Corrective Action Plans

Finding 2024-006 I. Procurement, Suspension and Debarment – Assistance Listing No. 14.881 Corrective Action Plan: Response/Planned Actions: CHA Management concurs with the finding. As background context, the previous Chief Legal Officer, at the request of the previous CEO, reviewed the original intergovernmental agreement (IGA) and determined that the agreement had not expired and required no additional board approval or agreement. This is why each year since, Legal has provided authorization for purchase order creation and payment to Chicago Police Department (CPD). The agency is working with CPD to formalize a new IGA. Contact Person: Shelia Johnson, Deputy Chief Procurement Anticipated Completion Date: End of 4th Qtr. 2025

CORRECTIVE ACTION PLAN YEAR ENDED SEPTEMBER 30, 2024 Identifying Number: 2024-001 Finding: During testing of a sample micro-purchase transactions, transactions were identified that lacked contemporaneous documentation supporting a reasonable price determination. From the sample of 40 micro-purchase transactions, half lacked proper contemporaneous documentation supporting a reasonable price determination. Proper approvals were sited for any vendor agreements, invoices, and journal entries as applicable noting due diligence was performed. Corrective Actions Taken: In FY25, IRI revised the process for price justification documents related to micro-purchases. These documents must now be attached to the AP bill in JAMIS (previously, program teams maintained them in their own folders), ensuring that all supporting documentation is stored electronically alongside each transaction. In addition, IRI is rolling out the online contractual system Agiloft, through which all contracts and supporting documents for micro-purchases will be processed electronically, making them easily accessible for review and amendments. Contact Person(s): Procurement and Finance teams: Jessie Ash and Vitaliy Fesun Global Operations team: Brian Zupruk Person Responsible: Vitaliy Fesun, Director of Finance Anticipated Completion Date: October 01, 2025

Conservation and Rehabilitation of Natural Resources on Military Installations – Assistance Listing No. 12.005 Recommendation: CLA recommends regular review of the Organization's procurement policies to ensure they continue to meet procurement standards, as set by Uniform Guidance, and they continue to be consistently implemented. CLA also recommends reviewing internal controls surrounding procurements to ensure they are sufficient to prevent noncompliance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Previous corrective actions were completed in April 2024 upon receipt of our FY 2022 audit and further amended in August 2024 during FY 2023 audit to update internal procurement policies to match Uniform Guidance requirements. We believe these corrective actions would have captured most, if not all, of the incidents in February and March 2024 that contributed to this repeat finding. That said we will continue to regularly review the Organization’s procurement policies to ensure they meet procurement standards. We also aim to implement an annual internal control review to ensure they are sufficient to prevent noncompliance. Name(s) of the contact person(s) responsible for corrective action: Gary Slater Planned completion date for corrective action plan: 10/01/2025

Corrective action plan: Management believes that the procurement process has improved considerably. Managers are following the procurement policy by making price comparisons and submitting quotes when required. Approvals for larger purchases are obtained by Resolution from Council. The Finance Manager and the Accounts Payable Clerk monitor the documents submitted with purchase requests to ensure that the required documents have been submitted. Management believes that it is an isolated instance where a transaction lacked procurement documentation. Personnel responsible for corrective action: Lisa Donham (Finance Manager), Deidre Moyle (Accounts Payable), and Program Managers. Estimated corrective action completion date: December 31, 2025

Communicate with the Budget Board regarding this finding. We have already introduced to the budget board, a form guideline called "Payne County Grant Administration Plan" to aid in proper documentation, reporting and proper spending of all grant awards, including creating a capital outlay sub account as recommended.

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

Corrective action planned – Management recognizes that procurement is a material concern of the organization both from an operational efficiency and regulatory compliance perspective. During the audited time period, procurement responsibilities were decentralized, resulting in inconsistent compliance. In April 2025, Management decided to create a dedicated Procurement Department and began staffing the department. The new Procurement team is tasked with reviewing all current procurement policies and procedures, revising and creating new processes as needed, and partnering with the compliance team to monitor compliance going forward. The policy and procedure revisions will be implemented by the end of the fourth quarter of 2025. Staff will receive training by the first quarter of 2026, and after the training rollout, we will begin internal audits to ensure successful training, implementation and compliance with the new policies and procedures. Name(s) of contact person(s) responsible for corrective action – Alison Spens, Senior Director of Project Management and Procurement Anticipated completion date – August 15, 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.

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

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

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

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.)

