Corrective Action Plans

Coronavirus Relief Funds – Assistance Listing No. 21.027 Recommendation: CLA recommends the County review and follow their procurement policy. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Dickinson County will follow their procurement policy related to federal awards. Name of the contact person responsible for corrective action: Brian Bousley, Controller/Administrator Planned completion date for corrective action plan: December 31, 2024

Finding 2024-002 Corrective Action: We will update our procurement policies and procedures to align with the latest Uniform Guidance requirements, including the 2024 updates that mandate documentation of price reasonableness for all micro-purchases. We plan to adopt a standardized coding submission that clearly articulates the various types of purchases and the appropriate documentatoin for each type of purchase. We will adopt regular training sessions for procurement and grant management staff to reinforce comnpliance requirements and proper documentation practices. Person Responsible: Interim CFO - Bruce Tyler and Finance Director - Jason Phillips Timing for Implementation: October 31, 2025

We agree with the finding that internal controls were not sufficient to maintain compliance with federal procurement standards under Title 2, Subtitle A, Chapter II, Part 200, Subpart D, 200.318 to 200.327 for a non-federal entity. However, the funds were expended for the intended purpose of the federal award. The Company is committed to implementing internal controls to ensure procurement related to federal awards follow 2 CFR section 200.318 to 200.327. The Company will update the procurement policy to ensure it complies with the requirements of 2 CFR section 200.318 through 200.327, that includes the written standards of conduct covering conflicts of interest, governing the actions of its employees who select, award and administer procurement contracts. This policy will include procedures to ensure proper procurement for small purchases to ensure sufficient price quotations are obtained from the required number of qualified sources, proper sealed bids or proposals are obtained through public advertising, an appropriate cost or price analysis is performed for procurement actions exceeding the simplified acquisition threshold, documentation is retained, and proper oversight is exercised to demonstrate compliance with 2 CFR section 200.318 through 200.327. While the Company did not perform a check of each vendor against the SAM Exclusions prior to selecting a vendor, the Company has procedures in place to ensure the vendors are approved by Corporate purchasing and in good standing, which limits the risk of conflict of interest between employees and vendors, and contracting with a vendor who is suspended or debarred from federal related contracting. Further, the Company confirmed the vendors that were contracted with were not included on the SAM Exclusions listing. Contact Person Michael Davis, Chief Financial Officer of Southern Regional Hospital Expected completion date: The procurement policy will be updated by September 30, 2025, and training will be provided to all employees who are relevant to the procurement process of federal contracts by December 31, 2025.

We agree with the finding that internal controls were not sufficient to maintain compliance with federal procurement standards under Title 2, Subtitle A, Chapter II, Part 200, Subpart D, 200.318 to 200.327 for a non-federal entity. However, the funds were expended for the intended purpose of the federal award. The Company is committed to implementing internal controls to ensure procurement related to federal awards follow 2 CFR section 200.318 to 200.327. The Company will update the procurement policy to ensure it complies with the requirements of 2 CFR section 200.318 through 200.327, that includes the written standards of conduct covering conflicts of interest, governing the actions of its employees who select, award and administer procurement contracts. This policy will include procedures to ensure proper procurement for small purchases to ensure sufficient price quotations are obtained from the required number of qualified sources, proper sealed bids or proposals are obtained through public advertising, an appropriate cost or price analysis is performed for procurement actions exceeding the simplified acquisition threshold, documentation is retained, and proper oversight is exercised to demonstrate compliance with 2 CFR section 200.318 through 200.327. While the Company did not perform a check of each vendor against the SAM Exclusions prior to selecting a vendor, the Company has procedures in place to ensure the vendors are approved by Corporate purchasing and in good standing, which limits the risk of conflict of interest between employees and vendors, and contracting with a vendor who is suspended or debarred from federal related contracting. Further, the Company confirmed the vendors that were contracted with were not included on the SAM Exclusions listing. Contact Person Michael Davis, Chief Financial Officer of Southern Regional Hospital Expected completion date: The procurement policy will be updated by September 30, 2025, and training will be provided to all employees who are relevant to the procurement process of federal contracts by December 31, 2025.

The Board of Health will adopt updated written policies periodically in accordance with the Uniform Guidance to help improve internal controls over federal compliance for the findings listed in this number.

