Corrective Action Plans

FINDING 2023-005 Finding Subject: Special Education Cluster (IDEA) – Procurement and Suspension and Debarment Summary of Finding: Procurement Federal regulations allow for informal procurement methods when the value of the procurement for goods or services does not exceed the simplified acquisition threshold, which is customarily set at $250,000. However, Indiana Code 5-22-8 has a more restrictive threshold of $150,000 or less for when small purchase procedures may be used. This informal process allows for methods other than the formal bid process. The informal process is divided between two methods based on thresholds. Micro-purchases, typically for those purchases $10,000 or under, and small purchase procedures for those purchases above the micro-purchase threshold, but below the simplified acquisition threshold. Micro-purchases may be awarded without soliciting competitive price rate quotations. If small purchase procedures are used, then price or rate quotations must be obtained from an adequate number of qualified sources. If it is determined a single source provider can be used for a small purchase, documentation must be retained supporting the determination. The Cooperative did not adhere to the requirements necessary for them to be in compliance with the procurement of small purchases during the audit period. Suspension and Debarment The School Corporation did not have internal controls in place to ensure compliance with the suspension and debarment requirement. The Cooperative did not have adequate internal controls in place to ensure all applicable vendors were not suspended or debarred prior to entering into a covered transaction. As such, the Cooperative never entered into a contract, although their payments to the vendor exceeded $50,000. The Cooperative did not perform procedures to ensure that the vendor was not suspended or debarred from participation in federal programs. Contact Person Responsible for Corrective Action: Julie Dudley Contact Phone Number and Email Address: 812.537.7205 jdudley@lburg.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The ROD Special Education Cooperative will make notes in the Board Minutes regarding the fact that only one vendor can provide specific services prior to entering into a contract or purchasing said services. Each company providing services will be checked on the SAM.gov website to ensure that the vendor has not been suspended or debarred. This documentation will be provided to the ROD board for review, and our Superintendent is a member of that board. Anticipated Completion Date: February 1, 2024

Specific corrective action plan for finding: Christi Walter, Coordinator Purchasing Department along with the Dom Atcitty, Grants Specialist, will review vendors that are issued requisitions at each approval level to assist in catching $25K or more for Suspension and Debarment. A printed document from SAM.GOV verifying eligibility to Requisitions over $25K should be attached. At the initial setup of new vendors, the Purchasing Department will review vendors in SAM.GOV. A printed document from SAM.GOV verifying eligibility of vendor will be attached to the vendor file. Timeline for completion of corrective action plan: July 1, 2023 Employee position(s) responsible for meeting the timeline: Dom Atcitty, Grants Specialists; Christi Walter, CPO; Lisa Smith, Purchasing Specialist; Bellamie DeHerrera-Presley, Federal Grants Coordinator and Erica Benally, Federal Grants Specialist

FINDING 2023-005 Finding Subject: Child Nutrition Cluster - Procurement and Suspension and Debarment Summary of Finding: Management had not developed a system of internal controls that would have ensured compliance with the grant agreement and the Procurement and Suspension and Debarment compliance requirement. The failure to establish an effective internal controls system enabled material noncompliance to go undetected. Noncompliance with the grant agreement and the Procurement and Suspension and Debarment compliance requirement could result in the loss of future federal funds to the School Corporation. We recommended that the School Corporation's management establish a system of internal controls to ensure compliance with the Procurement and Suspension and Debarment compliance requirement. Contact Person Responsible for Corrective Action: Andrea Miller Contact Phone Number and Email Address: 765-564-2100, millera@delphi.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The Food Service Director will obtain 3 quotes for any purchase over $10,000 from different vendors, in addition if the purchase is over $50,000 a contract will be awarded. Vendors will be verified by SAM.gov for suspension and disbarment, a record of these searches will be printed and kept in the vendor file. In addition, a vendor list will be provided annually to the school board for approval. Anticipated Completion Date: July 2024

