Corrective Action Plans

Condition: The District did not follow the small purchase method for procurement that is required for purchases made between $10,000 and $250,000. This method requires that price or rate quotations must be obtained from an adequate number of qualified sources (2 CFR section 200.320(b). Recommendation: We recommend that care is taken to ensure that all the procurement requirements are followed based on the amount of the purchase being made with the federal funds. Management Response: We will follow the procurement standard when not in urgent situations for the product or service we are seeking. Anticipated Date of Completion: June 30, 2024

Recommendation: JTCHS should review federal procurement guidelines and revise its procurement policy to be in compliance with the federal procurement guidelines. Responsible Official’s Response: Management will review adopt a procurement policy in accordance with the Uniform Guidance. Planned Implementation Date of Corrective Action Plan: Management has started revising its policy and expects to have a revised procurement policy during fiscal year ending January 31, 2024.

2022-003 – 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

Material Weakness in Internal Control Over Compliance (Federal Award Program) The City will develop and implement formal written procedures for the management of Federal award expenditures and procurement activities. All fund transfers will require documented approval by authorized personnel. Procurement processes will include verification of vendor eligibility, compliance with bid law, and retention of supporting documentation. Staff will be trained on federal compliance requirements. Responsible Party: Robert Nielson, Temporary Fiscal Administrator Timeline: December 31, 2025

Significant Deficiency in Internal Control over Compliance Details: During procurement purchase testing, it was noted no formal policy over procurement or conflict of interest existed that met the requirements of 2 CFR §200.318(a) & 2 CFR §200.318© Recommendation: Recommend adopting a procurement and conflict of interest policy that aligns with Uniform Guidance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Include Conflict of interest in current financial management plan. The recipient or subrecipient must maintain written standards of conduct covering conflicts of interest and governing the actions of its employees engaged in the selection, award, and administration of contracts. No employee, officer, agent, or board member with a real or apparent conflict of interest may participate in the selection, award, or administration of a contract supported by the Federal award. A conflict of interest includes when the employee, officer, agent, or board member, any member of their immediate family, their partner, or an organization that employs or is about to employ any of the parties indicated herein, has a financial or other interest in or tangible personal benefit from an entity considered for a contract. An employee, officer, agent, and board member of the recipient or subrecipient may neither solicit nor accept gratuities, favors, or anything of monetary value from contractors. However, the recipient or subrecipient may set standards for situations where the financial interest is not substantial or a gift is an unsolicited item of nominal value. The recipient's or subrecipient's standards of conduct must also provide for disciplinary actions to be applied for violations by its employees, officers, agents, or board members. Name(s) of the contact person(s) responsible for corrective action: Cora Alyea Planned completion date for corrective action plan: October 17, 2025

Procurement and Suspension and Debarment: The College agrees with the finding and takes note of the previous corrective actions that did not fully resolve the issue. The College will update its Purchasing and Accounts Payable Policy to require SAM.gov verification prior to awarding contracts. The College will conduct mandatory procurement training to strengthen compliance with federal requirements.

Procurement and Suspension and Debarment College of the Marshall Islands acknowledges the finding and confirms that the gaps noted resulted mainly from the previous manual filing system and limited internal procurement controls. The College has since upgraded and institutionalized a cloud-based filing system to ensure complete documentation, proper retention, and easy retrieval of procurement records. Internal control policies and procedures have been strengthened to ensure compliance with the RMI Procurement Code, including vendor selection documentation, verification of suspension and debarment status, and equitable distribution of micro- purchases. In addition, newly hired staff dedicated to Procurement and Accounts Payable have been onboarded to improve oversight and compliance. With these new systems, strengthened controls, and added staffing capacity, the College is now better positioned to maintain full compliance. Staff have been trained—and will continue to be trained twice a year—on procurement requirements and federal regulations to prevent recurrence of similar issues in future audits.

I believe this has to do with the sewer project. I was thrown into the middle of this. I don’t believe proper records were started or kept by the former Fiscal Officer. I only have what happened since I was here.

View of Responsible Officials and Corrective Action Plan 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. Corrective Action Plan Timeline 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. Corrective Action Plan Timeline • 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.

The Board of County Commissioners, with the cooperation and participation of all elected officials, reviews, develops and implements policies and procedures to create a strong internal control environment. The Board of County Commissioners will work with all elected officials, the third-party administrator, and federal, state and local partners to develop policies, procedures, and internal controls designed to accurately track grants, including the application process, verification, oversight, and reporting of grant requirements. The Board of County Commissioners will work with the third-party administrator to ensure proper grant administration.

Individual(s) Responsible: Chelsea BadHawk, Chief Financial Officer Action: Management will prepare and implement an internal control system that provides effective oversight of operations, reporting, and compliance. The systems and controls will be designed based on standards set forth in the Government Accountability Office Green Book. Anticipated Completion Date: 12/31/2025.