Person responsible for this corrective action plan: Jana Kent, Executive Director Corrective Action Plan: YNHA is developing a suspension and debarment training for all staff and program managers to ensure that suspension and debarment requirements are adhered to and include a search on Sam.gov, as required. Estimated Completion Date: October 31, 2025

Finding 2024-004 Federal assistance listing number and name: 10.415 Rural Rent Housing Loans Awards numbers and years: 2024 Federal agency: United States Department of Agriculture Compliance Requirement: Procurement Questioned Costs: None Name of contact person and title: Pat Bishop, President Condition and Context: The entity has not established or documented a formal procurement policy or procedures to guide the acquisition of goods and services. No written guidelines were provided during the review period. Management Response: Management intends to establish a procurement policy. Status: In progress Anticipated Completion Date: Estimated 2025

Contact Person (s): Jim McCarthy - jim@waterwatch.org ; Neil Brandt – neil@waterwatch.org Corrective actions planned: The following corrective actions are being immediately implemented for contracts in WaterWatch’s restoration program in order to achieve compliance: 1. Language requiring all contractors to comply with the Build America, Buy America (BABA) Act is added to all new WaterWatch contracts and all current contracts via amendment. 2. Language requiring all contractors to comply with federal suspension and debarment contracting standards is added to all new WaterWatch contracts and all current contracts via amendment. 3. WaterWatch will keep formal documentation of debarment searches for all contractors. 4. WaterWatch will keep formal documentation of contractor procurement process in both Southern Oregon and Portland offices. Anticipated completion date: September 1, 2025

Material weakness in internal control over compliance with procurement procedures meeting the requirements of 2 CFR Part 200. Management Response: We acknowledge the finding and provide the following corrective action plan. Corrective Action Plan: PDA adopted a new, updated procurement policy in October 2024. PDA worked with Clark Nuber to develop this policy. Anticipated Completion Date: October of 2024 Name(s) of the Contact Person(s) Responsible for Corrective Action: Barbara Donohue, Director of Finance Lisa Daugaard, Tara Moss, and Fe LopezGaetke Co-Executive Directors

Finding 2024-004: Written Policies and Procedures • Planned Corrective Action: We will adopt formal policies and procedures that document our current practices and also meet the requirements of the Code of Federal Regulations (CFR). • Anticipated Completion Date: September 30, 2025. • Responsible Contact Person: Rick Smith, Executive Director

FA 2024-001 Strengthen Controls over Expenditures Compliance Requirement: Activities Allowed or Unallowed Allowable Costs/Cost Principle Procurement and Suspension and Debarment Internal Control Impact: Significant Deficiency Compliance Impact: Nonmaterial Noncompliance Federal Awarding Agency: U.S. Department of Agriculture Pass-Through Entity: Georgia Department of Education Assistance Listing Number and Title: 10.553 - School Breakfast Program 10.555 - National School Lunch Program Federal Award Number: 245GA324N1199 (Year: 2024), 235GA32N1099 (Year: 2023) Questioned Costs: $7,388 Description: A review of expenditures charged to the Child Nutrition Cluster revealed that the School District's internal control procedures were not operating appropriately to ensure that expenditures were reviewed and approved and that the School District's procurement and suspension and debarment procedures were followed. Corrective Action Plans: The following corrective actions will be implemented by the School District: 1. Implement Strengthened Pre-Approval and Documentation Procedures: a. All Child Nutrition purchases will require a completed purchase request form that clearly identifies the funding source, purpose, and allowability under federal guidelines. b. Documentation (invoices, quotes, purchase orders) must be attached and reviewed by the School Nutrition Director and CFO or designee before approval. 2. Enhance Segregation of Duties: a. The individual initiating a purchase or expenditure will not be the same person approving or reconciling it. b. Monthly expenditure reviews will be performed jointly by the Finance Department and School Nutrition leadership to ensure accuracy and compliance. 3. Establish an Internal Monitoring Checklist: a. The School Nutrition Department will implement a monthly internal monitoring checklist that includes documentation review, reconciliation of expenditures, and verification of procurement compliance. The CFO will meet with the Nutrition director monthly. 4. Update Written Polices and Procedures: a. The district's Financial Procedures Manual and the School Nutrition Operations Manual will be updated by December 2025 to reflect all new internal control steps and approval requirements specific to federal expenditures. Estimated Completion Date: June 30, 2026 Contact Person: Tiffany Crockett, Chief Financial Officer Telephone: 478-946-5521 Email: tiffany.crockett@wilkinson.k12.ga.us