This document serves as the response to the 2022-2023 Financial Audit on behalf of BELIEVE Schools, Inc. We’ve identified and reviewed the finding outlined below: The results of our auditing procedures disclosed one instance of noncompliance which is required to be reported in accordance with Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (“Uniform Guidance”) and which is described in the accompanying schedule of findings and questioned costs as Finding No. 2023- 001. Our opinion on the major federal programs is not modified with respect to these matters. In an effort to address the finding and to ensure the school's alignment with federal compliance standards, the following corrective action plan has been implemented for all purchases made with federal and state program funds: 1. For any procurement or contract ranging from $10,000-$250,000, The Principal, Angel Jackson-Anderson, should seek to acquire as many quotes as possible, aiming for up to five. Prior to finalizing any purchase order, invoice, or commencement of production, the school is mandated to receive and assess three price comparisons from different businesses or organizations. These price comparisons must be logged in the BCCHS Quote Comparison Template and reviewed by the following parties: a. The individual conducting the price comparison b. Building Level Operations Leader c. Executive Director for purchases or contracts exceeding $20,000 2. For any purchase or contract exceeding $250,000, a formal bidding process is required. BELIEVE Schools has adopted resources provided by the Indiana Department of Education: a. Procurement Checklist b. Procurement Plan Template (accessible through DOE) This protocol has been incorporated into the Standard Operating Procedures and School Handbooks, with all relevant stakeholders duly informed on February 16th, 2024.

FINDING 2023-003 Finding Subject: Subject: Child Nutrition Cluster - Procurement Summary of Finding: An adequate number of quotes were not obtained for small purchases. Contact Person Responsible for Corrective Action: Kellie Romer (Corporation Treasurer/Finance Director), Shelley Gardner (Corporation School Food Authority) Contact Phone Number and Email Address: 765-653-9771 Ext. 1010, kromer@greencastle.k12.in.us, 765-653-9771 Ext. 1011, sgardner@greencastle.k12.in.us Views of Responsible Officials: We concur with the finding Description of Corrective Action Plan: The procurement (small and micro purchases) will be verified by a two-person internal control; the food services director and food services assistant, finance director or deputy treasurer. We will also establish a process to address small and micro purchases. This would include acquiring bids for any combined expenditure(s) over a $150,000, acquiring quotes for any small purchase(s) between $10,000 and $150,000, and documenting equitable distribution among vendors concerning any micro purchases under $10,000. All vendor contracts will be approved yearly. All quotes and purchases will be verified by two-person internal control. Anticipated Completion Date: Immediately 2/8/2024

Condition: The organization did not have adequate controls in place to ensure compliance with the applicable procurement and suspension and debarment standards and its own internal procurement policy. Planned Corrective Action: Management has revised the Finance Management Manual with an updated procurement policy in accordance with federal regulations. The Council has developed detailed procedures and required documentation for staff to ensure compliance. Mandatory training will be provided to staff that engage in purchasing activities. Contact person responsible for corrective action: Misty Jordan, Director of Administration Anticipated Completion Date: 11/14/2023

2023-002 Suspension and Debarment Recommendation: We recommend the University document suspension and debarment procedures going forward for any aggregate disbursements with vendors greater than $25,000. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: A signed debarment letter is now a required document for vendors greater than $25,000. This letter is verified by our University procurement office before the item is purchased.   Name(s) of the contact person(s) responsible for corrective action: Dawn Durham Planned completion date for corrective action plan: 10/6/2023

Recommendation: Additional training should be provided to individuals responsible for the development of written policies and procedures in accordance with the Uniform Guidance. Action Taken: One City Schools is in the process of identifying a required training program for all staff members involved in the submission, review and/or approval of the schedule of expenditures of federal awards. This includes One City’s Executive Chef, Executive Director of K-8, COO and VP of Government Relations (who oversees compliance). Designated staff will take advantage of all DPI-provided training seminars and resources available, and we will track attendance of relevant staff members. This process will be in place by June, 2024.

Corrective Action Planned: This was first brought to the Authority’s attention in the current year. At such a late date in the federal project that has been in the works for multiple years, the Authority determined established procurement procedures would not be written and approved. The Authority did not make this decision in haste. The Authority met compliance guidelines for the procedures of items during the project. What we lack is an approved written document, which at this time is something we do not have the resources to undertake. Anticipated Completion Date: Ongoing Contact Person Responsible: Jennie Weary, Treasurer/Secretary

Finding 2023-004 Procurement, Suspension, and Debarment Material Weakness in Internal Control over Compliance Finding summary: During the course of the engagement, Eide Bailly identified that the district did not have a procurement policy in compliance with Uniform Guidence. Responsible Individuals: Rhandi Knutson, Director Corrective action plan: A procurement policy in compliance with Uniform Guidance will be approved and implemented. Anticapted Completion Date: June 30, 2024.

2023-003: Written Debarred, Suspended Vendors & Federal Standards of Conflict Finding Condition - The Town of Dayton did not have written controls in place to ensure that vendors were not suspended or debarred or included on 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 engaged in the selection, award, and administration of Federal grants 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. That being said, the Town will develop a written internal control plan and a policy on procurement for debarment in the coming months.

