Corrective Action Plans

CORONAVIRUS STATE AND LOCAL FISCAL RECOVERY FUNDS, ASSISTANCE LISTING No. 21.027, PROCUREMENT AND SUSPENSION AND DEBARMENT Name of contact person: County Commissioners Corrective Action: Roosevelt County will follow the procedure of verifying contractors through SAM or GSA Websites when using SLFRF funds. Proposed Completion Date: Immediately.

FINDING 2024-002 Subject: Child Nutrition Cluster - Internal Controls Federal Agency: Department of Agriculture Federal Program: School Breakfast Program, National School Lunch Program Assistance Listing Number: 10.553, 10.555 Federal Award Numbers and Years (or Other Identifying Numbers): FY 22-23, FY 23-24 FINDING 2024-002 (Continued) Pass-Through Entity: Indiana Department of Education Compliance Requirement: Procurement and Suspension and Debarment Audit Finding: Material Weakness Condition: An effective internal control system was not in place at the School Corporation to ensure compliance with requirements related to the Child Nutrition Cluster and Procurement and Suspension and Debarment compliance requirements. Context: Procurement The School Corporation participates in the Food2School Child Nutrition Cooperative which procures vendors for food purchases and other supplies on behalf of its members. During the audit period, the School Corporation purchased supplies and equipment from vendors not procured by the Cooperative. One vendor with aggregate annual purchases of $118,390 and $68,859 for fiscal year 2023 and fiscal year 2024, respectively, exceeded the small purchase threshold ($50,000 - $150,000) and was not subject to the School Corporation’s procurement policy to solicit multiple quotes and to document the method and rationale for procurement. Suspension and Debarment For three vendors tested which were not procured by the Cooperative and had aggregate annual disbursements exceeding the federal suspension and debarment threshold of $25,000, the School Corporation did not perform suspension and debarment checks to confirm the vendors were not suspended or debarred before entering into the contract or disbursing federal funds. Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Management will implement a procurement checklist that is reviewed after the purchasing process has been completed to ensure compliance with purchasing requirements for federal awards. Sam.gov will be checked for each vendor with aggregate purchases above $25,000. Responsible Party and Timeline for Completion: Shane Hacker, Assistant Superintendent of Operations; Corey Ebert, Director of Finance; Jordan Ryan, Director of Nutrition Services Anticipated Completion Date: February 1, 2025.

Child Nutrition Cluster – Assistance Listing No. 10.553, 10.555, 10.559, and 10.582 Recommendation: We recommend that the Board enhance controls and procedures to ensure that it follows its procurement policies for all goods and services charged to the program. Documentation should be readily available for audit. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Purchasing procedures and thresholds were discussed at a leadership meeting of the Department of Food and Nutrition Services. Specifically, the need for at least two quotes for purchases between $15,000 and $50,000 was reiterated. On an ongoing basis, expenditures by vendor will be reviewed to ensure compliance with the procurement policy. Name of the contact person responsible for corrective action: Jaime Hetzler, Director of Food and Nutrition Services Planned completion date for corrective action plan: For immediate implementation and ongoing.

Federal Agency Name: Department of Housing and Urban Development Continuum of Care, Federal Financial Assistance Listing 14.267, Affects all grant awards included under Federal Financial Assistance Listing 14.267 on the Schedule Finding Summary: Catholic Charities has documented procurement procedures that conform to applicable federal standards regarding testing vendors for suspension and debarment; however, the procedures were not followed for four vendors selected for testing. Corrective Action Plan: Procurement, suspension and debarment procedures were largely decentralized across the agency. In response, the organization has an internal, cross-functional compliance team that has reviewed and is developing process changes to ensure appropriate systems are developed and documentation is maintained for purchasing related to federal programs. Responsible Individuals: Chief Legal Officer, Controller Anticipated Completion Date: June 30, 2025

