Corrective Action Plans

FINDING 2024-002 Finding Subject: Child Nutrition - Procurement, Suspension, and Debarment Summary of Finding: There were no controls in place to ensure that the School Corporation complied with the small purchase requirements. The School Corporation obtained quotes for the two vendors that qualified for the small purchase threshold, but no oversight performed. There were no controls in place to ensure that the vendors included a suspension and debarment clause or check the Sam.gov website. Contact Person Responsible for Corrective Action: Micah Williams Contact Phone Number and Email Address: 765-832-2426/mwilliams@svcs.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The finance department will work in conjunction with the Food Services Director to ensure that quotes are obtained from vendors that are listed on Sam.gov or have a suspension and debarment clause before making in purchases. There will be an email thread detailing the request, the quotes, and the process for ensuring suspension and debarment. Anticipated Completion Date: Immediate.

Finding: While testing the procurement requirement, we 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: Management became aware of the need to perform additional procedures to comply with Uniform Guidance part way through the year ended June 30, 2024 and completed the evaluation once it became known. However, by that time, the vendor was already charged to the grant prior to the completion of the vendor evaluation. UW Health has developed processes and procedures to ensure compliance with the Uniform Guidance and that evaluations are taking place prior to any vendors being charged to the grant. UW Health is also in the process of updating policy to comply with Uniform Guidance. Anticipated completion Date: June 2025 UW Health employees responsible for Corrective Action Plan: James Hood, Director of Procurement Services and Jamie Soyk, Program Director – Financial Reporting

2024-001 (Procurement and Suspension & Debarment) Management Comments and Corrective Action: Due to the growing need to adequately care for the minors at SWK’s shelters coupled with the limitations of access to vendors caused by COVID-19, SWK utilized existing vendor to minimize significant disruptions to operations. The Organization is aware they are operating under contracts that were procured in previous years that may not have all the records maintained. Reprocuring all of these contracts at once would potentially cause disruptions in operations due to the products/services related to those vendors playing an important role in the Organization’s dayto- day operations. In April 2021, the Organization hired new procurement leadership and invested in Full Time Employees (FTEs) to develop a robust procurement department. Due to this procurement revamp, Procurement adopted a hybrid model, and Desktop Protocols were established to provide universal procedures to fulfill policy. Protocols instruct staff on obtaining three quotes and provide tools for selecting the vendor. In addition, quality protocols and tools are currently in development to verify a random sample of procurement transactions and files. The Organization still has several active contracts procured under the old policies that they are working on reprocuring as these contracts’ renewal dates arise, if not earlier. Proposed Implementation Date of Corrective Action: In process and to be completed by December 31, 2025. Person Responsible for Corrective Action: Steven Beckman, CFO 45

The district will establish a system of internal controls with the Cooperative (NISEC) to ensure formal procurement methods are properly followed.

Type of Finding : Significant Deficiency Over Compliance with Procurement and Suspension Debarment Delta County Joint School District No. 50J had the following regarding internal controls in Nutritional Services: The District did not properly procure one vendor within the Child Nutritional Cluster that incurred questioned costs in excess of the $25,000 threshold, based on 2 CFR 200.516. Delta County Joint School District No. 50J concurs with finding 2024-001 and will implement the following corrective steps: Additional procedures have been put in place, and documentation will be maintained for purchases to satisfy Procurement and Debarment requirements.

In the future, we intend to advertise for a longer period of time and if needed re-advertise for a second job walk. We will note each company that attends and if they did or did not chose to bid the job. The documentation of each bid and the board approval for the awarded bid will now be maintained at both the Construction, Maintenance, and Operations Department and the District Office to lessen the loss of documentation due to employee turnover.

January 5, 2024 To: Nigro & Nigro PC Regarding Audit Finding 2024-001 Procurement (5000) Assistance Listing #10.533, 10.55- U.S Department of Agriculture, California Department of Education, Child Nutrition Cluster We agree with the auditor's comments and the following actions will be taken to ensure the district is compliant with Code of Federal Regulations, CFR 200.320. 1) Implement a district system to track all formal bids, informal bids and RFQ's by contract year 2) Documents will include key information such as bid solicitation dates, contract dates and renewal dates for all Nutrition Services bids, RFPs, RFQs and micro-purchases. 3) The Director of NUtrition Services will review all contracts at the beginning of each school year. These steps along with training key personnel will make sure we are in compliance with Code of Federal Regulations, CFR 200.320 Michelle Cagle Director, Fiscal Services