Significant Deficiency in Internal Control over Compliance, Other Matters Description of Finding Coventry Public School’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 concurs with the finding. Corrective Action Coventry Public Schools will review the district’s current purchasing policy and make sure that it is following the criteria as set out in the 2 CFR sections 200.318 and 200.326. The policy will then be updated and communicated to all personnel involved in the procurement process. Name of Contact Person Christopher Deverna, CPA, Director of Finance, Coventry Public Schools Projected Completion Date June 30, 2025

Recommendation: We recommend that VSS reviews the current financial policies and procedures in order to better serve the organization in documenting compliance with federal cost principals and requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: VSS accepts this finding and has contacted an outsourced CPA for review and update of our policies to meet federal cost principals and requirements. These are currently pending approval by the Board of Directors for implementation. Name(s) of the contact person(s) responsible for corrective action: Jessica Franco, Director of Finance Planned completion date for corrective action plan: 10/1/2022

2022-008 Procurement Policy and Procedures Finding: Under Uniform Grant Guidance (2 CFR 200.318 through 200.327) non-federal entities other than states must follow the procurement standards set out in 2 CFR sections 200.318 through 200.327. They must use their own documented procurement procedures, which reflect applicable state and local laws and regulations, provided that the procurements conform to applicable federal statutes and the procurement requirements identified in 2 CFR Part 200. The Corporation does not maintain a formal procurement policy and procedures that meets the requirements of the Uniform Guidance, including procedures addressing allowable costs exceeding the small purchase threshold. The lack of such a formal policy increases the risk that purchases are made that do not comply with Uniform Guidance requirements. Corrective Actions Taken or Planned: While Saint Anthony Hospital has a procurement policy in place, we needed to order computers within a certain timeframe in order to secure funds from the grant and utilized our main supplier. Thus, we did not get more than 1 quote for the computers. 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. Name of contact person responsible for corrective action: Cindy Cisneros, Grant and Partnership Specialist

Audit Finding Reference: 2022-003 Implement Controls & Documentation Over Procurement Planned Corrective Action: Procurement supporting documentation will be maintained for all vendor transactions $10,000 and greater, including a suspension and debarment check to ensure the vendor organization is not excluded from being eligible to receive federal funds due to past misconduct. Planned Implementation Date of Corrective Action: March 14, 2025 Person Responsible for Corrective Action: Nick Fisichelli, President & CEO

Audit Finding Reference: 2022-004 Improve Controls and Documentation Over Procurement Planned Corrective Action: Revise Policy and Procedure Policies to require prior written approval from the Executive Director prior to entering into any agreement for expenditures between $10,000 and $49,999. If it is a sole source, written justification must be submitted and approved by Executive Director prior to execution of agreement. If multiple bids were obtained, these must also be submitted and the selected vendor approved by Executive Director prior to execution of agreement. Planned Implementation Date of Corrective Action: 2/5/2025 Person Responsible for Corrective Action: Director of Finance

2022-004 Summary of Finding Missing documentation for procurement, suspension and debarment: Bid or sole source documentation was missing for all five contracts that we selected for testing and there was no documentation of the verification that the contractor was not suspended or debarred. It is important to determine that contractors used are eligible for work and that they have not been suspended or debarred from performing work on projects supported by federal funds It is also important to have full and open competition on contract work that is federally funded. As a result, the Organization was missing documentation relating to the requirements for procurement, suspension and debarment. Statement of Concurrence or Nonconcurrence This finding was concurred with due to staff turnover and the department being short-staffed. Corrective Action In response to the noted deficiencies in procurement, suspension, and debarment documentation, the Organization has developed a comprehensive Grant Cycle Standard Operating Procedure that aligns with OMB Uniform Guidance. This procedure reinforces the existing Procurement policy, ensures all staff receive targeted training on relevant requirements, and incorporates additional review measures into the onboarding process for new hires. Furthermore, a new position has been created, and a new management platform has been implemented to manage purchase orders, maintain all sourcing documentation, and verify all contractors are not suspended or debarred, thereby ensuring full compliance with federal requirements and promoting transparency in contractor eligibility and competitive bidding.

CONDITION: The City of McKeesport contracted with a third-party vendor (A&H Equipment) for the purchase of a street sweeper. The contract with the third-party vendor, which was procured through a cooperative purchasing group (COSTARS), exceeded the threshold for competitive procurement. The City 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 City 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 prescribes the bidding requirements for equipment, supplies, and work of any nature made by a non-federal entity whereby the cost exceeds the Simplified Acquisition Threshold. The cost of the street sweeper exceeded the simplified acquisition threshold of $250,000. As specified in 2 CFR 200. 318(i) of the Uniform Guidance, the City must maintain sufficient records 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. MANAGEMENT’S CORRECTIVE ACTION PLAN: Management of the City will review and update as necessary its procurement policies to ensure In instances where the procurement cost incurred for goods and/or services exceeds the Uniform Guidance Simplified Acquisition, including such instances whereby the City is using a contract vehicle from a cooperative purchase network, that the City is in compliance with all applicable sections of the Uniform Guidance, in specific, Section 2 CFR 200.318(i) of the Uniform Guidance. In addition, I recommend that the City 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. The timeframe for completion of this review will occur during the first nine months of calendar year 2025 with the intention of having the City be in full compliance with Sections 2 CFR 200.318(i) and 2 CFR 200. 324(a) of the Uniform Guidance.

