Corrective Action Plans

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.

Management concurs with the audit finding. The City will develop written policies and procedures for procurement, including the relevant provisions required by 2 CFR § 200.318 through 2 CFR § 200.326 Contract provisions. Management will evaluate the need to contract with local government consultants to perform control procedures where City personnel are not available or qualified to perform.

The City has identified federal grants subject to the Uniform Guidance and will develop written policies and procedures which include the relevant provisions required by 2 CFR § 200.318 through 2 CFR § 200.326 Contract provisions.

The City will develop written standards of conduct in that satisfy the requirements of 2 CFR § 200.318(c)(1).

County Commission gave former County Manager direction to consult with legal counsel to determine premium pay for County staff who worked throughout the Pandemic. A meeting was held between Former County Manager, Financial Specialist, County Sheriff and VMDC Warden to discuss premium pay for all staff as well as public safety recruitment and retention. Former County Manager stated after consulting with County Legal Counsel and NMC General Counsel, all County staff including, Elected Officials were eligible to receive “premium pay” in compliance with the American Rescue Plan Act Rule. Financial Specialist and County Sheriff questioned the eligibility for Elected Officials to receive premium pay referencing N.M. Const. Art IV, section 27 “No law shall be enacted giving any extra compensation to any public officer, servant, agent or contractor after services are rendered or contract made; nor shall the compensation of any officer be increased or diminished during his term of office, except as otherwise provided in this constitution.”, and NMSA 4‐44‐4.1 related to County Elected Official Salary caps. Former County Manager responded premium pay should be issued to all staff including Elected Officials through the accounts payable department instead of payroll to avoid violating New Mexico Constitution and State Statute and premium pay is not considered a salary increase but “premium pay” outside of regular salary paid to “essential workers”. Former County Manager went on to explain that all law enforcement officers were eligible for premium pay because they were described as “essential” within the American Rescue Plan Act Rule. In a regular Commissioner Meeting held on 10/12/2021 Former County Manager presented to Commission and recommended approval of public safety recruitment and retention plan as well as a one‐time payment to current staff of $5,000 who worked from January 2020 through October 2021 and a prorated rate be awarded to any employee that worked a portion of that time. She also stated new information was received that confirms all County employees are eligible for the premium pay, currently 88 employees. She also stated that public health contractors are also eligible for premium pay and recommended payment be made to 2.5 full time positions to contracted health care services provider. Commission approved the request from the Former County Manager based on her recommendation. Former County Manager drafted, reviewed and approved a list of employees scheduled to receive payment including 5 contracted medical service provider including the CEO of the company. Former County Manager directed accounts payable clerk to issue payment through accounts payable. On November 8th 2021, Former County Manager presented to and recommended approval additional premium pay be awarded to Employees that had retired and worked part of the period of January 2020 though October 2021 and two full time Employees that were laid off. In January 2022 Elected Officials requested a meeting be held to discuss the issuing of 1099 forms to employees who received premium pay. Also present in the meeting was Commission Chairman. Elected Officials raised concern that staff was issued a 1099 and questioned if this was correct. Former County Manager informed staff the advice the County got was to issue a 1099‐NEC, under the circumstances. However, upon review of email communication former County Manager received an opinion from her personal Tax Accountant stating that the payments should have been run through payroll and recommended Former County Manager either correct the original error and would require several steps including corrected 941’s and corrected w‐2’s or issue a 1099 NEC. Former County Manager directed accounts payable clerk to issue a 1099 NEC. Commission Chairman questioned several expenditures from American Rescue Plan Act Fund, including the additional 2 full time positions and CEO of the company not approved by Commission, it was later determined that several expenditures were not allowable under the American Rescue Plan Act Fund Rule. Colfax County Staff submitted written report to Office of the State Auditor as required under NMSA 1978, Section 12‐6‐6 (criminal violations) an agency or auditor shall notify the state auditor immediately, in writing upon discovery of any violations of criminal statute in connection with financial affairs. Former County Manager announced her resignation February 28, 2022. It was later discovered through communication with County legal Counsel and NMC General Counsel that Former County Manager mislead the County Commission, Elected Officials, and County Staff and did not consult with County Legal Counsel or NMC General Counsel as previously stated and as directed by the Commission before making recommendations for approval of American Rescue Plan Act Funds.

Finding Number: 2022-004 Condition: WakeMed does not have a written policy in place over procurement methods which covers 2 CFR 200.317 - 200.327, nor did WakeMed follow required procurement guidelines. Planned Corrective Action: WakeMed is in the process of updating their existing procurement policy to include the relevant sections from the Code of Federal Regulations and will provide education to the areas involved in procurement and use of federal funds on these requirements. Contact person responsible for corrective action: Lynn Bailey Anticipated Completion Date: 12/5/2024

FA 2022-001 Strengthen Controls over Expenditures Compliance Requirement: Activities Allowed or Unallowed Allowable Costs/Cost Principle Procurement and Suspension and Debarment Internal Control Impact: Material Weakness Compliance Impact: Material Noncompliance Federal Awarding Agency: U.S. Department of Education Pass-Through Entity: Georgia Department of Education Assistance Listing Number and Title: COVID-19 - 84.425D - Elementary and Secondary School Emergency Relief Fund Federal Award Number: S425D210012 (Year: 2021) Questioned Costs: $189,893 Description: The policies and procedures of the School District were insufficient to provide adequate internal controls over expenditures as it relates to the Elementary and Secondary School Emergency Relief Fund program. Corrective Action Plans: Management has implemented internal controls procedures to ensure transactions are properly processed and reported. Additional procedures have been established to review transaction to make they align with the approved budget. Estimated Completion Date: June 30, 2024 Contact Person: Georgette Evans Telephone: 478-374-3783 Email: gevans@dodge.k12.ga.us