Corrective Action Plans

In FY24, the Food Service Department piloted a recurring “Pizza Friday” program as part of its student lunch offerings. The District utilized Domino’s due to its demonstrated reliability, familiarity with school food service requirements, and consistent performance. The total annual cost of the purchases exceeded the federal micro-purchase threshold of $5,000. As a result of this finding, the District has updated its internal procurement practice to ensure multiple quotes and/or participation in approved consortiums and purchasing co-ops for services anticipated to exceed this cost. Additionally, the Board has updated policy to increase the threshold from $5,000 to $10,000.

Single Audit Finding: 2024-001 Federal Agency Name: Colorado Department of Transportation  Program Name: Formula Grants for Rural Areas and Tribal Transit CFDA #: 20.509 Finding Summary: Procurement and Suspension and Debarment, Significant Deficiency in Internal Control over Compliance. Responsible Individuals: Heidi Wise - Acting Deputy Chief Financial Officer, Marisa Rupp - Grants and Contracts Specialist, Bob Grogan - Purchasing Manager, Sarah Hill - Transportation Director, Calia Kimball - Transportation Specialist Corrective Action Plan: The City of Durango concurs with this finding and has planned steps to strengthen its internal controls related to procurement and suspension and debarment. In response, the City will implement a formal, standardized procurement process for these services, in coordination with the Risk Management division. This process will be adopted on a citywide basis and occur annually to ensure consistent application and compliance with federal and state regulations. To further reinforce compliance and oversight, a citywide Request for Proposals (RFP) for these types of services will be initiated in the coming weeks. The Transportation Director will coordinate with the Safety/Risk Administrator to lead this effort. Additionally, the City has scheduled an organization-wide training session to reinforce key procurement policies and best practices, with a focus on suspension and debarment compliance. Additionally, a new Purchasing Policy was adopted in early 2025, which includes enhanced documentation and verification requirements, specifically addressing procurement documentation - suspension and debarment checks for vendors. These measures are designed to ensure compliance with applicable procurement standards and reduce the risk of future deficiencies. Ongoing training and monitoring will be conducted to verify continued adherence and to promote accountability across all departments. Anticipated Completion Date: Implementation activities for the procurement in question, will begin in the coming weeks, with the RFP process and staff training scheduled for completion in the third quarter of 2025.

The City concurs with the observation and will implement procedures in 2025 as recommended.

Views of Responsible Officials: FASEB acknowledges the findings identified by the audit regarding procurement and suspension and debarment. We recognize the importance of maintaining adequate records of the procurement process to ensure compliance with federal regulations and to promote transparency and accountability in our operations. Managements Response to Audit Finding on inadequate recording of procurement history or justification: 1. Review and Update Procurement Policies:  We will conduct a thorough review of our current procurement policies and procedures to identify any gaps or areas requiring improvement.  Updates will be made to ensure that our procurement policies align with federal regulations, including those related to suspension and debarment. 2. Training for Staff:  We will provide comprehensive training for all staff involved in the procurement process to ensure they understand the updated policies and the importance of maintaining proper records.  Training will include guidance on documentation requirements, vendor selection criteria, and compliance with federal regulations. 3. Implementation of Record-Keeping System:  We will implement a centralized, secure, and user-friendly record-keeping system to document all procurement activities.  This system will include templates and checklists to guide staff in capturing all necessary information, including vendor selection, bid evaluations, contract awards, and verification of suspension and debarment status. 4. Regular Monitoring and Audits:  We will establish a schedule for regular internal audits of the procurement process to ensure ongoing compliance and to identify any potential issues promptly.  Findings from these audits will be reviewed by senior management, and corrective actions will be taken as needed. 5. Vendor Verification:  We will enhance our procedures for verifying the suspension and debarment status of potential vendors before awarding contracts.  This verification process will be documented and retained as part of the procurement records. Conclusion: FASEB is committed to addressing the findings related to procurement and suspension and debarment. We believe that the steps outlined in our corrective action plan will ensure compliance with Federal regulations and enhance the integrity and transparency of our procurement process. We appreciate the opportunity to improve our practices and will provide updates on our progress as requested.

