Corrective Action Plans

U.S Department of Education 2023-002 Special Education Cluster – Assistance Listing No. 84.027 and 84.173 Recommendation: CLA recommends the District puts in place the proper procedures for sufficiently documenting all procurements and methodology used. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The District will work to revise its procedures as necessary to ensure that all procurements which are charged to federal programs are fully documented, including support for noncompetitive proposals. Name(s) of the contact person(s) responsible for corrective action: Marie Schrul, Executive Director of Finance Planned completion date for corrective action plan: January 31, 2024

Program: Choice Neighborhoods Implementation Grants Federal Agency: Department of Housing and Urban Development AL #: 14.889 Federal Award Identification Number and Year: Various - See SEFA Pass-through Entity: N/A Type of Compliance Finding: I - Procurement, Suspension, & Debarment Internal Control Impact: Material Weakness Finding: The City did not provide evidence supporting the City's compliance with this requirement. Status: Resolved Corrective Action Plan: Since the CNI grant has ended, the corrective action plan will apply to future grants. When the City obtains future grants utilizing and/or funding projects in multiple City Departments, operating procedures will be in place to comply with 2 CFR sections 200.318 through 200.326 to ensure compliance and the required grant documentation will be centrally located and filed. Person(s) Responsible for Implementation: Jeffrey Williams, Director of City Planning, Telephone: (816) 513-8803; Email: Jeffrey.Williams@kcmo.org

Landesa will revise it’s Procurement Policy to meet the standards of the United States Federal Government and all components of 2 CFR Section 200.320. Landesa will revise the Procurement Policy to include clear thresholds for small purchases and simplified acquisitions and clearly address the topics of sealed bids, price analysis, and acquisition costs. Landesa will revise existing procurement forms, such as the third-party due diligence form, to ensure compliance with the revised policy. Landesa will provide training to all relevant staff on the revisions to the Procurement Policy by March 2024. The Director of Program Effectiveness will monitor staff implementation of the revised policy and procedures to ensure compliance with revised policy. Contact person: Director of Program Effectiveness and Anticipated completion date: March 2024

The district will create a checklist that will include a review of vendors on Sam.gov and print the findings so we may provide necessary documentation. We do have in policy that prospective bidders to contracts are to certify they are not suspended or debarred. Policy EFAB-E. We will review our current policies to ensure this requirement is met going forward.

Dover 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: Department of Education Pass-through Agency: Pennsylvania Department of Education Assistance Listing Number: COVID-19 – Education Stabilization Fund – 84.425 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: Miranda Weaver, Chief Financial & Operations Officer

Coronavirus State and Local Fiscal Recovery Funds – Assistance Listing No. 21.027 Substance Abuse and Mental Health Services Projects of Regional and National Significance – Assistance Listing No. 93.243 Recommendation: We recommend that the Organization review its procurement policy and conflict of interest policy and make necessary changes to comply with the criteria as set out in 2 CFR sections 200.318 and 200.326. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The conflict-of-interest policy has been added to the fiscal policies. Management is in the process of enhancing the federal procurement policy to include sections 200.318 – 200.326. Name of the contact person responsible for corrective action: Lisa Maraia, CFO Planned completion date for corrective action plan: December 1, 2023

Finding number: 2023-003; Finding: While testing the procurement requirement, we were able to test compensating controls, but noted that internal controls were not properly designed over the procurement requirement. Prior to receiving federal funding beginning in August 2022, the program conducted a request for proposal (RFP) process and began contracting with a vendor. When federal funding was obtained, the vendor was not reevaluated in accordance with the Uniform Guidance to ensure the procurement requirements were being met. In addition, we noted UW Health – Madison’s procurement policy documents do not include all of the information that is required by the Uniform Guidance. Correction actions taken or planned: UW Health will develop processes and procedures to ensure compliance with the Uniform Guidance. Vendors will be reevaluated for compliance with the Uniform Guidance prior to being charged to any grant. Anticipated completion Date: June 2024; UW Health employees responsible for Corrective Action Plan: James Hood, Director of Procurement Services, and Sara Schiek, Manager of Procurement Services

As a result of the deficiency noted, the Business Services and Procurement Departments have revoked all purchasing privileges from the Magnet Program Office for a period of 90 days. All purchases, including school level purchases, must be approved by Business Services or Procurement directly. During this time, the MSAP program office personnel will undergo specific training related to federal compliance including procurement, suspension and debarment. Following this 90-Day period, the District will implement additional monitoring procedures to ensure transactions that do not qualify as “small-purchases” be performed by the District Procurement Department.