Finding 2024-001 Condition: Three vendors were awarded a contract without a proper competitive procurement process. A fourth vendor was awarded a contract that the School believes is a sole source procurement, but written documentation of the circumstances and rationale for the non-competitive procurement, as well as a history of the process, was not maintained by the client. Corrective Action Planned: The School intends to implement additional internal controls including employee training and enhancements to its federal awards policies and procedures to better ensure compliance. Anticipated Completion Date: March 31, 2025. Contact: Cathleen Ellis, Business Manager

CORRECTIVE ACTION PLAN OF CURRENT AUDIT FINDINGS June 30, 2024 FINDING 2024-001 Information on the federal program: Subject: Child Nutrition Cluster - Procurement and Suspension and Debarment Federal Agency: Department of Agriculture Federal Program: School Breakfast Program, National School Lunch Program, Summer Food Program, School Summer Food Service Program Assistance Listing Number: 10.553, 10.555, 10.559 Federal Award Numbers and Years (or Other Identifying Numbers): FY 2023, FY 2024 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Procurement and Suspension and Debarment Audit Finding: Material Weakness Condition: An effective internal control system was not in place at the School Corporation to ensure compliance with requirements related to the Child Nutrition Program and Procurement and Suspension and Debarment compliance requirements. Context: Procurement Federal regulations allow for informal procurement methods when the value of the procurement for property or services does not exceed the simplified acquisition threshold, which is set at $250,000 unless a lower, more restrictive threshold is set by a non-Federal entity. As Indiana Code has set a more restrictive threshold of $150,000, informal procurement methods are permitted when the value of the procurement does not exceed $150,000. This informal process allows for methods other than the formal bid process. The informal process is divided between two methods based on thresholds. Micro-purchases, typically for those purchases $50,000 or under, and small purchase procedures for those purchases above the micropurchase threshold, but below the simplified acquisition threshold. The School Corporation's policy states that the small purchase threshold is between $10,000 and $150,000. If small purchase procedures are used, then price or rate quotations must be obtained from an adequate number of qualified sources. For fiscal year 2023, two vendors, totaling $109,657 and $53,441, were selected for testing at the small purchase threshold. The School Corporation did not obtain price or rate quotes nor was there documentation detailing the history of procurement, which must include the reason for the procurement method used. The lack of internal controls and noncompliance was isolated to fiscal year 2023. Suspension and Debarment Prior to entering into subawards and covered transactions with federal award funds, recipients are required to verify that such contractors and subrecipients are not suspended, debarred, or otherwise excluded. "Covered transactions" include but are not limited to contracts for goods and services awarded under a non-procurement transaction (i.e., grant agreement) that are expected to equal or exceed $25,000. The verification is to be done by checking the SAMs exclusions, collecting a certification from that vendor, or adding a clause or condition to the covered transaction with that vendor. During the audit period, there were ten vendors identified which exceeded $25,000 in disbursements on an annual basis. Six vendors were selected for testing. In one instance, the School Corporation's contract with the vendor did not include any suspension and debarment clause and the School Corporation did not verify the vendor's suspension and debarment status prior to payment. The lack of internal controls and noncompliance was isolated to fiscal year 2023. Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Management will ensure that the School Corporation's procurement policy is being followed for all procurement thresholds. Management will perform a periodic check of federal fund disbursements to see if any vendors exceed procurement or suspension and debarment thresholds on an annual basis to ensure compliance with federal and state procurement guidelines. The School Corporation will ensure that all contracts exceeding $25,000 include a suspension and debarment clause and will verify that the vendor is not suspended or debarred prior to entering into the contract. Responsible Party and Timeline for Completion: The Food Service Department has already implemented these changes as the issue was not present in fiscal year 2024.

The Village of Lexington hired, through a bid process, Townley Engineering to design needed water and sewer expansion and upgrades for the purpose of submitting to USDA for Water and waste disposal systems for rural communities grants in 2017. The Village was awarded funding and hos worked closely with USDA representatives as we have moved through the program. A budget for all costs was approved as part of the grant award. All invoices, including all engineering fees, are approved directly by our assigned Area Specialist. The project costs are currently all within budget. The Village of Lexington will ensure that engineering services follow correct procurement procedures in any future grant program it is awarded.