Views of responsible officials and planned corrective action: The Town Treasurer is working on updating the current purchasing policy. Within this policy, the Town Treasurer will implement language to reference the Uniform Guidance procurement standards.

THE DISTRICT DOES NOT HAVE DOCUMENTED PROCUREMENT PROCEDURES IN ACCORDANCE WITH THE PROCURMENT STANDARDS SET OUT AT 2 CFR SECTION 200.318 THROUGH 200.326. STATEMENT OF OCCURRENCE: MANAGEMENT AGREES WITH THE AUDIT FINDING CORRECTIVE ACTION: THE INTERIM EXECUTIVE DIRECTOR WILL DEVELOP A PROCURMENT POLICY IN ACCORDANCE WITH FEDERAL STANDARDS TO INCLUDE ALL GENERAL REQUIREMENTS SUCH AS OVERSIGHT OF CONTRACTORS' PERFORMANCE, MAINTAINING WRITTEN STANDARDS OF CONDUCT FOR EMPLOYEES INVOLVED IN CONTRACTING, AWARDING CONTRACTS ONLY TO RESPONSIBLE CONTRACTORS, MAINTAINING RECORDS TO DOCUMENT HISTORY OF PROCUREMENTS AND CONDUCTING PROCUREMENT TRANSACTIONS IN A MANNER PROVIDING FULL AND OPEN COMPETITION. PROJECTED COMPLETION DATE OF FINDING: FULL IMPLEMENTATION OF CORRECTIVE ACTION IS EXPECTED IN CALENDAR YEAR 2024. NAME OF CONTACT PERSON REGARDING FINDINGS: BRIAN KALOSKY, INTERIM EXECUTIVE DIRECTOR (860) 489-2535 BJKALOSKY@CT-TRANSWB.COM

Polk County acknowledges the finding stated in the audit and is in the process of developing a corrective action plan. To address the finding the County will increase its monitoring of procurement procedures related to federal award purchases. Increased monitoring will include additional reviews and discussions by County staff (Finance Director/Administrative Officer/County Counsel) during the initial stages to be certain we meet all federal requirements.

Finding Number 2023-003 • Significant deficiency in internal controls over compliance related to procurement. Federal Agency: U.S. Department of Commerce Program Title: Pacific Fisheries Data Program Assistance Listing Number: 11.437 Award Numbers: NOAA-NMFS-AK-2023-2007663 Award Period: October 1, 2022 to September 30, 2027 Criteria • 2 U.S. Code of Federal Regulations (CFR) Part 200 Uniform Administrative Requirements, Procurement Standards require that awardees use documented procurement procedures for the acquisition of property or services required under a Federal award or subaward. Condition/Context for Evaluation • IPHC's internal controls over procurement do not include the controls and procedures required by 2 CFR 200. Questioned Costs • Not applicable. Cause • IPHC has not yet modified its procurement policies with the requirements of the 2 CFR Part 200 Procurement Standards. Effect or Potential Effect • As a result, IPHC cannot be certain that procurements were conducted in accordance with the 2 CFR Part 200 Procurement Standards. Repeat Finding • Not applicable. Recommendation • We recommend that IPHC update its procurement policy to include all procurement requirements of 2 CFR Part 200. - Procurement standards 2 CFR 200 Subpart D or 200.318-200.327 - Requirement for documented policies consistent with standards 200.318(a) Contact Person(s): • Executive Director: David Wilson (david.wilson@iphc.int); • Assistant Director: Andrea Keikkala (andrea.keikkala@iphc.int) Explanation and specific reasons for disagreement with the audit finding or that corrective action is not required (if applicable): Not applicable. Corrective action planned: As this was the IPHC’s first full GAAP Audit, Single Audit of federal grant funds, and also our first year transitioned from a Cash-basis of accounting to an Accrual-basis of accounting, there are a number of policies and procedures that are in the process of being amended. It will take the Secretariat several months to bring our written process guides into alignment with “2 U.S. Code of Federal Regulations (CFR) Part 200”, as well as our Financial Regulations (2021) that will be considered for amendment at the upcoming 100th Session of the IPHC Finance and Administration Committee (FAC100) and subsequent 100th Session of the IPHC Annual Meeting (AM100) in late January 2024. During the 2nd quarter of FY2024 (1 January – 31 March 2024) the IPHC will undertake a thorough review of “2 U.S. Code of Federal Regulations (CFR) PART 200—UNIFORM ADMINISTRATIVE REQUIREMENTS, COST PRINCIPLES, AND AUDIT REQUIREMENTS FOR FEDERAL AWARDS” and update our procurement policies and processes accordingly. Anticipated completion date: Deadline: 1 April 2024.

