Corrective Action Plans

The City staff will be stricter in following its established internal control procedures to ensure that all reporting requirements are met and submitted timely. The City will also establish access to the Integrated Disbursement and Information System (IDIS) for another member of the Finance Department in a backup capacity. Where applicable, the City will request an extension from the funding agency and maintain a record of the approval when a report cannot be submitted by the due date.

Federal Award Finding: 2024-002 Material Weakness in Compliance and Internal Control over Procurement and Suspension and Debarment Name and Contact Person: Adrienne Gaines, Executive Director Corrective Action: WISH has evaluated the processes and procedures regarding procurement and suspension and debarment, as well as the processes for maintaining records supporting all procurement activity. Management will appoint an individual to oversee this. Proposed Completion Date: June 30, 2025

Reporting - FSRS Opioid STR - FSRS were not timely submitted resulting in noncompliance with the reporting requirement. Corrective Action Plan: ADAD will meet with the program staff to complete the implementation of the policies and procedures relating to the reporting of subawards to the new FSRS system to comply with the Federal reporting requirements. Implementation Date: July 1, 2025 Responding Official: John Valera and Melanie Muraoka, Administrative Officer/Alcohol and Drug Abuse Division

Corrective Action Plan Procurement – Finding 2024-003 Roof Above will amend the procurement policy to document the criteria for vendor selection, including bids, quotes, and sole source justification and follow the policy when contracting with new vendors using federal funding. Contact person responsible for corrective action: Kaedon Grinnell, Chief Program Officer Anticipated completion date: March 31, 2025

FINDING 2024-004 Finding Subject: Child Nutrition Cluster – Procurement and Suspension and Debarment Contact Person Responsible for Corrective Action: Kelli Keith Contact Phone Number and Email Address: 812-438-2655, kkeith@risingsun.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: We had never been instructed to do price quotes for items purchased from the HPS Purchasing Co-Op before. In the future, we will obtain price quotes when purchasing from HPS when purchases are above the micro-purchasing threshold. Or we will find a different purchasing avenue and will not use HPS. The cafeteria director is currently discussing this with each of the cafeteria supervisors to decide which avenue they will use to avoid the finding in the future. Going forward, for any vendor expected to equal or exceed $25,000 that is paid from school lunch funds (or any federal funds for that matter), someone at the school corporation will verify those vendors aren’t suspended or debarred. Anticipated Completion Date: 08/01/2025: The next school year.

CORRECTIVE ACTION PLAN (CONCERNING FINDING 2024-001-RF3-407-3.0) Contact Person Responsible for Corrective Action: Judy L Hayward Corrective Action Plan: The Royalton Fire District 1 will take the following actions to address finding 2024-01. We will prepare and adopt a federal procurement policy, Anticipated Completion Date: June 30, 2025.

FINDING 2024-012 Subject: Special Education Cluster (IDEA) - Procurement and Suspension and Debarment Federal Agency: Department of Education Federal Programs: Special Education Grants to States, COVID-19 - Special Education Grants to States, Special Education Preschool Grants, COVID-19 - Special Education Preschool Grants Assistance Listing Numbers: 84.027, 84.027X, 84.173, 84.173X Federal Award Numbers and Years (or Other Identifying Numbers): 22611-027-PN01, 22611-027-ARP, 22619-027- ARP, 23611-027-PN01, 23619-027-PN01 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Procurement and Suspension and Debarment Audit Findings: Material Weakness, Modified Opinion Contact Person Responsible for Corrective Action: Beth Husband/Alexandria Eckert Contact Phone Number 260-356-8312 Email Address: bhusband@hccsc.k12.in.us/aeckert@hccsc.k12.in.us Views of Responsible Officials: We concur with the finding Description of Corrective Action Plan: All future expenditures triggering procurement and suspension and debarment requirements will include implementing the following procurement policies: Reference Procurement Standards 2 CFR 200.318 Districts may not enter into contracts with entities that have been suspended or debarred from participating in contracts with federal funds. For contracts over $25,000, districts must verify a contractor is not excluded or disqualified. Contractors must be verified in one of three ways: 1. Checking the System for Award Management (SAM) (www.SAM.gov) 2. Collecting a certificate from that contractor. 3. Adding a clause or condition to the covered transaction with that contractor. (Recommended) **Proper verification and documentation must be sent to the LEA for audit purposes. Methods of Procurement Where specific EDGAR/UG thresholds apply, Districts must meet baseline requirements for procurement. If State or local rules have more restrictive thresholds, the most restrictive rule must be followed. Anticipated Completion Date: All expenditures initiated after March 26, 2025