Re: Finding 2024-001: Procurement (50000) Nutrition Services currently uses US Foods for the purchase of various commercial food items throughout the year (candy, chips, soda, bread, hotdogs, popcorn, coffee, hot cocoa, churros, cookies, etc). A vast majority of the purchases are for non-program foods for catering or Snack Bar Sales at Fred Kelly Football Stadium. Occasionally, US Foods is used to purchase specialty items for students with food allergies (i.e. gluten free) and baby food for students that require a pureed diet. Nutrition Services compares prices between US Foods and Smart and Final periodically throughout the year. Smart and Final purchases are made in store and Nutrition Services would have to provide pictures of price tags on the shelf at Smart and Final to show compliance with this request. Nutrition Services requested a price quote for products purchased through US Foods. Unfortunately, the company representative told us their prices are variable based on the market and could change weekly. Nutrition Services would only be able to provide auditors of screenshots ofUS Foods online ordering portal, which would consist of hundreds of pages given the expansive foods available. To correct the finding, Nutrition Services will do the following: 1. Request piggybackable formal bid options from US Foods. To that end, the Nutrition Services and Purchasing directors will seek board approval no later than March 1, 2025. 2. Take necessary steps to increase micropurchase threshold to $50,000. 3. Consider opening a Purchase Order with Sysco Foods to spread the micropurchases to another online retailer, thus mitigating the issue of in-person shopping and price comparisons. 4. Work with Purchasing Department to ensure open Purchase Orders do not exceed $50,000 for any vendor that does not have formal procurement in place. To that end, the Nutrition Services Accounting Technician and the Purchasing Supervisor will review quarterly expenditures for all open purchase orders effective December 1, 2024.

The Purchasing department will develop and maintain written procurement procedures requiring that “small purchases” of equipment or services made under a Federal award or sub-award above the micro purchase threshold require multiple quotes and that these quotes are properly documented as evidence. “Small purchases” are those where the total dollar amount is higher than the micro-purchase threshold but does not exceed the simplified acquisition threshold. Purchasing department staff will be trained on this procedure and the District will adopt a board policy to address this procedure. The contact person is Philippa Townsend and the anticipated completion date is 11-1-2025.

Procurement Federal Program Title: Research & Development Cluster Assistance Listing No. 47.083 Type of Finding: Significant Deficiency in Internal Control over Compliance Other Matters Recommendation: We recommend the University evaluate its procedures and implement an additional control to document reasons for obtaining competitive bids. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Grant Accounting and Purchasing will both review requisitions within Jaggaer to make sure appropriate bids, and or exemptions are documented or attached. Name(s) of the contact person(s) responsible for corrective action: Lisa Leyshon, AVP Finance/Controller and Kirsten Broughton, Director of Grant Accounting Planned completion date for corrective action plan: July 1, 2024

Management Response: The management staff of Hubbs-SeaWorld Research Institute take very seriously the federal compliance related to the procurement of goods and services. Hubbs-SeaWorld Research Institute acknowledges the finding and has subsequently updated their procurement policy and procedures to be in compliance with 2 CFR 200.303. Management has adopted a plan of action to prevent future instances of non-compliance. Action Taken: Hubbs-SeaWorld Research Institute plans to modify its procurement procedures for federal grants to comply with 2CFR section 200.319 by continuing to require at least three bids (or a sole source statement, if applicable) for any purchases over the micro-purchase threshold, currently $10,000. In addition, we will monitor cumulative vendor purchases on a monthly basis to ensure that price or rate quotations are obtained from an adequate number of qualified sources, that is, at least three bids (or a sole source statement, if applicable.)

Procurement and Suspension and Debarment The College acknowledges the finding and recognizes the need for additional improvements to ensure full compliance with federal procurement regulations. Moving forward, procurement procedures will be strengthened by incorporating vendor eligibility verification requirements, including review of SAM.gov prior to contract execution or purchase approval. The college will also implement recurring training and oversight measures for employees involved in procurement activities to improve adherence to federal standards and internal procedures.

Planned Corrective Action: We concur with the finding. Management has issued guidance to obtain at least two quotes when practicable. Procurement procedures are being reviewed to strengthen competition, and staff will retain date-stamped SAM.gov screenshots to document suspension and debarment checks before awards. Proposed Completion Date: On-going Name and Contact of Responsible Person: Sherilynn Madraisau Director Bureau of Public Health & Human Services Contact: 680-488-2552 Email: Sherilynn.madraisau@palauhealth.org Gail Rengiil Director Bureau of National Treasury Ministry of Finance Contact:680-767-2561 Email: gailr@palaugov.org