Corrective Action Planned: The District has reviewed the applicable Uniform Guidance from the Federal Office of Management and Budget, its own existing Board Policies, and has developed administrative procedures to aid with ensuring that all procurements financed with federal funding fully comply with Uniform Guidance procurement requirements. Effective for the 23-24 fiscal year and going forward the District will fully deploy the administrative procedures and controls to all applicable District stakeholders and monitor all such procurements for compliance purposes. The District followed appropriate procedures to ensure that procurements financed with federal funding fully comply with Uniform Guidance procurement. The District sought competitive proposals for major Middle School HVAC replacement project. The District maintains record of the process. Anticipated Completion Date: Action has already been taken by the District to resolve the underlying issue of the finding in the current fiscal year. Contact Person Responsible: Cory Hoffman, Business Manager/Board Secretary

Mechanicsburg Area School District respectfully submits the following corrective action plan for the year ended June 30, 2023. The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule of findings and questioned costs. Finding 2023-001 - Procurement Federal Agency: U.S. Department of Agriculture Pass-through agency: Pennsylvania Department of Education Assistance Listing Number: Child Nutrition Cluster – 10.553/10.555 Corrective Action Planned: The District will establish processes to ensure that the procurement policy is followed when applicable and necessary. Anticipated Completion Date: Action has already been taken by the District to resolve the underlying issue of this finding. Contact Person Responsible: Greg Longwell, Director of Business Operations/CFO If there are any questions regarding this plan, please call Greg Longwell, Director of Business Operations / CFO, at 717-506-0869 or email at glongwell@mbgsd.org

Views of Responsible Officials and Planned Corrective Actions: Our management team has acknowledged the finding and is committed to ensuring that we adhere to the $10,000 threshold. To facilitate this, we will conduct a review of all vendor invoices to identify any instances where adjustments may be necessary. We will also assign a dedicated team member to review purchases on a monthly basis. This proactive measure will enable us to stay vigilant and address any potential deviations from the established threshold promptly. Moreover, if during our monthly reviews we identify that we are approaching the $10,000 threshold, we will take the initiative to seek additional quotes if necessary. Contact person responsible for corrective action: Brittany Fuentes, Director Completion date: January 4, 2024

Higher Education Emergency Relief Funds - Institutional Portion – Assistance Listing No. 84.425F Recommendation: Recommendation for the College to revise their processes to establish procedures that will ensure procurement policies are properly followed and documented for all general disbursements paid for by federal funds. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: All contracts under consideration will go through the college’s procurement process even if there is an existing comparable contract with an existing vendor. Name(s) of the contact person(s) responsible for corrective action: Leigh FitzHenry Planned completion date for corrective action plan: 11/30/2023

Broadlawns Medical Center respectfully submits the following corrective action plan for the year ended June 30, 2023. Audit period: July 1, 2022 – June 30, 2023 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. FINDING—FEDERAL AWARD PROGRAMS AUDITS DEPARTMENT OF AGRICULTURE 2019-001 Special Supplemental Nutrition Program for Women, Infants and Children – CFDA No. 10.557 Recommendation; We recommend the Organization obtain quotes or bids as necessary for purchases that exceed the micro-purchase threshold. Additionally, we recommend the Organization maintain documentation of all quotes and bids to support the vendor chosen. In situations where there is an alternative method utilized, we recommend clearly documenting that process to ensure compliance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization adopted a procurement policy meeting the recommendations above and the requirements noted in 2 CFR Part 200 §200.318 in December 2020. The policy will be reviewed annually with staff involved in the purchasing process to ensure compliance. Additional procedures will be put in place for WIC department expenditures. Non-salary expenditures of the WIC department expected to be over $5,000 or more will be discussed with the CNO for approval prior to purchase. The Purchase Requisition form will be used to document purchasing approvals. Quotes or bids along with a written rational for vendor selection will be included with the Purchasing Requisition form. Once reviewed and approved by the CON, the Purchase Requisition, quotes/bids, and selection rationale will be sent to Director of Accounting and Cost Accountant. The Director of Accounting will timely review the documentation and forward it to the purchasing department to place the order. Both the Director of Accounting and the Cost Accountant will maintain copies of the documentation for reporting and auditing purposes. Name of the contact person responsible for corrective action: Jim Lynch Planned completion date for corrective action plan: January 31, 2024 If there are questions regarding this plan, please call Jim Lynch at 515-282-2296