Year Ended: October 31, 2024 Finding Number: 2024-001 Name oflndividual Responsible for Correction Action: Alissa Rodgers, CFO Cause: Austin Street was previously in compliance due to using a Sole Source Provider for Food that provided the food services as well as the food supply vendors. August Street discontinued services with the food service provider however maintained the food supply vendors. Since they were not new vendors it was misunderstood to pass those vendors through procurement once again since the sole source was no longer connected to the food program. Corrective Action Plan: On April 17, 2025, Austin Street Center's business office has published and distributed an RFP for food vendors to comply with procurement requirements as food costs are usually more than $250,000 per year. ProcW"ement Processes have been followed in all other areas of the organization and Austin Street is placing month end procedures in place to ensure no vendors unexpectedly rise above thresholds that require additional procurement or analysis.

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: 225GA324N1099 (Year: 2024), 245GA324N1199 (Year: 2024) Questioned Costs: $77,285 Prior Year Finding: FA 2023-001 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: Berrien will look at the current procedures for expenditures and make sure that every program is following the same protocols. We have a system in place to ensure that we can check suspension and debarment. Also, we have protocols in place to make sure all contracts are current. Estimated Completion Date: 9/30/2025 Contact Person: Jamie Taylor, Finance Director Telephone: 229-686-2081 Email: jamie.taylor@berrien.k12.ga.us

Name of Contact Person:Veronica Williams, Interim Executive DirectorCorrective Action: KHMA’s Board has approved new written policies and procedures and are in place now.Appropriate staff have begun taking proper safeguards for purchasing and procurement actions to ensure proper accountability. The new policy addresses the three types of procurement under CFR 200.320 informal and formal procurement and noncompetitive procurement. Thresholds have been set for Micro purchases and thus simplified procurement under informal practices. Formal methods include Sealed bids and Proposals when sealed bids are not appropriate.All checks are handled in accordance with the new check writing policy and have the necessary documentation to support the purchase and is filed in such a manner to be available for future reviews. This documentation will be made available to the Authority's fee accountant.All procurement actions will be handled in accordance with the new procurement policy and CFR 200.Proposed Completion Date: Immediately

2024-001 (Significant Deficiency over Compliance): Insufficient Design of Procurement Policy Criteria: Under CFR 200.320, three types of procurement methods are outlined based on the dollar amount and nature of transactions. Condition: The Organization’s existing procurement policy outlines the three methods described under CFR 200.320. However, the policy does not incorporate sufficient monitoring procedures to ensure compliance with the procurement policy Questioned Costs: There were no questioned costs associated with this finding. Effect: This error potentially resulted in the payment of higher prices for goods and services, violating federal procurement regulations. Planned Corrective Actions: The Organization agrees with the finding and will review and revise its procurement policies and procedures to align more closely with current Uniform Guidance and establish monitoring procedures to ensure compliance with CFR 200.320. The Organization will provide additional training to employees and board members to ensure policies and procedures are being followed.

The District of Columbia Public Library (DCPL) concurs with the auditor’s findings and recommendations. Management acknowledges the finding regarding the procurement that was awarded prior to receiving the federal funding and the procurement did not fully adhere to the standards outlined in 2 CFR Section 200. The Procurement was awarded under the District’s Municipal Regulations policies and procedures, we recognize that the 2 CFR Section 200 requirements are stricter. Effective June 12, 2025, DCPL will ensure that all Procurements comply with 2 CFR Section 200, including procurements awarded prior to receiving Federal funding. This includes: • Enhancing our internal review process and documentation to confirm the funding source and ensure Federal procurement regulations are followed. • Identify training for Procurement, Budget and Program Staff on Federal grant compliance and Procurements that fall under 2 CFR Section 200. Contact: Richard Reyes-Gavilan, Executive Director Estimated Completion Date: September 30, 2025 See Corrective Action Plan for chart/table