CONDITION: The City of McKeesport contracted four (4) vendors for the purchase of seven separate purchases of equipment for the City. These contracts individually exceeded the Uniform Guidance micro purchase threshold of $10,000, but did not exceed the Simplified Acquisition Threshold of $250,000. All of these purchases were procured through a cooperative purchasing group (COSTARS). The City was unable to 1) provide records sufficient to detail the history of procurement for these contracts and 2) provide documentation to verify that price or rate quotations were obtained from an adequate number of qualified sources. This is a repeat finding (2021-005) for the prior year. CRITERIA: Section 2 CFR 200.320(a)(2)(i) of the Uniform Guidance prescribes the bidding requirements for equipment, supplies, and work of any nature made by a non-federal entity whereby the cost exceeds certain dollar thresholds as adjusted periodically. In instances where the cost incurred exceeds the Uniform Guidance micro purchase threshold of $10,000 but does not exceed the Simplified Acquisition Threshold of $250,000, price or rate quotations must be obtained from an adequate number of qualified sources. In addition, as specified in 2 CFR 200. 318(i) of the Uniform Guidance, the City must maintain sufficient records to detail the history of procurement. MANAGEMENT’S CORRECTIVE ACTION PLAN: Management of the City will review and update as necessary its procurement policies to ensure In instances where the procurement cost incurred for goods and/or services exceeds the Uniform Guidance micro purchase threshold of $10,000 but does not exceed the Simplified Acquisition Threshold of $250,000, that 1) price or rate quotations are obtained from an adequate number of qualified sources, and 2) sufficient records are maintained to detail the history of procurement. The timeframe for completion of this review will occur during the first nine months of calendar year 2025 with the intention of having the City be in full compliance with Sections 2 CFR 200.320(a)(2)(i) and 2 CFR 200. 318(i) of the Uniform Guidance.

Finding Number: 2022-006 Condition: Policies and procedures in place over procurement, suspension, and debarment are not in conformance with Uniform Guidance. Additionally, the Organization did not procure in accordance with the regulations, including maintaining records sufficient to detail the history of each procurement transaction nor did they comply with suspension and debarment rules. Planned Corrective Action: Management will implement written policies and procedures over procurement, suspension, and disabarment that conform with Uniform Guidance Contact person responsible for corrective action: Chief Financial Officer Anticipated Completion Date: 06/30/2025

Assistance Listing Number 21.027 Noncompliance Over Procurement and Suspension/Debarment - Major Federal Program - Coronavirus State and Local Fiscal Recovery Funds Muskogee County has hired an internal grant administrator to assist in keeping the county compliant with all local, state, and federal requirements. Efforts will be made going forward to ensure that all grant funds are properly expended. This includes that all expenditures are properly documented and that all vendors are ferderally eligible to perform services

2022-004 Procurement Criteria: The Town must follow the procurement standards set out at 2CFR Section 200.318 through 200.326. This requires bids to be obtained for purchases ranging from $10,000 - $250,000. The Town currently has policies in place to utilize the state library which is a listing of approved vendors for potential purchases of over $50,000. The CFR does allow an entity to increase the lower limit from $10,000 to $50,000 in certain circumstances. One of the conditions is that the entity qualifies as a lowrisk entity. The Town currently does not qualify as low risk; therefore, the Town does not qualify for the increase of the lower limit from $10,000 to $50,000. Sole source vendors are the exception to this rule. Condition: The Town did not obtain three bids for over $10,000 purchases. Did use the state library to identify eligible vendors but failed to obtain the required three bids. Cause: The Town relied on the state library which is not an approved listing according to the CFR. Effect: The Town is not in compliance with 2CFR Section 200.318 through 200.326 and therefore, the Town has the possibility of not being able to renew contracts in the future. Recommendation: We recommend that the Town obtain the required three bids for purchases over $10,000. Views of Responsible Officials and Planned Corrective Actions: The Town has hired an Asset Support Specialist to help ensure compliance with such requirements and understands the importance of meeting the requirements.

Contact Person Dan Juve Planned Corrective Action The District will implement the recommendation from Brady Martz. Planned Completion Date The planned completion date will be the start of fiscal year 2023.

As part of our current review and revision process, the Organization plans to adopt the 2 CFR §200.320 procurement guidance and develop supporting policies and procedures to ensure compliance with federal standards. Additionally, the Organization will incorporate the standards outlined in 2 CFR §200.318 to further align our operations with Uniform Guidance requirements, reinforcing our commitment to meeting federal compliance standards. The Organization has prioritized the completion and distribution of the updated financial policies and procedures, including the 2 CFR §200.320 procurement guidance by December 31, 2024.

Although the PILC verifies the suspension and debarment status of every vendor for potential purchases above $150,000, we had not been routinely printing documentation verifying this process. In the future, the School will be printing off evidence of a dated keyword search to demonstrate that a vendor is not listed on the www.SAM.gov suspension/debarment list for procurement purposes.