Planned Corrective Action: We concur with the finding. Management has issued guidance to obtain at least two quotes when racticable. Procurement procedures are being reviewed to strengthen competition, and staff will retain date-stamped SAM.gov screenshots to document suspension and debarment checks before awards. Proposed Completion Date: On-going Name and Contact of Responsible Person: Sherilynn Madraisau Director Bureau of Public Health & Human Services Contact: 680-488-2552 Email: Sherilynn.madraisau@palauhealth.org Gail Rengiil Director Bureau of National Treasury Ministry of Finance Contact:680-767-2561 Email: gailr@palaugov.org

Planned Corrective Action: We concur with the finding. Management has issued guidance to obtain at least two quotes when practicable. Procurement procedures are being reviewed to strengthen competition, and staff will retain date-stamped SAM.gov screenshots to document suspension and debarment checks before awards. Proposed Completion Date: On-going Name and Contact of Responsible Person: Ida R. Kilcullen Director Bureau of Curriculum & Instruction Ministry of Education Contact: 680-488-2547 Email: ikilcullen@palauschools.org Gail Rengiil Director Bureau of National Treasury Ministry of Finance Contact:680-767-2561 Email: gailr@palaugov.org

Planned Corrective Action: We concur with the finding. Management has issued guidance to obtain at least two quotes when practicable. Procurement procedures are being reviewed to strengthen competition, and staff will retain date-stamped SAM.gov screenshots to document suspension and debarment checks before awards. Proposed Completion Date: On-going Name and Contact of Responsible Person: Gail Rengiil Director Bureau of National Treasury Ministry of Finance Contact:680-767-2561 Email: gailr@palaugov.org

2023-003 Procurement Policy Recommendation: Auditors recommend that CIES create a procurement policy and procedures to ensure that all required procurements are performed in accordance with the guidance and criteria outlined above. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: CIES will develop a procurement policy and procedures that ensure all required procurements are performed in accordance with the criteria identified. Name(s) of the contact person(s) responsible for corrective action: Michael Parker, Executive Director Planned completion date for corrective action plan: May 2026

FINDING 2023-004 Contact Person Responsible for Corrective Action: Craig Zandstra Contact Phone Number: 219-945-0543 Ext 234 Contact Email: craigz@lakecountyparks.com Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan As this finding is shared between The Lake County Board of Commissioners and the Lake County Parks & Recreation Department, both departments will develop procedures to ensure the appropriate procurement methods are used for vendors that are within the Small Purchase Threshold. Both departments will also ensure that vendors are not suspended or debarred when expanding federal funds. Lastly, appropriate documentation will be maintained to ensure compliance with procurement, suspension and debarment in the future. Completion Date: June 2026

Cause: While policies were in place, detailed written procedures for consistent grant administration had not been developed or formally documented. Corrective Action Taken: A procedure manual has been written to incorporate required compliance areas, including allowability of costs, procurement, equipment management, cash management, time and effort reporting, suspension and debarment, and record retention. Planned Corrective Actions / Preventive Measures: 1. Procedure Development: Document clear written procedures including requisitioning, approvals, reimbursements, reporting, and monitoring. 2. Training and Implementation: Provide training to all staff involved in grant administration on the new procedures. Establish a schedule for periodic refresher training and updates when regulations or program requirements change. 3. Ongoing Monitoring: Designate the Business Administrator (or designee) to monitor compliance and review procedures annually. Update policies and procedures as needed to reflect changes in federal requirements or internal practices. Timeline: Procedures completed: September 2024. Staff training and implementation: June 2026. Ongoing monitoring: Annually, beginning March 2026 Responsible Parties: Lori Schmidt, Business Administrator: Oversight of policy and procedure revision, implementation, and monitoring. Scott LaFortune, Finance Manager/Grant Manager: Day-to-day adherence to procedures and reporting. School Board: Formal policy approval.

Audit Finding: 2023-003 – 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

Chairman of the Board of County Commissioners: These procurement issues originated during the prior County Clerk’s administration, but the current leadership is focused on corrective measures. Together, we are: • developing a SOP to ensure vendor checks for suspension and debarment are conducted on all purchases over $25,000, • establishing written standards of conduct to address conflicts of interest and set clear procurement guidelines, • and enhancing oversight and review to ensure all procurement processes are fully compliant with federal regulations. Our goal is to build a consistent, transparent procurement framework that safeguards both compliance and public trust. County Clerk: I was not the County Clerk in office at this time. To correct this issue, the County plans to develop a SOP to timely and accurately track and report on the SEFA. The SOP will be reviewed, adopted, and monitored by the Board of County Commissioners.

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.