including eligibility reviews, audit follow-up, and subrecipient communication. - Staff Training and Process Improvements: Staff responsible for subrecipient oversight will receive updated training on monitoring standards, documentation expectations, and federal compliance protocols. These actions will be implemented prior to any future program launches involving subawards of federal funds and will also apply to the monitoring of any current active grants. Although no additional funding of this type was issued in 2024, the City will be subject to audit for this period and will ensure compliance with all applicable requirements, including collecting the FY2024 Single Audit reports as required. Corrective Action Plan – Procurement "The City's internal controls were ineffective for ensuring it complied with federal procurement requirements. Although the City has written procurement policies, they do not address requirements for piggybacking and purchasing through a cooperative." Our response to the auditor's statements regarding the vehicles purchased with ARPA funds are as follows. "The City's internal controls were ineffective for ensuring it complied with federal procurement requirements. Although the City has written procurement policies, they do not address requirements for piggybacking and purchasing through a cooperative." - The City's Purchasing Policy addresses requirements for "piggybacking" and purchasing through a Cooperative in section 13.0 lnterlocal Agreements. However, the City should update the Purchasing Policy section 11.0 Procurement Using Federal Funds to include the same language that specifies the process of Interlocal and Cooperative agreements, or “piggybacking”. - As stated in the auditor's draft notification, state and federal requirements allow it to bypass normal procurement laws through a process commonly referred to as "piggybacking". This process allows entities to purchase goods and services using contracts awarded by another government or group of governments via an interlocal agreement or cooperative. When piggybacking, the entity must enter into an agreement before it purchases services or goods from another entity's contract. If the City uses such an agreement, federal regulations require it to confirm the awarding entity followed all procurement laws and regulations applicable to the entity when selecting the contractor. To ensure compliance, - Although the city did confirm that the vendor followed their own bid law requirements, the City will do a better job documenting that verification in any future equipment purchases using federal funding.

FINDING 2023-004 Contact Person Responsible for Corrective Action: Craig Zandstra Contact Phone Number: 219-945-0543 Ext 234 Contact Email: craigz@lakecountyparks.com Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan As this finding is shared between The Lake County Board of Commissioners and the Lake County Parks & Recreation Department, both departments will develop procedures to ensure the appropriate procurement methods are used for vendors that are within the Small Purchase Threshold. Both departments will also ensure that vendors are not suspended or debarred when expanding federal funds. Lastly, appropriate documentation will be maintained to ensure compliance with procurement, suspension and debarment in the future. Completion Date: June 2026

Cause: While policies were in place, detailed written procedures for consistent grant administration had not been developed or formally documented. Corrective Action Taken: A procedure manual has been written to incorporate required compliance areas, including allowability of costs, procurement, equipment management, cash management, time and effort reporting, suspension and debarment, and record retention. Planned Corrective Actions / Preventive Measures: 1. Procedure Development: Document clear written procedures including requisitioning, approvals, reimbursements, reporting, and monitoring. 2. Training and Implementation: Provide training to all staff involved in grant administration on the new procedures. Establish a schedule for periodic refresher training and updates when regulations or program requirements change. 3. Ongoing Monitoring: Designate the Business Administrator (or designee) to monitor compliance and review procedures annually. Update policies and procedures as needed to reflect changes in federal requirements or internal practices. Timeline: Procedures completed: September 2024. Staff training and implementation: June 2026. Ongoing monitoring: Annually, beginning March 2026 Responsible Parties: Lori Schmidt, Business Administrator: Oversight of policy and procedure revision, implementation, and monitoring. Scott LaFortune, Finance Manager/Grant Manager: Day-to-day adherence to procedures and reporting. School Board: Formal policy approval.

Views of Responsible Officials and Corrective Action While the Organization concurred with the prior year (2022-003) and current year renumbered recommendation (2023-003), the Organization notes the corrective actions that have been implemented, specifically related to the 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); and development of a comprehensive HRSA group of related policies and procedures. A. Financial Policies – May 2025. While the Organization initially prioritized the completion and distribution of the updated financial policies and procedures by December 31, 2024, by May 2025, the Organization 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. Simultaneous to the policy work described above, several processes to guide and align procurement practices, throughout the Organization, was initiated, including the use of MTPF, Request(s) for Professional Services Qualifications, Request(s) for Professional Services, Request(s) for Proposal, and to date implementation of the processes continue. C. HRSA Policies – July 2025. By July 2025, the Organization 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. In August 2025, the Board was provided policies developed within the Organization’s policy framework, including the above policies. The current practices of the Organization, to the present period of the report dated March 2, 2026, is consistent with such developed policies.