2024-009 Material Weakness and Material Noncompliance - Procurement and Suspension and Debarment Audit Finding: The Town did not have documentation to support following their purchasing policy for two out of six selections. The Town did not have documentation to support verification that four vendors were not excluded from federal contracts due to debarment or suspension. Corrective Action Taken: Procurement findings: 1. Performance Foodservice had two (2) invoices dated May 2023 (FY23) paid in FY24. For FY23 the BOE had a contract with Performance. The invoices were for prior year. No purchases were made in FY24, only payment from FY23 purchases. BOE believes the purchasing policy was followed. 2. Sardilli Produce, had 3 PO’s entered in FY24. One PO was for $80,000 for yearly invoices. 58 invoices were charged to PO. Average invoice total was $1,289. The approved PO did not follow purchasing policy. Suspension and Debarment addressed in 2024-005. Name and Phone # of Person Responsible for Implementation Mr. Peter Mynarski, Comptroller 203-622-2226

Finding 2024-003 Federal Grantor: United States Department of Health and Human Services Planned Corrective Actions: Monthly Suspension and Debarment files will be reviewed, and documented approval will be retained within the monthly files. Responsible Official – Dawn Ksepka, VP of Finance and System Controller Anticipated completion date –June 30, 2025 Management agrees with the finding. Remediation: Starting June 2025, the monthly suspension and debarment file will be reviewed. A signed statement confirming its accuracy will be included post-review. The accounts payable standard work document will be updated accordingly.

Finding 2024-002 Federal Grantor: United States Department of Health and Human Services Planned Corrective Actions: Responsible Official – Dawn Ksepka, VP of Finance and System Controller Anticipated completion date – July 31, 2025 Management agrees with the finding. Remediation: Fairview updated its internal control processes to better retain and document sole source procurement justification before entering vendor agreements. A standard form for sole source justification will be implemented to enhance documentation.

Person(s) responsible for corrective action: Lucy Yanez, Contract Specialist, Tracy Johnson, Accounts Payable, Tina Hurtado Controller, NWIFC staff and supervisors engaged in procurement and contracting. Management’s Response/Corrective Action Plan: The NWIFC implemented corrective measures related to procurement in March of 2024. See FY23 Corrective Action Plan. However, the one procurement sample that was cited as not including “documentation of bidding, alternative price quotes or sole source documentation” contained a sole source justification that was developed before implementation of the FY23 Corrective Action Plan. The sole source justification was based on the specialized knowledge and specific expertise. Procurement samples for purchases or contracts after the implementation of the FY23 Corrective Action Plan, show compliance of adequate bidding, price quotes or sole source documentation consistent with 2 CFR 200. The NWIFC will continue to implement the FY23 Corrective Action Plan, by requiring NWIFC managers and their staff to be responsible for soliciting bids or developing sole source justifications for procurements and contracts consistent with 2 CFR 200. The Contract Specialist will ensure that bid solicitations and sole source justifications are properly documented and filed with each contract. Similarly, the audit noted that certain suspension and debarment samples selected, before the FY23 Corrective Action Plan was implemented in March 2024, lacked documentation of a suspension and debarment review prior to doing business with vendors. In response, the FY23 Corrective Action Plan, put into effect in March 2024, included measures to ensure that both new vendor and annual reviews are documented. The Accounts Payable department will continue to conduct suspension and debarment reviews for all new vendors before conducting business and perform annual reviews of all vendors, in line with the FY23 Corrective Action Plan. Anticipated completion date: Completed March 2024.

The Division will formalize and adopt a procurement policy. This will also include a suspension and debarment check of vendors. Anticipated Completion Date: 8/1/25. Responsible Contact Person: Yohannes Gedlu, NW Divisional Finance Director & Julie Luft, NW Social Services Director

The City concurs. The City is revising its policies and procedures for federal award programs to include procedures related to simplified acquisitions.