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

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

Action taken in response to finding: •LMC staff will receive further training in the use of sole source documentation, and the established policies and procedures for purchasing and procurement. •LMC staff responsible for purchasing and agreements will follow the established policy and procedures for procurement. •LMC staff will develop and maintain tracking mechanisms related to the methodology used for each noncompetitive procurement. Name(s) of the contact person(s) responsible for corrective action: Melissa D’Onorio, CEO, and Donna Landy, CFO. Planned completion date for corrective action plan: 07/14/2025

Finding 2024-004 – Procurement (repeat finding): Type: Material Weakness in Internal Control/Noncompliance. Condition: The CMHSP did not follow the formal procurement methods outlined in 2 CFR 200.320 prior to entering into contracts for services under the grant. Also, the CMHSP did not verify that the vendors were 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. Corrective Action: Current Finance staff will ensure that procurement measures are followed and that vendors are not suspended or debarred or disqualified. Contact Person: Kevin Hartley, CFO Completion date: October 1, 2024

Management of Franciscan Alliance, Inc. and Affiliates (“Franciscan”) considers the implementation and monitoring of effective internal controls to be one of its most important responsibilities, especially as they relate to the funds received from the Federal government. Management has continued to promote sound business practices and effective internal controls across the organization through communication, training, and consistent enforcement of the Franciscan’s policies. The following are the Views and Corrective Action Plans of Management regarding the Schedule of Findings and Questioned Costs for the year ended December 31, 2024 for Franciscan. AUDIT FINDING 2024-001 – Compliance with Reporting Requirements MANAGEMENT’S RESPONSE: Management concurs that the sole source justification was not formally documented prior to the time of procurement. Franciscan’s procurement policy already includes clear criteria for sole source contracting, including the requirement that such procurements be supported by documented justification and approved by the Vice President Supply Chain. The policy outlines specific conditions under which sole source justification is permitted and requires Supply Chain to verify price reasonableness using benchmarking tools or known pricing data. CORRECTIVE ACTION PLAN: Franciscan implemented a new procurement software in the fourth quarter of 2024. The software has a required field for users to select if the procurement is sole-source and if it is, another required field activates for the user to provide a reason for sole-source. Once a procurement request is submitted by the user, the sourcing team reviews the request and verifies it has the appropriate approval if it is sole-sourced. RESPONSIBLE PERSONS: Sarah Burdick, Administrative Director Strategic Sourcing, Franciscan Alliance, Inc. COMPLETION DATE: December 2024

FINDING 2024-002 Finding Subject: Water and Waste Disposal Systems for Rural Communities – Procurement and Suspension and Debarment Contact Person Responsible for Corrective Action: Thomas A. Dippel, CPA Contact Phone Number and Email Address: (812) 683-2211 / ct@huntingburg-in.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: We will work with the City’s attorney to revise its current policy to include federal regulations and procedures related to Procurement and Suspension and Debarment. Once revised, the City will follow its policy to ensure compliance with the compliance requirement. Anticipated Completion Date: September 30, 2025

The College will retain all procurement documentation going forward..

Corrective action planned: Two new policies will be implemented; a board policy to cover board approvals for the bidding of large projects and an internal policy and procedure which spells out additional requirements, like requiring three written bids for large purchases. In addition, all members of the Board of Directors and senior leadership team will sign Conflict of Interest statements on an annual basis to confirm that they do not have any potential conflicts that could impact purchasing decisions. Anticipated completion date: July 31, 2025 Contact person responsible for corrective action: Steve Lindemann, Interim CFO

2024-001 Federal program 10.855 – Distance Learning and Telemedicine Loans and Grants – Procurement, Suspension, and Debarment Condition The County used a noncompetitive procurement method without receiving written approval or meeting one of the other allowable circumstances for a procurement that was greater than a micro-purchase but less than the simplified acquisition threshold. Recommendation Whenever possible, we recommend that the County request written permission from the awarding agency if it seeks to use noncompetitive procurement methods for grants. We also recommend that the County consider updating its procurement policy to make it clear that the circumstances in which noncompetitive procurements can be used with federal assistance differ from normal circumstances. Comments on the Finding Recommendation The County is aware of the finding and will take steps to mitigate the risk of this happening again in the future. Action Taken Before the end of calendar year 2025, the County’s procurement policy will be updated to clarify when noncompetitive methods can be used with federal funding. Additionally, all staff involved with grant management have been instructed to request written documentation from awarding agencies whenever they are attempting to use noncompetitive procurement methods.

Capitalization Grants for Clean Water State Revolving Funds – Assistance Listing No. 66.458 Recommendation: District personnel should familiarize themselves with the documentation requirements required by the CFR related to procurement. In addition, District policies and procedures should be modified to ensure documentation is maintained on the justification for any noncompetitive procurement transactions that are entered into and that the justification is reviewed and approved by someone other than the one making that determination. The written policies should be expanded to clearly address all five procurement methods allowed under Uniform Guidance. The District should also make sure to update its conflict of interest policy to specifically address situations with federal awards and also create written policies and procedures related to suspension and debarment. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: Commissioners will discuss at future regularly scheduled meetings and Clerk/Director will make sure any decisions made include documentation as to why they differ from established policy. Name(s) of the contact person(s) responsible for corrective action: Eric Donaldson Planned completion date for corrective action plan: 31 December 2025