Procurement, Suspension and Debarment Significant Deficiency in Internal Control over Compliance Finding Summary: In our testing of procurement, suspension and debarment it was identified that the District did not go out for quotes on one contract over the mircro purchase threshold. Responsible Individuals: Beth Slette, Superintendent Corrective Action Plan: The District will ensure all contracts comply with their procurement policy and the procurement standards as identified in 2 CFR sections 200.317 through 200.327. Anticipated Completion Date: June 30, 2025

NONCOMPLIANCE WITH PROCUREMENT AND SUSPENSION AND DEBARMENT REQUIREMENTS, CORONAVIRUS STATE AND LOCAL FISCAL RECOVERY FUNDS; AL No. 21.027; GRANT No. Direct allocation and AM-23-0287 Name of contact person: Kelly Strecker Corrective Action: The City commits to ensuring that a procurement policy be put in place that will allow it to comply with procurement standards outlined in the Uniform Guidance. Proposed Completion Date: Immediately

MATERIAL WEAKNESS 2024-002 Child Nutrition Cluster – Assistance Listing Number 10.553 and 10.555 Procurement Recommendation: We recommend that the Organization establish and maintain effective internal controls over procurement requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: One City Schools adopted a procurement policy in November 2023 that, if followed, resolves this finding. A new primary food vendor was selected in summer of 2024, and the selection did adhere to the new procurement policy. This policy and all procedures were edited to be comprehensive of all uniform grant requirements through the development and adoption of the Federal Funds Procedural Manual. Name(s) of the contact person(s) responsible for corrective action: Janel Vertz, Finance Director Planned completion date for corrective action plan: January 2025

Corrective Action: Management will continue to stress the importance of following the detailed procedures for preparation and review of the SEFA. The SEFA checklist is updated to include a thorough review of expenditure details to ensure no prior-year expenses are reported. Responsibility for compiling the SEFA was assigned to a Senior Program Accounting Manager who is tasked with assuring the schedule and all the support reconciliation are complete and accurate. Both the Director of Program Accounting and the Executive Director of Finance/Controller will review the SEFA for completeness, accuracy, and compliance with CFR Section §200.510(b). Estimated completion date: June 30, 2025 Individual Responsible for Corrective Action Plan: Contact: Reginald Gregory Title: Executive Director/Controller Phone Number: 202-772-4300

December 18, 2024 Donovan CPAs 9292 N. Meridian Street, Suite 150 Indianapolis, IN 46260 Subject: Response to Uniform Guidance Audit Finding for FY23-24 Finding 2024-001 Procurement Significant Deficiency Federal Program: Charter Schools Program Assistance Listing Numbers: 84.282A Springville Community Academy (SCA) plans to develop a written procurement policy that incorporates the Federal regulations and procurement standards identified in §200.317 through 200.327. I, Corbin Dietrich, will work with the Board of Directors of SCA and our consultants with Indiana Charters to develop the appropriate procurement policies and procedures. We plan to draft and approve the required policies at the board meeting in January 2025. Sincerely, Corbin Dietrich, Treasurer

FINDING 2024-005 Subject: Special Education Cluster (IDEA) - Procurement and Suspension and Debarment Federal Agency: Department of Education Federal Program: Special Education Grants to States Assistance Listing Number: 84.027 Federal Award Numbers and Years (or Other Identifying Numbers): H027A210084, H027A220084, H027A230084 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Procurement and Suspension and Debarment Audit Finding: Material Weakness Condition: An effective internal control system was not in place at the School District to ensure compliance with requirements related to the Special Education Cluster and Procurement and Suspension and Debarment compliance requirements. Context: During the audit period, the School District purchased Special Education contracted services from one specialist with aggregate payments for each fiscal year which were within the small purchases threshold ($10,000 - $150,000) under Federal and State procurement regulations. The School District did not solicit multiple quotes for services, document the method and rationale for procurement, and did not perform a check to confirm the service provider was not suspended or debarred before entering into the contract and disbursing federal funds. FINDING 2024-005 (Continued) Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Management will implement a procurement checklist that is reviewed management to ensure compliance with the School's purchasing policy for federal awards. Sam.gov will be checked for each vendor being paid from Federal Funds. Responsible Party and Timeline for Completion: Moriah Crane - Treasurer and Andrew Grismore - Grant Coordinator starting immediately.