CORRECTIVE ACTION PLAN Pursuant to federal regulations, Uniform Administrative Requirements Section 200.511, the following are the findings as noted in Monroe Community Mental Health Authority’s (MCMHA) Single Audit report for the year ended September 30, 2024, and corrective actions to be completed. Finding: 2024-001 – Procurement, Suspension and Debarment Auditor Description of Condition and Effect: The CMHSP did not document the noncompetitive procurement process pursuant to 2 CFR 200.320 prior to entering into a contract for services under the grant. Also, the CMHSP did not verify that the vendor was not suspended, debarred, or otherwise excluded or disqualified in accordance with 2 CFR requirements prior to entering into a contract for services under the grant. Auditor Recommendation: That the CMHSP review/update policies and procedures to ensure that formal procurement methods are documented, and verification of suspension, debarment, or exclusion is conducted prior to entering into a contract. Corrective Action: Management acknowledges the situation and is developing process and procedure to correct this going forward. Responsible People: Chief Financial Officer and Chief Operating Officer. Anticipated Completion Date: September 30, 2025

Recommendation – We recommend that management revise policies to ensure proper vendor compliance in the future. Views of Responsible Officials and Planned Corrective Actions – Procurement Policy was updated and documentation will be maintained to support vendor verification in the future.

FINDING 2024-001: The entity did not have a control in place to review cost transfers to federal awards to ensure the entity followed the appropriate procurement policies for these costs. Without adequate controls over cost transfers, there is an increased risk of non-compliance with procurement policies. Corrective Action Plan: Management will design and implement a control to review cost transfers from non-federal awards to federal awards to ensure we follow our procurement policies. This will be achieved by adding a new step to the non-payroll cost transfer form that requires the requestor to include a copy of the Procurement authorization form if the procurement policies apply. The Procurement authorization form documents the process, rationale, and justification for procurements. If the purchase being transferred did not go through the appropriate procurement procedures at the time of purchase, then the transfer from the non-federal award to the federal award will not be allowed. Management will also provide additional training around procurement and our related policies and ensure staff involved in this area are aware of the new step embedded in the non-payroll cost transfer form. Remediation Date: July 2025

Views of Responsible Officials: BCHC is in the process of composing a formal procurement policy, which will address requirements for open competition and establish thresholds for different procurement amounts/processes. The policy will clearly outline the conditions where a noncompetitive purchase is allowable. We anticipate having this policy written by June 1 and will submit to the BCHC Board for review and approval. I

Finding 2024-004 Significant Deficiency in Internal Control over Compliance, Other Matters Description of Finding The Town of Lincoln’s procurement standards do not include the essential elements as outlined in 2 CFR sections 200.303, and 200.318 through 200.326 within Uniform Guidance. Statement of Concurrence or Nonconcurrence Management concurs with the finding. Corrective Action Management is working with our current auditors to update the Town’s procurement policies to be in compliance with Uniform Guidance. Name of Contact Person John Cimino, Finance Director Projected Completion Date 6/30/2026

Reference Number: 2024-001 Description: Procurement Corrective Action Plan: The Organization will revise its procurement policy to align approval thresholds with current operations and best practices. Organization will then train staff involved in procurement of the revised policy and will ensure compliance before payment is made which would violate its policy. Anticipated Corrective Action Plan Completion Date: June 30, 2025. Contact Information: For additional information regarding this finding please contact Stephen Bauer, CEO at 414.345.3240.