Action taken: The district entered into a shared services agreement with Capital Region BOCES in March of 2022 for management of the School Nutrition program. It was assumed that this was a procedure they followed; however, documentation was not provided and the external auditors inciuded it as a finding. The School Nutrition Director resigned and was replaced by a new School Nutrition Director with BOCES (Greg Nalewjka) and he was unaware that this was necessary. He is working with his supervisors to provide documentation to the district that due diligence has been done to meet this requirement. Anticipated completion date: 11/10/2023

MATERIAL WEAKNESS IN INTERNAL CONTROL OVER COMPLIANCE AND MATERIAL NONCOMPLIANCE – U.S. DEPARTMENT OF EDUCATION, PASSED THROUGH MINNESOTA DEPARTMENT OF EDUCATION, SPECIAL EDUCATION CLUSTER (INCLUDING COVID-19 FUNDING) – FEDERAL ALN 84.027 AND 84.173 AND – U.S. DEPARTMENT OF THE TREASURY, PASSED THROUGH MINNESOTA DEPARTMENT OF EDUCATION, COVID-19 – CORONAVIRUS STATE AND LOCAL FISCAL RECOVERY FUNDS – FEDERAL ALN 21.027 2023-001 Internal Control Over Compliance and Material Noncompliance With Federal Procurement, Suspension, and Debarment Requirements Finding Summary 2 CFR § 180.425-430 and 2 CFR § 200.318-327 requires Independent School District No. 12 (the District) to establish and maintain effective internal control over compliance with requirements applicable to federal program expenditures, including procurement, suspension, and debarment requirements applicable to the special education cluster and coronavirus state and local fiscal recovery funds federal programs. During our audit, we noted the District did not have sufficient controls in place resulting in material noncompliance within its special education cluster and coronavirus state and local fiscal recovery funds federal programs to ensure compliance with federal procurement requirements related to methods of procurement and to assure that it was not contracting for goods or services with parties that are suspended or debarred, or whose principals are suspended or debarred from participating in contracts involving the expenditures of federal program funds. Corrective Action Plan Actions Planned – The District is in the process of reviewing and updating its policies and procedures relating to procurement, suspension, and debarment for its federal programs to ensure compliance with the Uniform Guidance in the future. The review of procedures will also include steps to assure that district personnel are following the requirements of the Uniform Guidance related to methods of procurement and maintaining appropriate documentation. Official Responsible – The District’s Executive Director of Business Services, Patrick Chaffey. Planned Completion Date – December 31, 2023. Disagreement With or Explanation of Finding – The District agrees with this finding. Plan to Monitor – The District’s Executive Director of Business Services, Patrick Chaffey, will assure appropriate internal controls and procedures are updated and in place to ensure compliance with procurement, suspension, and debarment requirements.

Name of Contact Person: Daniel Schuler, Business and Operations Manager Corrective Action Plan: The District did identify in late spring/early summer that the existing relationship with US Foods had not been bid in the prior year. In order to address this issue, the District Administration identified, recommended and received Board of Education approval to access a US Foods State of Alaska Contract with the State of Alaska Department of Corrections. This action, coupled with the one-year extension of an existing agreement with Alaskan & Proud Markets for the purchase of milk, will bring the District into compliance with procurement procedures as outlined by the National School Lunch Program and DEED. Proposed Completion Date: December 2023.

Views of Responsible Officials and Planned Corrective Action: The University agrees with the finding, a revised policy has been drafted and was approved in September 2023.