The procurement policy as well as all policies are reviewed every three years to comply with Joint Commission Standards. Saint Anthony will review its existing procurement policy to ensure that all elements required by the Uniform Guidance are incorporated. The review was completed on March 28, 2025.

Reference Number: 2023-007 Finding: Improve Controls and Compliance with Procurement Name of Contact Person: Christine Chamberland Corrective Active Plan: The City will develop and implement standardized procurement procedures specifically for federally funded purchases, ensuring that all transactions are fully documented in accordance with applicable procurement policies. Staff will be trained on these procedures, and a central repository will be established to maintain executed contracts and all supporting documentation. Regular audits will be conducted to verify compliance and that all required records are retained and readily accessible. Proposed Completion Date: 6/30/26

In response to noted deficiencies in procurement, suspension, and debarment documentation, the Organization has developed a comprehensive Grant Cycle Standard Operating Procedure aligned with the OMB Uniform Guidance to ensure compliance going forward. This procedure reinforces the existing Procurement policy, which ensures staff receive targeted training on relevant requirements, and incorporates additional review measures, including during the onboarding process for new hires. Furthermore, the Grants Director must review all invoices and ensure procurement support is provided prior to approval. The Organization also implemented a new management platform to manage purchase orders, maintain sourcing documentation, and verify contractors are not suspended or debarred, thereby ensuring full compliance with federal requirements and promoting transparency in contractor eligibility and competitive bidding. In addition, prior to contract execution or payment, staff are required to perform and document a SAM.gov suspension and debarment verification for all vendors exceeding the micro-purchase threshold. Documentation of the veri􀀁ication is maintained in the procurement 􀀁ile and must be present prior to invoice approval. Payments cannot be processed without this documentation.

The department will adopt written policies with the Uniform Guidance for Federally Funded Grant Programs accepted by the department.

Audit Finding: 2023-003 – Procurement Documentation Planned Corrective Action(s): SIG-NAL will strengthen its procurement controls by fully implementing the updated Procurement Policy and Standard Operating Procedure adopted in 2025. Standardized procurement documentation templates will be developed, including checklists for method of procurement, contractor selection, cost/price analysis, and justification, and will be used for all purchasing actions. The organization will require that all procurement records are completed and retained in accordance with 2 CFR §§ 200.318–320. Anticipated Completion Date ● April 2026 Responsible Party ● Director of Operations, with support from the Finance Team and Executive Director

FA 2023-001 Improve/Strengthen Controls over Expenditures Compliance Requirements: Internal Control Impact: Compliance Impact Federal Awarding Agency: Pass-Through Entity: Assistance Listing Number and Title: Federal Award Number: Questioned Costs: Repeat of Prior Year Finding: Activities Allowed or Unallowed Allowable Costs/Cost Principles Period of Performance Procurement and Suspension and Debarment Material Weakness Material Noncompliance U.S. Department of Education Georgia Department of Education 84.371C - Comprehensive Literacy Development S371C190016-19A (Years: 2017-21) $124,399.84 FA 2022-002 Description: A review of expenditures and journal entries charged to the Comprehensive Literacy Development program revealed that the School District's internal control procedures were not operating to ensure that appropriate reviews and approvals occurred and the School District's procurement procedures were followed. Corrective Action Plans: The School District will review established internal controls and procedures with pertinent staff to ensure all are being followed. Expenditures related to the grant will be reviewed by the Director in charge of the grant to ensure proper approvals are maintained and packing slips are submitted with the invoice for payment. In the event a packing slip is not received, a note will be included to indicate such. All journal entries related to the grant will be submitted by the Finance Director to the Director in charge of the grant for approval. The School District will review established internal controls and procedures with pertinent staff to ensure all are being followed. Procurement transactions related to the grant will be reviewed by the Director in charge of the grant to ensure proper supervisor review and approvals are maintained. The Director in charge of the grant will review and update the current procedures to ensure that the required procurement methods are properly identified and followed and that required procurement documentation is properly identified, safeguarded, and retained. Estimated Completion Date: June 30, 2026 Contact Person: Dr. Angela Williams, Superintendent Telephone: 706-554-5101 Email: amwilliams@burke.k12.ga.us