Condition: Controls were not sufficient to ensure that the history of procurement decisions was documented, as required by 2 CFR 200 and management's internal policies and procedures related to procurement, suspension, and debarment. Planned Corrective Action: Management agrees with the improvement of documentation of procurement, suspension, and debarment. As noted below, purchasing policies are being followed, but were not always formally documented. Careful consideration was done in selecting the vendors to look at obtaining the best cost for the value of the service as IWS was responsible for a portion of the expenses. The findings noted three procurement contracts that were more than $50,000 that did not properly document the rationale for selection and/or sole procurement. The first contract was a single source provider for the replacement of thermostats. Other heating and air conditioning vendors would not handle the replacement of the thermostats as it was not their equipment. There was also a preventative maintenance agreement with the vendor: Phoenix Heating and Air. We will document the use of a single source contractor as allowed in our purchasing policies. We did follow the other control procedures regarding contract approvals, obtaining Certificates of Insurance and verifying completion of the work. The second contract was related to our website and marketing company: Brand Vibe. We did an open bid process, two years earlier, and renewed the contract without a formal bid process. As mentioned above, we did follow the proper approval process and verified the work was completed. The total of this contract for FY 2024 was $74,665, however only $3,600 was charged against the federal grant. Going forward, we will document the rationale for renewing the contract. The third contract was for a bi-lingual APN, with a Psych. Certificate, who was a former employee. She wanted to work part-time, and we switched her to a 1099 employee. With her experience and work record, we allowed her to transition to a part-time contractor. Our experience finding bi-lingual providers has been difficult, and the agency costs are almost double the cost paid for this contractor. The amount charged to the Trauma-Informed Centers of Care was $47,769. In the future, we will formally document the selection and use of this contractor. As noted, we did have a formal contract. and all providers are approved by the Board. Management will make necessary revisions to the existing procurement processes and controls in a timely manner to ensure that procurement decisions are documented, as required by 2 CFR Part 200. Specifically, management will ensure the history of procurement - whether obtained through quotes, formal competitive bids, or through non-competitive means – is documented, including evidence that a cost-price analysis was performed for all purchases in excess of the simplified acquisition threshold. Additionally, before entering a covered transaction with third parties, management will have a form completed by the outside parties stating they are not suspended or debarred from engaging in federal activity before entering a covered transaction. This form will be retained, and we will check and document Sam.gov, excluded parties listing. Contact person responsible for corrective action: Karen L. Williams, Chief Financial Officer Anticipated Completion Date: 06/30/2025

2024-001 Federal Program - Federal Program AL# 93.526 - Health Center Infrastructure Support - Significant Deficiency in internal control over federal award program and Noncompliance - Procurement Recommendation – We recommend that management reinforce adherence to the Center’s procurement policy by providing periodic training to all staff involved in the purchasing process, with a focus on the appropriate application of procurement methods in accordance with 2 CFR § 200.320. Additionally, management should implement a formal review and oversight mechanism to ensure that all procurement transactions exceeding established thresholds are properly evaluated on an aggregate basis, fully documented, and compliant with both internal policies and federal regulations. Action Taken – We concur with the audit finding. While the Center has a policy that meets the compliance requirements, management is responsible for the implementation and monitoring of those processes and procedures. the Center will conduct training for all relevant staff on the proper application of procurement thresholds and documentation requirements. Additionally, management will implement a procurement review checklist and approval process to ensure that all purchases are evaluated in accordance with applicable procedures. These corrective actions will be implemented by December 31, 2025.

Procurement Cluster: Research and Development (R&D) Federal Agency: Various Assistance Listing Title and Number: Various Award Name: Various Award Identifying Number: Various Award Year: Fiscal year 2024 Pass-Through Entity: VariousThe University concurs with the auditors' finding. The University did not communicate the change in auditee status and the resulting impact on the micro-purchase threshold to Procurement Services in a timely manner. This oversight led to continued application of the higher $75,000 threshold after the University no longer qualified under 2 CFR 200.320(a)(1)(iv). To address this issue, management is implementing the following corrective actions: 1. Cross-Functional Communication Protocol – A formal communication protocol will be established between Accounting and Financial Reporting and key compliance stakeholders to ensure timely notification of changes in auditee status or other compliance-related designations following the completion of the annual financial statement audit. 2. Policy Update and Staff Training – Procurement policies and procedures will be updated to reflect the requirement that UAH is subject to the lower micro-purchase threshold. Staff will be trained to take appropriate action when the University either qualifies for or no longer meets the criteria for a higher micro-purchase threshold, including timely adjustments to procurement policies and procedures. 3. Monitoring and Review – The Controller’s Office will conduct an annual review of auditee status immediately upon issuance of the audited financial statements, with documented confirmation sent to key compliance stakeholders. The University expects to complete this corrective action plan by September 30, 2025. For follow-up questions or if you need any additional information, please feel free to contact Brad Cooper, Interim Chief Financial Officer, at jbc0038@uah.edu who is responsible for this corrective action.

The City will provide staff training on appropriate procurement methods and ensure that procurements relating to federal funds follow the procurement methods described in CFR 200.320.