Condition: We noted during testing that the City had omitted a subrecipient from its search to ensure that the subrecipient was not suspended, debarred, or otherwise excluded pursuant to 2 CFR section 180.300. Planned Corrective Action: Procedures have already been put into place to ensure that each new contractor is not on the Federal list of suspended and/or debarred contractors. Furthermore, all vendors previously paid have been searched for in the Federal list and none were suspended and/or debarred. Contact person responsible for corrective action: Lee Ward, Director of Finance. Anticipated Completion Date: 12/15/2023

Sheila Nolan, Child Nutrition Supervisor, acknowledges the finding regarding the purchase of produce products for SY 2022-23. There is only one regional produce distributor that successfully delivers to the Franklin Parish area with accurate invoices and timely deliveries based on past history. Due to staff changes and re-assignment of essential job functions, the produce bid was overlooked for this this year only. Moving forward, the CNP Supervisor has established a procurement schedule for developing and revising necessary formal bids in compliance with Federal and State requirements and all CNP central office staff. During SY 2022-23, the Franklin Parish Child Nutrition Program experienced multiple shortages of canned and frozen vegetables and fruits. This made it essential to fill in with fresh produce to meet meal pattern requirements. This created a marked increase in the cost of the fresh produce available to us and increased our reliance on fresh produce.

2023-005 – Procurement, Suspension & Debarment – Significant Deficiency in Internal Controls over Compliance Recommendation: The auditors recommend the University implement controls to ensure all employees making federal purchases on behalf of the University are aware of the University’s documented procurement policy that is in accordance with 2 CFR Part 200. In addition, the auditors recommend the University document its standard of conduct that covers conflicts of interest and governs the performance of its employees engaged in the selection, award, and administration of contracts. Planned corrective actions: The university puts measures in place to guarantee that every employee who makes federal purchases on the university's behalf is aware of the documented procurement policy that complies with 2 CFR Part 200. The University will formalize its code of conduct, which addresses conflicts of interest and sets performance standards for staff members who choose, award, and manage contracts. Name of Responsible Party: 1. Aaron Krantz, IT Director 2. Jeffrey Beehler, Physical Plant Director 3. Yolanda Maltos, Grant Accountant 4. Melissa Hill, Provost 5. Alysia Stevens, Controller 6. VP of Administration/CFO 7. Dr. Andrew Sund, President Anticipated completion date: 6/30/2024

2023-001: Special Education Cluster – Procurement Context/Condition - Of the four procurement transactions subjected to testing, there were two professional service contracts that the District did not have documentation supporting the sole source procurement method. Corrective Action Plan – Laramie County School District No. 1 (LCSD1) appreciates the thorough review conducted by the auditing team, identifying the lack of documentation for two sole source contracts for special education trainers hired in response to the Wyoming Department of Education’s monitoring review. In response, LCSD1 has undertaken a comprehensive corrective action plan to rectify the identified issues and prevent future occurrences. Immediate steps include a detailed review of the existing contract, identification of missing documentation, engagement with legal counsel to ensure compliance, and the development of clear procedures for documenting sole source justifications. To address potential gaps in staff understanding, LCSD1 has implemented additional training programs and reviews by procurement staff. LCSD1 will also evaluate federal, state and district procurement policies and initiate additional internal monitoring requirements for special education contracts. LCSD1 does not dispute the finding and will continue to improve processes and procedures with a focus on periodic reviews to enhance procurement practices. Contact Person – Jed Cicarelli, Chief Financial Officer Anticipated Completion Date – Immediately

Findings and Questioned Costs Related to Federal Awards Finding Number: 2023‐001 Program Name/Assistance Listing Title: Education Stabilization Fund Assistance Listing Number: 84.425U Contact Person: Diana Fitzpatrick, Director of Finance Anticipated Completion Date: April 30, 2024 Planned Corrective Action: When notified by the audit firm of the error in procurement procedures, district employees were notified of the correct procedures. This information has been and will continue to be made known to district employees who are delegated authority to procure goods and services during monthly leadership meetings. During this spring’s annual budget workshop with district staff, a brief training session will be held on Federal, State, and Board procurement policies and procedures. Also, a record of vetting vendors has been implemented this current fiscal year via the Sam.gov website.