We will give instructions to the Contract Division to use a contract model that includes all the required federal clauses for contracts formalized that are subsidized with federal funds

Name of Contact Person: Darla Hawkins, City Treasurer, City of Sheridan, Wyoming Corrective Action Plan: Due to personnel changes, obtaining authorization to access the reporting site proved to be a challenging and time-consuming process. To prevent similar issues in the future, a cross-training program and centralized task list are being developed to ensure multiple staff members are familiar with all tasks and have backup access to logins when available. Proposed Completion Date: June 30, 2025

The corrective action plan listed below is response to the San Bernardino Valley Municipal Water District’s single audit report for the fiscal year ending June 30, 2024, prepared by Rogers, Anderson, Malody and Scott, CPA’s 2024-001 - Lack of Internal Controls Over the Reporting Process Significant Deficiency Reclamation States Emergency Drought Relief Program, AL 15.514 Recommendation: We recommend that the District develop and implement formal policies and procedures to ensure that federal reports are reviewed for accuracy, completeness, and timeliness prior to submission. Management should assign responsibility for report preparation and review, implement checklists or reconciliation processes, and provide training to sta􀆯 involved in federal reporting. Corrective Action: To ensure compliance for future reporting, the District has implemented procedures that prior to submission of grant reporting, the accounting department will approve the report for all grant expenditures. In addition, the District has arranged for sta􀆯 training for employees involved with federal grants and reporting. Person Responsible for Corrective Action: Chief Financial O􀆯icer Senior Accountant Project Managers (Various Departments) Anticipated Completion Date for Corrective Action: Corrective Action is immediately implemented in response to the auditors’ recommendation.

Finding 2024-003 Contact Person Responsible for Corrective Action Plan: Brenda Layne, Food Service Director Contact Phone Number: 765-289-7323 We concur with the finding. Corrective Action plan: As of 3/1/25. Cindy will look the company up on Sam.gov. and the Food Service Director will look it over and both of us will initial and keep a copy on file. Anticipated Completion Date: March 2025

Finding Reference 2024-06 Corrective Action Plan: The Authority will revise its procurement policies and procedures to ensure that all federally funded projects undergo the appropriate competitive procurement processes. This will include consistent and standard guidelines for project scope determination, bidding process, and documentation requirements. Responsible: Eng. Maria Ayala Rivera, Construction Office Director Planned Implementation Date: December 31, 2025

Identifying Number: 2024-001 Audit Finding: Accounting for Pharmacy 340B Drug Pricing Program Transactions. While testing the 340B Program, revenue and accounts receivable, we identified the following errors: • The Organization overstated 340B Program accounts receivable and revenue by double-counting a 340B Program transaction in the amount of $213,887. • The Organization understated 340B Program accounts receivable and revenue by $45,038 by not properly recording a transaction with a pharmacy. • The Organization overstated 340B Program revenue and professional services expense by $1,111,252 by posting an incorrect adjustment to true-up revenue and expense for dispensing, processing and administrative fees associated with the 340B Program. Corrective Action Taken: The Controller will utilize program data reports to perform reconciliations periodically. The reconciliations will be reviewed by the VP of Finance and stored. Additionally, the Revenue Cycle Manager and the VP of Finance will assist and monitor TPA’s setup and conditions for proper program management. This will be implemented by June 30, 2025. Identifying Number: 2024-002 Audit Finding: Inadequate Internal Controls Over Payroll Transactions. In May 2024, the Organization failed to restrict the modification of payroll reports subsequent to approval. There was no final check performed to ensure that the final submitted payroll report agreed with the approved version. Corrective Action Taken: By June 2024, the Finance Director created additional checks and balances to ensure integrity of payroll. The Director will provide a trend analysis of payroll data for each payroll for the approval process. The analysis will show changes in employee pay and trends. We will also compare the final payroll totals with the website verification after submission to ensure the totals reviewed match what was submitted. Identifying Number: 2024-003 Audit Finding: While testing the procurement requirement for micro purchases, we noted there was one sample selection for which the Organization did not have documentation to support whether the procurement method used was appropriate. Corrective Action Taken: By June 30, 2025, the Operations team and the Accounts Payable Coordinator will maintain a centralized database of vendor contracts, bids, and other information regarding purchases. To ensure continuity through changes in personnel, Tapestry will store the data on the shared drives, allowing for a repository to persist over time. Purchases, contracts, and associated back up will be monitored by both Operations and Finance teams and will be assisted by Office Managers who may perform some ordering.