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

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

The Board of Supervisors will ensure staff are properly trained in procurement policy and future procurement activities comply with both Uniform Guidance and Mississippi Law. Anticipated Completion Date: 9/30/2025. Contact Person: Otis Griffin, County Administrator

Corrective Action: Request proof of contractor not being on the suspension or debarment listing from Engineering Firm. This finding was due to funds being transferred to a project that became a federal project once utilized. Stillwater County is careful when selecting contractors and as part of the bidding process assures that the contractors are in good standing. Additional vetting was needed when the funds were transferred to the project and the County was unaware of this requirement.

The City of North Bend acknowledges that a contract utilizing SLFR funds, and awarded to a software vendor, did not include within the contract, a required self-attestation concerning Suspensions and Debarment. The self-attestation was used in lieu of a documented review of the SAM.gov portal for suspensions and debarment. This was an oversight of the contract review process. Other contracts issued during the same period included self-attestation language from 2 CFR 200.317 through 2 CFR 200.327. In 2024 and 2025, the Public Works Deputy Director, Contract Specialist, and Capital Staff Accountant ensure adherence to all applicable local, State, and federal procurement laws and regulations as provided in the Uniform Guidance at 2 CFR 200.214, 2 CFR Part 180, and Treasury’s implementing regulations at 31 CFR Part 19, prohibiting recipients from entering into contracts with suspended or debarred parties. The City of North Bend understands the significance of the finding and immediately took steps to review all subsequent contracts for compliance.

CORRECTIVE ACTION PLAN FISCAL YEAR OF FINDING: June 30, 2023 AUDITOR FINDING: 2023-006 In accordance with 2 CFR Part 200.318 the recipient or subrecipient must maintain and use documented procedures for procurement transactions under a Federal award or subaward, including for acquisition of property or services. These documented procurement procedures must be consistent with State, local, and tribal laws and regulations and the standards identified in §§ 200.317 through 200.327. The Organization's purchasing policy did not contain elements of federal procurement requirements specified by Uniform Guidance. CLIENT PLANNED ACTION: The Organization will revise the Procurement Policy such that it is consistent with the appropriate regulations and standards and requires documentation of the vendor procurement policy. CLIENT RESPONSIBLE PARTY: Danielle Cordova, Controller COMPLETION DATE: July 1st, 2025

Corrective Action Plan Action Item Responsible Party Monitoring Require that procurement transactions be properly identified and tracked by federal program to ensure completeness and traceability. CFO / Procurement Staff Monthly review Maintain complete procurement documentation, including records of competition, procurement method, and verification of suspension and debarment in accordance with federal requirements. CFO / Procurement Department Periodic internal review Reconcile procurement-related expenditures to the SEFA and underlying accounting records to ensure a reliable population for compliance testing. CFO Documented reconciliation In FY 2026, management developed and implemented a formal Records Retention Policy to ensure that accounting records, supporting documentation, and organizational records are properly maintained and retained in accordance with applicable regulatory and audit requirements CFO Management oversight Implement supervisory review of procurement activity to ensure compliance with federal procurement requirements. CFO / Board Finance Committee Quarterly review ________________________________________ Management Response Management notes that no additional federal grants, other than the HRSA Section 330 program grant (Assistance Listing 93.224), were received in FY2025 or FY2026. Prior management did not provide a reconciled SEFA schedule for earlier reporting periods, which contributed to the documentation limitations identified during the audit. Beginning in FY2026, management has developed a detailed SEFA tracking schedule for the HRSA Section 330 grant that identifies the date federal funds were drawn down, the amount received, the related expenditures, and the corresponding disbursement dates. This schedule is maintained to improve reconciliation between drawdowns, expenditures, and the general ledger and to ensure documentation is readily available for audit and compliance purposes. In FY2026, management implemented an updated and comprehensive set of policies and procedures designed to strengthen internal controls and promote consistent, standardized accounting and administrative practices. These updates establish clearer documentation requirements, defined responsibilities, and improved oversight to ensure compliance with applicable regulations and the safeguarding of organizational records and financial information. ________________________________________ Responsible Official: Chief Financial Officer Expected Completion Date: FY 2026

