Corrective Action Plans

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.

The City will develop written policies and procedures which include the relevant provisions required by 2 CFR § 200.318 through 2 CFR § 200.327 Contract provisions.

Response to finding 2023-002 – Procurement, Suspension, and Debarment Views of Responsible Officials: CSforALL management agrees with the conditions identified by SAX Advisory Group, including the noted causes and resulting effects under 2023-002. Due to the organizational pause at the end of 2024 and the transition period throughout 2025, the Organization operated with significantly reduced staffing and limited capacity, which delayed the development of procurement policies addressing suspension and debarment requirements. Initial governance updates occurred during the 2025 Q4 Board meeting, where the Board approved a revised version of the By-Laws focused on correcting deficiencies in board structure and conflict-of-interest provisions. Procurement procedures recommended in this finding were not included in that initial revision but are scheduled for development and implementation as part of the 2026 rebuilding phase. Corrective Action taken in 2025: While no procurement-specific corrective action has yet been implemented, foundational updates to the By-Laws were approved at the 2025 Q4 Board meeting to address structural governance issues. These updates establish the basis for incorporating required procurement, suspension, and debarment procedures. The Operations Manager and Advisory Consultant have begun drafting updated procurement policies to ensure compliance with federal requirements. Corrective Action Planned for 2026: Draft procurement, suspension, and debarment policies will be completed and presented to the Board as a formal resolution in early 2026. Upon approval, these policies will be incorporated into the By-Laws and will take immediate effect. The Board has also approved the planned hiring of a consultant with Executive Director and strategy experience in 2026 to support policy implementation, training, staff alignment, and ongoing compliance review. These measures will ensure full compliance with procurement requirements throughout the 2026 operating year and beyond.

Finding 2023-003: Test no 15 is for Department of Education and the rest are for Department of Health. • For test no. 15, obligation 361854 – Of 3 quotations obtained for a small purchase transaction, the highest quotation was selected, there was no documented justification to support the procurement selection. • For test no. 16, obligation 372216 – The procurement was sourced from one vendor and lacks additional quotations. There was no documented justification to support the sole-source procurement. • For test no. 17, obligation 372215 – The procurement was sourced from one vendor and lacks additional quotations. There was no documented justification to support the sole-source procurement. • For test no. 22, obligation 334914 – The procurement file included 2 quotations and a justification form that did not relate to the transaction as it cites an explanation for purchasing goods from other vendors unrelated to the actual transaction. Of the 2 vendors included, there did not appear to be a notable difference in goods/services offered, however the higher of the 2 was selected. Consequently, we could not determine the ultimate basis for vendor selection. • For test no. 30, obligation 358537 – The procurement as sourced from one vendor and lacks additional quotations. There was no documented justification for the sole-source procurement. Root Cause Analysis Ineffective documentation filing and retention controls, further impacted by the relocation of the State Treasury office. Corrective Actions • Strengthen procurement documentation controls and ensure rationales and justifications for vendor selection are retained in procurement files. Responsible Parties Director of Education and its administrative officers Director of Health and administrative officers Director of DOTA, certification and payable section Timeline Verification of Effectiveness Periodically verify the department's purchases to ensure that no instances of noncompliance are still taking place.

Finding 2023-003: Test no 15 is for Department of Education and the rest are for Department of Health. • For test no. 15, obligation 361854 – Of 3 quotations obtained for a small purchase transaction, the highest quotation was selected, there was no documented justification to support the procurement selection. • For test no. 16, obligation 372216 – The procurement was sourced from one vendor and lacks additional quotations. There was no documented justification to support the sole-source procurement. • For test no. 17, obligation 372215 – The procurement was sourced from one vendor and lacks additional quotations. There was no documented justification to support the sole-source procurement. • For test no. 22, obligation 334914 – The procurement file included 2 quotations and a justification form that did not relate to the transaction as it cites an explanation for purchasing goods from other vendors unrelated to the actual transaction. Of the 2 vendors included, there did not appear to be a notable difference in goods/services offered, however the higher of the 2 was selected. Consequently, we could not determine the ultimate basis for vendor selection. • For test no. 30, obligation 358537 – The procurement as sourced from one vendor and lacks additional quotations. There was no documented justification for the sole-source procurement. Root Cause Analysis Ineffective documentation filing and retention controls, further impacted by the relocation of the State Treasury office. Corrective Actions • Strengthen procurement documentation controls and ensure rationales and justifications for vendor selection are retained in procurement files. Responsible Parties Director of Education and its administrative officers Director of Health and administrative officers Director of DOTA, certification and payable section Timeline Verification of Effectiveness Periodically verify the department's purchases to ensure that no instances of noncompliance are still taking place.

We will continue to follow state purchase laws.

FINDING 2023-004 Finding Subject: Drinking Water State Revolving Fund (DWSRF) Cluster - Procurement and Suspension and Debarment Contact Person Responsible for Corrective Action: Tyler Pearson, Clerk Treasurer Contact Phone Number and Email Address: 574-739-1416 clerktreasurer@cityoflogansport.org Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: We will develop and implement a formal process for verifying that vendors are not suspended, debarred, or otherwise excluded from receiving federal funds before entering into contracts or transactions that meet or exceed the $25,000 threshold. The City will develop a purchasing policy that reflects the applicable state laws and regulations related to procurement. The City will also maintain proper documentation to support the appropriate procurement method. Anticipated Completion Date: December 31, 2025

Condition: Controls in place were not adequate to ensure the policy included appropriate procurement thresholds and methods. Planned Corrective Action: Management understands the importance of adhering to procurement thresholds and methods. Procurement policies and grant policies will be updated to include federal thresholds and methods to reflect federal Uniform Guidance. Contact person responsible for corrective action: Stephanie Cihon and Andy Vollmar Anticipated Completion Date: October 31,2025

The Auditor’s Office will work with the Commissioner’s Office and Prosecutor’s Office to implement the required policies.

In regard to the village not having a written policy in place for the requirements outlined in the Code of Federal Regulations regarding the villages received Coronavirus funding, as previously stated the village does not routinely receive federal funds and was not aware at the time of having such a policy. The village is currently working with the village solicitor to rectify this issue. A new policy will be implemented to resolve this issue. – Mayor M. Shane Patrone