Contact Person Mark Bell Director of Finance vcc.m.bell@ontrackroguevalley.org Explanation and Specific Reasons for Disagreement With the Audit Finding or That Corrective Action is not Required (if Applicable) No disagreement. Corrective Action Planned 1. Develop and Implement a Formal Procurement Policy o A written procurement policy will be developed that aligns with 2 CFR 200.317 - 200.327, ensuring compliance with federal, state, and local regulations. 2. Enhance Internal Controls for Procurement Compliance o All procurement transactions will be reviewed and approved by designated personnel to verify compliance before finalizing agreements. o A procurement checklist will be used for each transaction to ensure that required documentation is maintained. 3. Mandatory Suspension and Debarment Verification o The Organization will implement procedures to verify all vendors against the System for Award Management (SAM.gov) database before entering into contracts. o Documentation of suspension and debarment searches will be retained in the procurement files. Anticipated Completion Date September 30, 2025

Finding No. 2024-004: Segregation of Duties and Oversight – Material Weakness in Internal Control over Financial Reporting Contact for Corrective Action: Matt Bergheiser, President The finance department will institute a monthly financial reporting package to be sent to the President of the organization which will include the monthly financial statements, general ledger detail, a listing of all journal entries made, significant accounts reconciliations, aged payables and receivables, and any significant adjustments in the previous period. Report will also include an update to the Schedule of Federal Awards and other significant grant reporting done in conjunction with the development team. President will review and approve the packet monthly. Expected Completion Date: 3/31/2025

Condition: During the audit, the auditors noted three of seven monthly Federal Financial Reports were filed late. Specifically, the July 2023, August 2023 and May 2024 reports were filed later than 30 days as required under the County’s contract. Recommendation: The auditors recommended that the County improve internal controls over grant reporting that includes a process that identifies reporting requirements, including reporting deadlines, and monitors timely grant reporting. Corrective Action Planned: The County Community Services department will improve the timeliness and accuracy of grant reporting by implementing the following measures. An automated task list will be implemented to clearly identify billing report due dates, responsible staff, report recipients, and the required reporting frequency. This system will enhance accountability and help ensure deadlines are consistently met. A separate automated task will be established to ensure Community Services receives accurate and timely billing reports from grantors. This proactive approach will help identify and resolve potential delays before they impact reporting compliance. If unforeseen circumstances impact reporting timelines Community Services will utilize internal departmental data to prepare preliminary billing reports to prevent delays and reconcile to final reporting when available. Additionally, Community Services will proactively communicate with grantors in the event of anticipated delays to maintain transparency and compliance. The County Finance department had already partially addressed this at the beginning of fiscal year 2025 with enhanced data gathering of grant reporting requirements and deadlines for each grant. This data is gathered prior to grant acceptance. The County Finance department will improve its process by providing frequent reminders at a standard frequency to all department directors and those who are directly responsible for grant reporting to follow the grantor reporting requirements. Additionally, these periodic communications will request that department directors confirm the accuracy of department grant contacts and provide updated contact information as needed. Contact Name: Christina Register, Assistant Director Community Services Anticipated Completion Date: June 30, 2025

CORRECTIVE ACTION PLAN March 17, 2025 Health Resources and Services Administration 5600 Fishers Lane Rockville, MD 20857 The Gavin Foundation, Inc. respectively submits the following corrective action plan for the year ended June 30, 2024. CohnReznick LLP 350 Granite Street, Suite 1200 Braintree, MA 02184 Audit Period: June 30, 2024 The finding from the June 30, 2024 schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. FINDING - FEDERAL AWARD PROGRAM AUDIT U.S. Department of Health and Human Services 2024-001 Congressional Directives - Assistance Listing No. 93.493 SIGNIFICANT DEFICIENCY Recommendation Management should establish procedures to ensure contract files include the history of procurements and the documentation is maintained. Action Taken The organization performed procurement procedures, including soliciting bids/proposals from multiple contractors, evaluating them and selecting the contractor based on their procurement procedures. However, as the project was completed we maintained the contracts related to the contractor selected but inadvertently disposed of the documentation related to the procurement process. We have met with employees responsible for completion and filing of the procurement documentation and discussed the importance of not only completing the documentation, but also the importance of its proper filing. We have updated our procedures to ensure procurement history is adequately documented and maintained in the contract files. These actions were implemented (or are anticipated to be implemented) effective March 17, 2025. If the Health Resources and Services Administration has questions regarding this plan, please call Peter Barbuto at (857) 496-7341. Sincerely yours, Peter Barbuto, CEO The Gavin Foundation, Inc.