The procurement policy as well as all policies are reviewed every three years to comply with Joint Commission Standards. Saint Anthony will review its existing procurement policy to ensure that all elements required by the Uniform Guidance are incorporated. The review was completed on March 28, 2025.

Reference Number: 2023-007 Finding: Improve Controls and Compliance with Procurement Name of Contact Person: Christine Chamberland Corrective Active Plan: The City will develop and implement standardized procurement procedures specifically for federally funded purchases, ensuring that all transactions are fully documented in accordance with applicable procurement policies. Staff will be trained on these procedures, and a central repository will be established to maintain executed contracts and all supporting documentation. Regular audits will be conducted to verify compliance and that all required records are retained and readily accessible. Proposed Completion Date: 6/30/26

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.

The Government concurs with the auditor’s findings and recommendations. The Government updated its procurement laws and issued revised procurement manuals, along with issuing position-specific Standard Operating Procedures. Processes for enforcing Internal controls and adherence to procurement laws have been established and are regularly reinforced. In early 2025, the Government-wide training reinforced expectations for full and open competition. User Agencies now access GVIBUY for informal solicitations in the eProcurement system, with ongoing training to prioritize competition and enhance oversight by the Department of Property and Procurement.

Management will review Uniform Guidance 2 CFR sections 200.318 through 200.327 to ensure the Organization’s procurement policy fully incorporates all federal compliance requirements. Management will develop and implement a formal, written procurement policy.

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.

Action Item Title 2023-005 – Federal Award Findings Status (Open: In-process) Condition General Procurement Standards - Written Policies Suspension and Debarment - Covered Transaction The Corporation has an outdated institutional procurement manual approved in 2014 that lacks written policies to ascertain compliance with the provisions of federal statutes, regulations, or the terms and conditions of federal awards regarding procurement, suspension, and debarment requirements. From a sample of eighteen disbursements, we selected eight disbursements to ascertain compliance with 2 CFR section 180.220, specifically regarding the inclusion of procurement contracts as covered transactions. We examined the procurement documents provided by the Corporation. From that sample, we identified that the Corporation did not perform the required verification process for covered transactions during the year ended June 30, 2023. Identified root cause The Corporation lacks internal controls and policies to ensure compliance with federal procurement requirements. In addition, the Corporation relies on the procedures performed by the Administration of General Services to comply with procurement requirements. As a result, the Corporation did not maintain its own documentation. Grantee resolution plan Procurement Policies and Covered Transactions The Corporation is currently in the process of reviewing its Procurement Procedure to align it with ASG guidelines and incorporate federal regulations. Completion date By December 31, 2025. Name and Title of contact: Linnette Dávila Alemán- Financial and Budget Assistant Manager Phone: 787-724-4747 ext. 2105 Email: ldavila@cba.pr.gov Jetppeht Pérez de Corcho Morgado – General Manager Phone: 787-724-4747 ext. 2102 Email: jperez@cba.pr.gov

Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) (Compliance) We recommend that management establish and enforce procedures to ensure all required federal financial and progress reports are submitted by the applicable due dates. Management's Response: The County concurs with the findings; Responsible Individual: Nicole Reinert, Public Health Director; Corrective Action Plan: Administrative staff will schedule out all required report dates in the Outlook calendar at least three weeks before the due date to keep responsible parties informed of deadlines. These set reminders will ensure timely submissions. The Department Head will review the submission process to eliminate congested workflow to ensure efficiency and identify any tasks that can be automated or improved. Regular check-ins will take place to discuss the status of ongoing reports.; Anticipated Completion Date: June 30, 2026.