Corrective Actions Planned To address the deficiency in internal controls over compliance with respect to procurement, CHC will implement the following corrective actions: CHC will develop and implement a written procurement policy that conforms to the Uniform Guidance.; CHC will ensure sta􀀁 receive adequate training on the procurement policy and the required methods of procurement to be made when making procurements with federal awards. Responsible Person(s): CHC President, Rob Dibble as Primary; CHC Vice President Betsy Gordon as Backup Corrective Action Plan Dates: Schedule implementation starts: February 1, 2026; Staff training starts: March 1, 2026; Review process in effect starts: April 1, 2026

Finding Reference: 2023-003 Coronavirus State and Local Fiscal Recovery Funds Description: During our discussions with management and testing of the major program, we noted that the Town is not verifying the eligibility of vendors to participate in Federal assistance programs. Recommendation: We recommend that the Town review the requirements of 2 CFR Section 200.213 and ensure that a review of the eligibility of potential vendors to participate in Federal assistance programs or activities is performed prior to disbursing funds to the vendor. Corrective Action: Moving forward, the Town of Guilderland will ensure that vendors are not included on the suspended or debarred list to ensure compliance with the requirements noted above. Person(s) Responsible for Corrective Action: Darci Efaw, Comptroller & Jessica Gulliksen, Fiscal Officer Anticipated Completion Date for Corrective Action: The practice noted above was implemented during September of 2024.

We acknowledge that the purchase of gift cards was not an allowable expense under federal grant guidelines. During the COVID-19 pandemic, our staff were tasked with responding to urgent and overwhelming public health demands, particularly as the New Mexico Department of Health became overextended. To recognize staff who went above and beyond to ensure timely case reporting and investigations for tribal communities, gift cards were used as a form of appreciation. Moving forward, we will ensure full compliance with federal grant requirements. Specifically: 1. We will adhere strictly to the cost principles and allowability guidance outlined in federal regulations and the terms of each Notice of Award. 2. In instances where the allowability of an expense is unclear, we will proactively seek guidance and written approval from our Federal Grant Management Officer before incurring the cost. 3. We will provide refresher training to program and fiscal staff on allowable costs under federal awards to prevent recurrence of similar findings. These corrective actions will ensure future expenditures are fully compliant with federal guidelines and that staff recognition practices remain appropriate, allowable, and consistent with award terms. • Immediate (Already in Effect): Ceased use of gift cards and other unallowable incentives. • Within 30 Days: Finance and program leadership will review current grant guidance and distribute a written summary of allowable/unallowable costs to all program managers. • Within 60 Days: Refresher training on federal cost principles (2 CFR 200) and Notice of Award guidance will be provided to all program and fiscal staff. • Ongoing: When ambiguity exists regarding allowable costs, staff will consult with the Federal Grant Management Officer prior to obligating or expending funds. Designation of Employee Position Responsible for Meeting Deadline Program Managers/Directors, Finance Officer, and Accounting Manager.

Management acknowledges this finding, which occurred during a period of rapid program expansion when procurement infrastructure had not yet been fully developed. Since the audit period, we have completely overhauled our procurement process to ensure full compliance with the Federal procurement standards. We have implemented a formal procurement policy, created a dedicated Procurement sub-department within Finance, hired a Procurement Supervisor and support team, and launched a new procurement software platform to ensure proper solicitation, documentation, approval routing, and record retention for all Federally funded programs. These upgrades establish consistent competitive bidding, justification procedures, conflict-of-interest safeguards, and transparent procurement. In addition, we have strengthened oversight, provided staff training on Federal procurement standards, and embedded monitoring practices to ensure ongoing compliance. Management is confident these substantial structural improvements have significantly reduced the risk of noncompliance and positioned the organization for full alignment with federal procurement standards going forward.