The Service Center will be sure to follow the federal procurement requirements pursuant to Policy 6325 and verify that appropriate controls and compliance with federal requirements are maintained with documentation supporting the procurement types.

Information on the federal program: Subject: Special Education Cluster (IDEA) – Procurement Federal Agency: Department of Education Federal Program: Special Education Grants to States, Special Education Preschool Grants Assistance Listing Number: 84.027 Federal Award Numbers and Years (or Other Identifying Numbers): H027A220084, H027A230084 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Procurement and Suspension and Debarment Audit Finding: Significant Deficiency Condition: An effective internal control system was not in place at the School Corporation in order to ensure compliance with requirements related to the grant agreement and the Procurement and Suspension and Debarment compliance requirement. 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. However, Indiana Code 5-22-8 has a more restrictive 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. The informal process is divided between two methods based on thresholds. Micro purchases, typically for those purchases $10,000 or under, and small purchase procedures for those purchases above the micro purchase threshold, but below the simplified acquisition threshold. Micro purchases may be awarded without soliciting competitive price rate quotations. If small purchase procedures are used, then price or rate quotations must be obtained from an adequate number of qualified sources. Context: The School Corporation did not obtain price or rate quotes for one out of four vendors tested that were less than the simplified acquisition threshold of $150,000 but exceeded the $10,000 micro-purchase threshold. Documentation of vendor contract, bids or the School Corporation's process and rationale for the chosen vendor was not available for audit. Further, the School Corporation could not provide evidence that a suspension and debarment check had been performed on the vendor prior to entering into contract. Corrective Action Plan: The Special Education Director will obtain pricing quotes from the appropriate amount of qualified sources, when cumulative costs are projected to exceed the micro purchase threshold. The Special Education Director will document and communicate the results of this process with the Business Manager and Superintendent. Person responsible for implementation and projected implementation date: The Special Education Director, the Business Manager, and the Superintendent will be responsible for overseeing the implementation of the corrective action plan, which will go into effect immediately.

2024-006 Contact Person: Duane Poitra, Business Manager Corrective Action Plan: To ensure compliance with applicable federal purchasing regulations, purchasing agents will be trained by business office staff on the micro-purchase threshold requirements in 2 CFR Part 200. Internal controls will be established for purchases over $10,000, competitive bidding, such as sealed bids, quotes, or competitive proposals, will be acquired by purchasing agents as required by the Uniform Guidance (2 CFR Part 200). The designated purchasing agent will follow these rules, and all federal funding purchases exceeding $10,000 will require approval from the Superintendent and Business Manager to ensure compliance. Anticipated Completion Date: Fiscal Year 2024-2025

March 26, 2025 CORRECTIVE ACTION PLAN FISCAL YEAR OF FINDING: June 30, 2024 AUDITOR FINDING: 2024-001 AREA: Procurement and Suspension & Debarment Compliance It was noted that (1) the Organization's documented procurement procedures must conform to the procurement standards identified in 2 CFR 200.317 through 200.327; and (2) in accordance with 2 CFR Part 180, contracts cannot be entered with certain parties that are debarred, suspended, or otherwise excluded from receiving or participating in federal awards. It is recommended for the Organization to comply with the Organization’s internal procurement policies and the Uniform Guidance with respect to obtaining vendor quotes and retain support for a check of suspension and debarment. CLIENT PLANNED ACTION: 1. WellPower will review and align its procurement policy with Uniform Guidance compliance requirements for procurement, suspension & debarment. 2. WellPower will provide the necessary training on Uniform Guidance procurement compliance requirements to its procurement department and other authorized purchasers within the organization 3. WellPower will update its suspension & debarment check procedures and record keeping thereof, to ensure that SAM.gov checks of vendors are obtained prior to contract / purchase order issuance / purchase, and at a minimum annually. All records will be maintained with Procurement. CLIENT RESPONSIBLE PARTIES: Angela Oakley, VP & Chief Financial Officer Wes Williams, VP & Chief Information Officer COMPLETION DATE: May 31, 2025