Finding 2024-005 – Procurement and Suspension and Debarment Contact Person Responsible for Corrective Action: Nate Moore, Finance Director Corrective Action: The Finance Department will regularly ensure that the procurement policy for the City is followed, and will be sure that it is reviewed often to be sure that no modifications or adjustments need to be made. Anticipated Completion Date: June 30, 2026

Reference: 2024-003 Corrective Action: The City will work on updating the procurement policy to include clearer expectations. Responsible Person: Kristopher Hanus Frederickson, Mayor; Patrick Reagan, City Administrator; Wendi Bixby, Finance Director/Treasurer Anticipated Completion Date: 12/31/2025

Procurement, Suspension, and Debarment Material Weakness in Internal Control over Compliance and Immaterial Instance of Noncompliance Finding Summary: The City does not have a written policy on procurement that satisfied the requirements of 2 CFR sections 200.318 through 200.326. Responsible Individuals: Finance Officer Corrective Action Plan: The City will establish controls to follow all applicable procurement requirements under Uniform Guidance and applicable CFR sections. Anticipated Completion Date: December 31, 2025

The executive level, including the finance director of SEVCA, acknowledge these weaknesses in our practice in FY24. SEVCA has renewed focus on well documented proper procurement procedures and accountability for oversight of procurement action steps by multiple team partners. The following corrective actions are in place: 1. Policy Reinforcement and Training o Conducted mandatory training for all staff involved in procurement, emphasizing the documentation requirements outlined in the Organization’s procurement policy.o Distributed updated procurement documentation checklists to ensure clear understanding of required elements for each procurement file. 2. Standardized File Documentation Process o Implemented a standardized cover sheet or checklist for each procurement file to be completed and reviewed before contract finalization. This indicates whether all required steps (e.g., solicitation of bids) were completed or, if not, the reason for deviation in standard practice. 3. Internal Review and Monitoring o Established a quarterly internal review of a random sample of procurement files to ensure compliance with documentation standards. o Assigned a staff member or team (e.g., Finance Support Specialist) to oversee this review process and report findings to Finance Director and Program Director. 4. Follow-Up and Accountability o Require program director and finance director sign-off on all procurement files over $20,000 to ensure all documentation requirements are fulfilled. o Include procurement documentation compliance as part of staff performance evaluations where relevant. Responsible Person: Finance Director, Lisa Whitney and Executive Director, Josh Davis

The School Department Failed to Check Vendors for Suspension and Debarment Before Contracting Name of Contact Person: Michael Perrone, Director of Business & Finance Corrective Action Plan: The District will apply procedures, and or processes, to document all contracts with vendors that exceed $25,000 to include verification that the vendor is not subject to suspension/debarment prior to contracting. It is important to note, that on every Middleborough Public School purchase order contains the language “The offerer certifies that they and any principals are not presently debarred, suspended, proposed for debarment,or declare ineligible for the award of contracts by any federal agency” The District believed that a vendor honoring our purchase order (Contract) was in essence certifying that they were compliant with the language on our purchase order. Proposed Completion Date: The District will immediately make the necessary changes to comply with the aforementioned finding. It would be helpful if your team would supply the District with examples from other municipalities with acceptable practices.

The Organization is in the process of revising its procurement and conflict of interest policies to ensure alignment with the requirements of 2 CFR §§ 200.318 through 200.326. During fiscal year 2026, the Organization will adopt updated written procedures and implement a formal internal control checklist to verify compliance with federal procurement standards across all grant-funded purchases. Staff responsible for procurement will receive training on the revised policies to ensure consistent application moving forward.

Corrective Action Plan: During Q4 2025, Shiloh’s general purchasing policy will be updated to consider the requirements included in 2 CFR 200.328 through 200.326. (Note: This update was originally to be implemented in Q4 2024 but was delayed due to unexpected turnover in the Business Department.)

Written procedures and conflict of interest policies in accordance with the Uniform Guidance will be established and implemented during the year ended June 30, 2026.