CORRECTIVE ACTION PLAN October 2023 Section III: Federal Award Findings and Questioned Costs Findings and questioned costs related to Federal awards which are required to be reported in accordance with the Uniform Guidance 2 CFR 200.516(a): Significant Deficiency 2023-001 Child Nutrition Cluster - Procurement Views of the Responsible Officials and Planned Corrective Actions: The District has reviewed the requirements of 2 CFR Section 200.213. The District is in agreement with the recommendation to implement a procedure to document the process used to verify the eligibility of potential vendors to participate in Federal assistance programs. The verification of excluded parties will be accomplished by accessing the System for Award Management (SAM.gov) website and selecting the “Excluded Entity” filter on the “Exclusions” search page to search for exclusions by Unique Entity ID or CAGE/NCAGE code as follows: 1. Select “Search” from the header menu from any page on SAM.gov 2. In the filters, under “Select Domain”, select “Entity Information”, then select Exclusions 3. Use the filters or keyword box to enter the search criteria and view the results 4. Document the results in the vendor file. Other alternatives for verification may include collecting a certification from the entity or adding a clause or condition to the covered transaction or contract with that entity. The Purchasing Agent is charged with the responsibility of monitoring and ensuring compliance with the suspension and debarment procedures and maintaining documentation that contracts expected to equal or exceed $25,000 have been verified on the System for Award Management (SAM) website before purchases are made. Responsible Person(s): Matt Leon, Assistant Superintendent for Business & Operations and Michael DeSantis, Purchasing Agent Deadline for Completion: On or before 12/1/23 for covered transactions with contracts or purchase orders meeting the threshold during the time period 7/1/22 - 10/31/23. Prior to contract approval or purchase order issuance for contracts or purchase orders meeting the threshold on or after 11/1/23.

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.

The District plans to follow the Washinton State Auditor's Office recommendation to formally adopt a procurement and debarment polices by July 2026. The District recognizes it is in the best interests of the public to have documented policies and procedures, and those policies shall be adhered to. The District is grateful that $947,806 in grant assistance was provided, as pass-through funds that assisted an affordable housing development, and wants to ensure the public that processes and procedures were in place that minimized the risk of disbursing funds to a debarred contractor. The District's bid documents, signed contracts, signed certifications, filings with WA State L&I, and outsourced bidder qualification review ensured qualifying bidder requirements were met prior to this projects commencement. These actions, which the SAO acknowledges did occur, address the concerns the SAO has identified. Still, the District agrees improvements can occur, and this will be addressed in a timely manner. Policies will be adopted that strengthen controls, which include increased documentation that meets recommended State and Federal guidelines.

The city will implement procedures to ensure preparation of the SEFA and retention of all required federal grants documentation , including ARPA reporting.

Department of Housing and Urban Development and Department of Veterans Affairs Federal Program Name: Emergency Solutions Grant Program and VA Homeless Providers Grant and Per Diem Program Assistance Listing Number: 14.231 and 64.024 Recommendation: We recommend that the Organization adopt a formal and written procurement policy. Additionally, management should develop controls to help ensure procurement procedures are followed and to monitor the amount spent with vendors throughout the year to ensure procurement procedures are initiated when the vendor costs exceed the procurement thresholds. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management has developed and implemented a formal written procurement policy aligned with applicable federal requirements and organizational purchasing practices. The policy includes required procurement methods, thresholds, documentation standards, conflict-of-interest provisions, and approval authority levels. In addition, the Organization has implemented internal monitoring controls to track cumulative vendor spending throughout the fiscal year and to ensure that procurement procedures are properly initiated when vendor costs approach or exceed established procurement thresholds. Staff responsible for purchasing and vendor management have been trained on the updated requirements and documentation expectations. Name(s) of the contact person(s) responsible for corrective action: Ryan Ross, Executive Director Planned completion date for corrective action plan: March 31, 2026

The District concurs with the finding. At the time the purchases were made, the District did not realize the federal funds provided required compliance with uniform guidance procurement rules. Therefore, the applicable Uniform Guidance procurement requirements were not applied. To correct this issue, management will update and formalize procurement policies and procedures to ensure potential federal funding sources are identified before or during the purchasing process and that purchases charged to federal awards comply with 2 CFR 200.318 through 200.320. The District will implement procedures to ensure the appropriate procurement method is used, competition requirements are met, cost or price analysis is performed when required, complete procurement documentation is retained, and compliance is reviewed for applicable transactions.