2024-004 Views of Responsible Officials and Planned Corrective Actions: Management agrees with the recommendation and has implemented measures to improve procurement recordkeeping and compliance. A structured procurement folders and subfolders system has been established to maintain all relevant documentation. Management is actively working with consultants to update policies and procedures. Staff is scheduled to complete a structured three-session training through GFOA to enhance their understanding of federal procurement regulations and best practices. The District will continue training and development efforts in public procurement, with a particular focus on federal compliance, strengthening internal controls, improving documentation, and ensuring adherence to regulatory requirements Responsible Party: Director of Finance & Administration and Department Managers Implementation Date: Ongoing; full implementation expected by June 30, 2025

x. Management Response and Corrective Action Plan: The first of the two identified vendors – Maxim/Amergis - is an employment agency with a specialty in staffing providers who work in the healthcare and social services field. NBCC was seeking to hire an RN. Significant documentable effort was invested in hiring an RN with the necessary experience to fill our vacant RN Healthcare Navigator position. After months of being unable to find an appropriate candidate, NBCC sought consultation from the Santa Barbara County Department of Public Health who advised us of the name of the employment agency (Maxim/Amergis) that is used by the Department of Public Health and Department of Behavioral Wellness to staff their RN positions. We reached out to Maxim/Amergis, provided them with the job listing, and reviewed resumes and interviewed candidates until we found an appropriate match. This was a prolonged and involved process where we spent a significant amount of time working to hire the best suited RN for working in the field with the homeless and formerly homeless individuals we serve. We did not perceive this to be a traditional procurement effort and therefore did not create a written analysis of our efforts to identify and hire an RN, nor did we conduct a SAM search on the company given that the company routinely staffs our departments of behavioral and public health. The second identified vendor is Paychex. We believe our efforts to secure a new payroll solution company were very much aligned with Uniform Guidance rules. Our external accounting firm and multiple staff spent more than one year interviewing multiple potential payroll solution providers, including but not limited to, Paychex, ADP, ClickUp, Inova, Credible, and Replicon, among others. We only reviewed two written cost proposals because only two of the researched and consulted companies were able to provide a solution that could potentially meet our government timesheet needs. We conducted multiple meetings with our external accounting firm and internal staff discussing and analyzing the solution options, but a summary of these discussions was not created. In addition, Paychex is a provider to a number of nonprofits we consulted, including a local grantee who was using their service, and who we were advised had developed a system similar to what we needed for our time and activity reporting requirements. We therefore presumed Paychex was not a debarred contractor given that other nonprofits we spoke to who have the same funding were utilizing their services. Moving forward, we recognize we must write a written analysis of our processes and that we should not assume a vendor has not been debarred given their existing customers and will be sure to confirm a company’s standing on SAM. As a further example of our commitment to always remaining current with procurement standards, at the direction of the Executive Director, our Operations Director had previously enrolled in a two-day Procurement Boot Camp training which occurred this week. Our Operations Director will revisit our procurement process as a result of this finding and after attending the procurement training and will make revisions to our procurement process as necessary to ensure future compliance with Uniform Guidance. Any updates will be made to the NBCC Internal Controls Manual and any new processes will be adhered to subsequent to those revisions. xi. Contact Person (s) Responsible for Corrective Action: Kristine Schwarz, Executive Director, kschwarz@sbnbcc.org Brenda Lang, Operations Director, blang@sbnbcc.org Michael Dzierski, Finance Director, mdzierski@sbnbcc.org xii. Anticipated Completion Date: The anticipated completion date is May 31, 2025.

FINDING 2024-003 Finding Subject: Special Education Cluster (IDEA) – Procurement and Suspension and Debarment Contact Person Responsible for Corrective Action: Bethany Cmar Contact Phone Number and Email Address: 765-641-2126 (Bcmar@acsc.net) Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: When it comes to procurements thresholds, ACS will prepare a policy to follow the necessary federal guidelines. For small purchases, three quotes or bids will be obtained to ensure compliance with the procurement guidelines. For all vendors expected to exceed over $25,000 in expenditures will be kept in a binder by the Special Ed Director to ensure that they are not suspended or debarred from federal awards. The CFO will then review and approve the documentation supporting this via signature. Anticipated Completion Date: June 30, 2025

Auditee Response: Management concurs with the finding. A new financial reporting calendar has been implemented and distributed to all staff. A formal review and approval process for financial reports has been implemented. The report for the quarter ended June 2024 will be submitted by end of March 2025.