COVID-19 - Coronavirus State and Local Relief Funds (CSLRF)-Assistance Listing No. 21.027 Procurement Recommendation: The Town should review and enhance controls and procedures to ensure that it follows the established procurement policy for all goods and services charged to the program and should ensure that all departments are subject to applicable controls, policies and procedures. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Town will implement procurement processes for goods or services exceeding $10,000 to ensure vendors are selected in a manner providing full and open competition where property or services are being acquired under a Federal award. Name(s) of the contact person(s) responsible for corrective action: Lewis George, Town Administrator Planned completion date for corrective action plan: 01/01/2026

Methodist recognizes the current gap between Supply Chain Services and the Research Institute related to retaining documents for procurement activities. Supply Chain Services will develop processes to retain written documentation for procurement activities in accordance with regulatory standards. As Methodist is in transition to a new ERP system in Quarter 1, 2026, Supply Chain Services will include strategies to address the needs in both the short term and long term.

2024-002 Finding Subject: COVID 19: Coronavirus State and Local Fiscal Recovery Funds - IFA Grant - White Ditch– Procurement and Suspension and Debarment Contact Person Responsible for Corrective Action: Mary Lynn Wall Contact Phone Number and Email Address: 219-873-1404 mlwall@emichigancity.com Views of Responsible Officials: We concur with the finding Procurement Federal regula􀆟ons allow for informal procurement methods when the value of the procurement for property or services does not exceed the simplified acquisi􀆟on threshold, which is customarily set at $250,000. However, Indiana Code 5-22-8 has a more restric􀆟ve 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. Micro-purchases are typically for those purchases $10,000 or under, and small purchase procedures are for those purchases above the micro-purchase threshold, but below the simplified acquisi􀆟on threshold. Micro-purchases may be awarded without solici􀆟ng compe􀆟􀆟ve price rate quota􀆟ons. If small purchase procedures are used, then price or rate quota􀆟ons must be obtained from an adequate number of qualified sources. Description of Corrective Action Plan: All purchases need to be made in accordance with the Sanitary District of Michigan City Purchasing Policy. All contracts will be supported by a written and signed contract document per Section 9.0 of the Sanitary District of Michigan City Purchasing Policy. Suspension and Debarment 2 CFR 200.303 states in part: "The non-Federal entity must: (a) Establish and maintain effective internal control over Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal awards in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in 'Standards for Internal Control in the Federal Government' issued by the Comptroller General of the United States or the 'Internal Control Integrated Framework', issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO)...." 2 CFR 200.320 states in part: "The non-Federal entity must have and use documented procurement procedures, consistent with the standards of this section and §§ 200.317, 200.318, and 200.319 for any of the following methods of procurement used for the acquisition of property or services required under a Federal award or sub-award. (a) Informal procurement methods. When the value of the procurement for property or services under a Federal award does not exceed the simplified acquisition threshold (SAT), as defined in § 200.1, or a lower threshold established by a non-Federal entity, formal procurement methods are not required. The non- Federal entity may use informal procurement methods to expedite the completion of its transactions and minimize the associated administrative burden and cost. The informal methods used for procurement of property or services at or below the SAT include: . . . (b) Formal Procurement Methods. When the value of the procurement for property or services under a Federal financial assistance award exceeds the SAT, or a lower threshold established by a non-Federal entity, formal procurement methods are required. Formal procurement methods require following documented procedures. Formal procurement methods also require public advertising unless a non-competitive procurement can be used in accordance with § 200.319 or paragraph (c) of this section. The following formal methods of procurement are used for procurement of property or services above the simplified acquisition threshold or a value below the simplified acquisition threshold the non-Federal entity determines to be appropriate: . . . (1) Sealed bids. A procurement method in which bids are publicly solicited and a firm fixed-price contract (lump sum or unit price) is awarded to the responsible bidder whose bid, conforming with all the material terms and conditions of the invitation for bids, is the lowest in price. The sealed bids method is the preferred method for procuring construction, if the conditions. . . . (2) Proposals. A procurement method in which either a fixed price or cost-reimbursement type contract is awarded. Proposals are generally used when conditions are not appropriate for the use of sealed bids. . . ." 31 CFR 19.300 states: "When you enter into a covered transaction with another person at the next lower tier, you must verify that the person with whom you do business is not excluded or disqualified. You do this by: (a) Checking the EPLS; or (b) Collecting a certification from that person if allowed by this rule; or (c) Adding a clause or condition to the covered transaction with that person." Description of Corrective Action Plan For all federally funded contracts exceeding $25,000, the Vendor will submit a statement indicating they were not suspended or debarred. For purchases not requiring a contract, the City Controller’s office will check the Excluded Parties List System prior to payment to the vendor. Anticipated Completion Date: 08/06/2025