Recommendations: Management should strengthen procurement controls to ensure all purchases follow 2 CFR §§200.318–200.320 and the operating contract. This includes documenting all bids, retaining procurement files, and obtaining required approvals prior to purchase. Views of responsible officials and planned corrective actions: Management agrees with the findings and will ensure all purchasing requirements are met as outlined in the operating contract, West Virginia State Code, and federal regulations and documented in applicable policies and procedures. Training on proper purchasing requirements is anticipated through the West Virginia Transit Authority. Anticipated Completion Date: May 1, 2024

U.S Department of Health and Human Services 2022-003 - Suspension and Debarment - Assistance Listing No. 93.243 Recommendation: We recommend the Organization retain documentation that SAM.gov was used to verify that vendors are not suspended, debarred, or otherwise excluded from participating in the transaction prior to contract. Explanation of disagreement with the audit finding: There is no disagreement with the audit finding. Action take in response to finding: Management will update procurement procedures to require documented SAM.gov verification for vendors prior to contract execution and periodically for existing vendors. Evidence of verification (e.g., screenshots or confirmation reports) will be retained in procurement files. Compliance will be reviewed as part of routine procurement oversight. Name(s) of the contact person(s) responsible for corrective action: Ben Bass, CEO Planned completion date for corrective action plan: May 2026

FEDERAL AWARDS – CORRECTIVE ACTION PLAN REFERENCE # 2022-001 PROCUREMENT SUSPENSION AND DEBARMENT – MATERIAL WEAKNESS- NON-COMPLIANCE Program Name/ALN Emergency Solutions Grant Program (ALN # 14.231) Criteria: As per § 200.318 General procurement standards. (a) The Non-Federal entity must have and use documented procurement procedures, consistent with State, local, and tribal laws and regulations and the standards of this section, for the acquisition of property or services required under a Federal award or subaward. The non-Federal entity's documented procurement procedures must conform to the procurement standards identified in §§ 200.317 through 200.327. (d) The Non-Federal entity must maintain records sufficient 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. Condition/Context: Condition: Based on our review of the Procurement compliance requirements, we noted that the Division has written procurement policies and competitive policies as required by CFR § 200.318 General procurement standards. We selected five (5) vendors for procurement Suspension and Debarment compliance testing of total population of 5 vendors subject to procurement and we were not provided with Procurement comparative bids therefore, we were unable: • To verify that the procurement method used was appropriate based on the dollar amount and conditions specified in 2 CFR section 200.320. • To Verify that procurements provide full and open competition (2 CFR section 200.319 and 48 CFR section 52.244-5). Questioned Costs: Cannot be determined Recommendation: We recommend that the Division must: (1) Use documented procurement procedures, consistent with State, and local, laws and regulations and the standards, for the acquisition of property or services required under a federal award or subaward. (2) The Division must maintain records sufficient to detail the history of procurement. These records should 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. Corrective Action Plan: The Division will work with Territorial Headquarters to document procedures as outlined in the Recommendations above. Step 1 Action Date: Ongoing Final Implementation Date: 12/31/2023 Name and Phone # Of Person Responsible for Implementation: Jeanne Stromberg, Major, Divisional Finance Secretary (916) 563-3710

The County will make sure that all federal documentation is maintained by each district for inspection and will ensure it is accurately reported on the SEFA.

Recommendation: We recommend the college implement policies and procedures to ensure all procurement documentation is complete and retained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Procurement policies are in place and trainings have been provided for Purchasing and Accounts Payable staff to ensure that all Procurement documentation is included in payment packets. Name of the contact person responsible for corrective action: Clarissa Salhus, Finance Manager, Duane VanderGriend, CFO Planned completion date for corrective action plan: Completed as of January 14, 2026

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.