FINDING 2024-001 Finding Subject: COVID-19- Coronavirus State and Local Fiscal Recovery Funds – Procurement and Suspension and Debarment Contact Person Responsible for Corrective Action: Mary Lynn Wall Contact Phone Number and Email Address: 219-873-1404 mlwall@emichigancity.com Views of Responsible Officials: We concur with the finding Procurement Federal regula􀆟ons allow for informal procurement methods when the value of the procurement for property or services does not exceed the simplified acquisi􀆟on threshold, which is customarily set at $250,000. However, Indiana Code 5-22-8 has a more restric􀆟ve 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. Micro-purchases are typically for those purchases $10,000 or under, and small purchase procedures are for those purchases above the micro-purchase threshold, but below the simplified acquisi􀆟on threshold. Micro-purchases may be awarded without solici􀆟ng compe􀆟􀆟ve price rate quota􀆟ons. If small purchase procedures are used, then price or rate quota􀆟ons must be obtained from an adequate number of qualified sources Description of Corrective Action Plan: All purchases need to be made in accordance with the City of Michigan City Purchasing Policy. Purchases made under the Special Purchase provision (I.C.5-22-10-1) will abide by section 7.4 of the Michigan City Purchasing Policy. This section describes the required record keeping. Suspension and Debarment Criteria 2 CFR 200.303 states in part: "The non-Federal entity must: (a) Establish and maintain effective internal control over Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal awards in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in 'Standards for Internal Control in the Federal Government' issued by the Comptroller General of the United States or the 'Internal Control Integrated Framework', issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO)...." 31 CFR 19.300 states: "When you enter into a covered transaction with another person at the next lower tier, you must verify that the person with whom you do business is not excluded or disqualified. You do this by: (a) Checking the EPLS; or (b) Collecting a certification from that person if allowed by this rule; or (c) Adding a clause or condition to the covered transaction with that person." 2 CFR 200.320 states in part: (a) "The non-Federal entity must have and use documented procurement procedures, consistent with the standards of this section and §§ 200.317, 200.318, and 200.319 for any of the following methods of procurement used for the acquisition of property or services required under a Federal award or sub-award. Informal procurement methods. When the value of the procurement for property or services under a Federal award does not exceed the simplified acquisition threshold (SAT), as defined in § 200.1, or a lower threshold established by a non-Federal entity, formal procurement methods are not required. The non- Federal entity may use informal procurement methods to expedite the completion of its transactions and minimize the associated administrative burden and cost. The informal methods used for procurement of property or services at or below the SAT include: . . . (2) Small purchases– (i) Small purchase procedures. The acquisition of property or services, the aggregate dollar amount of which is higher than the micro-purchase threshold but does not exceed the simplified acquisition threshold. If small purchase procedures are used, price or rate quotations must be obtained from an adequate number of qualified sources as determined appropriate by the non-Federal entity. . Description of Corrective Action Plan: For all federally funded contracts exceeding $25,000, the Vendor will submit a statement indicating they were not suspended or debarred. For purchases not requiring a contract, the City Controller’s office will check the Excluded Parties List System prior to payment to the vendor. Anticipated Completion Date: 08/06/2025 INDIANA STATE

Federal Award Findings Finding 2024-003 U.S. Department of Treasury Passed through State of South Dakota Board of Water and Natural Resources Federal Financial Assistance Listing 21.027 Coronavirus State and Local Fiscal Recovery Funds Finding Summary: The City does not have a formal documented procurement policy which includes written standards of conduct covering conflicts of interest and governing the actions of its employees engaged in the selection, award, and administration of contracts with federal funds . Responsible Individuals: Mike Steen, Mayor and Amanda Metzinger, Finance Officer Corrective Action Plan: Management plans to formally document and approve an official written procurement policy that follows all necessary state and federal laws, including the required procurement standards within 2 CFR sections 200.318 through 200.327. Anticipated Completion Date: 9/22/25

FINDING 2024-004 Contact Person Responsible for Corrective Action: Amy L. Glackman Contact Phone Number: 317-392-6310 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Control procedures will be put into place effective immediately, which will include implementing a federal procurement policy. The Auditor will start checking all vendors paid from grants for suspension, debarred or excluded from being able to enter into contracts. Anticipated Completion Date: August 30, 2025