Corrective Action Plans

FINDING 2023-003 Finding Subject: Child Nutrition Cluster – Procurement and Suspension and Debarment Summary of Finding: Procurement: For one of the two vendors tested for small purchases an adequate number of price or rate quotes were not obtained. Suspension and Debarment: The School Corporation purchased bread, dairy produce and commodities through Region 8 Education Service Center (Region 8) However, Region 8 had not received the SFA – only Cooperative classification from IDOE for fiscal years 2021-2022 and 2022-2023. As such, the School Corporation could not rely on Region 8’s verification of suspension and debarment and was required to complete their own verification. One covered transaction was identified and tested that equaled or exceeded $25,000. For the noted transaction, the School Corporation did not verify that the vendor was not excluded or disqualified from participation in federal award programs. Contact Person Responsible for Corrective Action: Susan Loftain Contact Phone Number and Email Address: (260) 693-2007 loftains@sgcs.k12.in.us Views of Responsible Officials: Option 1: “We concur with the finding.” Description of Corrective Action Plan: Procurement: All vendors procured through Region 8 we will need to take action to secure bids and quotes and keeps copies and make we are within compliance Suspension and Debarment: We will be sure to complete our own verifications and not rely on Region 8 to check on suspension and debarment Anticipated Completion Date: Today 2/28/24

Finding 2023-004 Finding Subject: Child Nutrition Cluster-Procurement and Suspension and Debarment Summary of Finding: The School Corporation had not properly designed or implemented internal controls over procurement and suspension and debarment Contact Person Responsible for Corrective Action: Dr. Tracy Lorey, Monica Young, April Hopf Contact Phone Number and Email Address: tlorey@gjcs.k12.in.us myoung@gjcs.k12.in.us ahopf@gjcs.k12.in.us 812-482-1801 Views of Responsible Officials: We agree with the finding. Description of Corrective Action Plan: The school corporation will follow our Procurement policy in the future. Anticipation Completion Date: August 2024—Beginning of New School Year

FINDING 2023-004 Finding Subject: Child Nutrition Cluster – Procurement, Suspension, and Debarment Summary of Finding: Material Weakness, Other Matters The School Corporation had not properly designed or implemented an effective system of internal controls to prevent, or detect and correct, noncompliance. Procurement: A School Nutrition Cooperative (Co-ops, Education Service Center, Group Purchasing Organization, etc.) that would like to be classified as a School Food Authority (SFA) Cooperative must complete a questionnaire and submit it to the Indiana Department of Education (IDOE). Once a questionnaire is received IDOE will review the answers to determine a Cooperative’s classification. Only Cooperatives that submit the questionnaire and receive a SFA-only Cooperative classification from IDOE in writing will be considered a SFA only Cooperative for the purposes of the procurement process and procurement reviews. When the value of goods or services exceeds the simplified acquisition threshold, the proper purchasing method would be the bidding process, unless the purchase meets certain other qualifications. Federal regulations allow for informal procurement methods when the value of the procurement for goods or services does not exceed the simplified acquisition threshold, which is customarily 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. If it is determined a single source provider can be used for a small purchase, documentation must be retained supporting the determination. The School Corporation purchased milk through Region 8 Education Service Center (Region 8). However, Region 8 had not received the SFAonly Cooperative classification from IDOE for fiscal years 2021–2022 and 2022-2023. As such, the School Corporation could not rely on the procurement done by Region 8. Region 8 could be considered one quote for procurement; however, the School Corporation did not obtain any other quotes related to the purchase of milk, therefore, an adequate number of quotes from qualified sources was not obtained. 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. INDIANA STATE BOARD OF ACCOUNTS 47 MADISON-GRANT UNITED SCHOOL CORPORATION Steve Vore., Superintendent Ben Mann, Chief Financial Officer Kristy Drewitz, Transportation Allison McGuire, Payroll/Benefits Anna Richards, Corp Secretary/Deputy Treasurer Inspire, Cultivate, and Promote excellence in every Argyll. Upon inquiry of the School Corporation in order to review the procedures in place for verifying that a vendor with which it plans to enter into a covered transaction is not suspended, debarred, or otherwise excluded, the School Corporation noted that vendor’s were checked against Sam. Gove and verified to not be suspended or debarred. Four covered transactions that equaled or exceeded $25,000 were identified. All for transactions, totaling $213,795, were selected for testing. For three of the four vendors, the School Corporation did not verify the vendor’s suspension and debarment status prior to payment. The total amount spent with the three vendors was $162,733. Contact Person Responsible for Corrective Action: Kathy Bernaix Contact Phone Number and Email Address: 765-536-0008 kbernaix@mgusc.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Procurement: Three quotes will be requested for “small purchases” and the process will be reviewed to ensure it is performed. Suspension and Debarment: Before purchasing goods that total $25,000 or more from a vendor, the Food Service Director will look up the vendor on SAM.gov for debarment activity. Anticipated Completion Date: February 2024

Finding Reference Number: 2023-001 Description of Finding: Written Procurement Policy (significant deficiency) Statement of Concurrence: Management concurs with the finding and had implemented a written procurement policy that complies with the requirements of the Uniform Guidance. Corrective Action: Management has established a written procurement policy and implemented the documented procurement procedures as of August 13, 2022. Name of Contact Person: Steve Tyrell, Senior Vice President, CFO & COO, 518-366-1533, steve.tyrell@WCMO.edu Projected Completion Date: The College’s corrective action plan is completed and in effect at this time.

FINDING 2023-005 Finding Subject: Child Nutrition Cluster - Procurement and Suspension and Debarment Summary of Finding: Management had not developed a system of internal controls that would have ensured compliance with the grant agreement and the Procurement and Suspension and Debarment compliance requirement. The failure to establish an effective internal controls system enabled material noncompliance to go undetected. Noncompliance with the grant agreement and the Procurement and Suspension and Debarment compliance requirement could result in the loss of future federal funds to the School Corporation. We recommended that the School Corporation's management establish a system of internal controls to ensure compliance with the Procurement and Suspension and Debarment compliance requirement. Contact Person Responsible for Corrective Action: Andrea Miller Contact Phone Number and Email Address: 765-564-2100, millera@delphi.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The Food Service Director will obtain 3 quotes for any purchase over $10,000 from different vendors, in addition if the purchase is over $50,000 a contract will be awarded. Vendors will be verified by SAM.gov for suspension and disbarment, a record of these searches will be printed and kept in the vendor file. In addition, a vendor list will be provided annually to the school board for approval. Anticipated Completion Date: July 2024

This document serves as the response to the 2022-2023 Financial Audit on behalf of BELIEVE Schools, Inc. We’ve identified and reviewed the finding outlined below: The results of our auditing procedures disclosed one instance of noncompliance which is required to be reported in accordance with Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (“Uniform Guidance”) and which is described in the accompanying schedule of findings and questioned costs as Finding No. 2023- 001. Our opinion on the major federal programs is not modified with respect to these matters. In an effort to address the finding and to ensure the school's alignment with federal compliance standards, the following corrective action plan has been implemented for all purchases made with federal and state program funds: 1. For any procurement or contract ranging from $10,000-$250,000, The Principal, Angel Jackson-Anderson, should seek to acquire as many quotes as possible, aiming for up to five. Prior to finalizing any purchase order, invoice, or commencement of production, the school is mandated to receive and assess three price comparisons from different businesses or organizations. These price comparisons must be logged in the BCCHS Quote Comparison Template and reviewed by the following parties: a. The individual conducting the price comparison b. Building Level Operations Leader c. Executive Director for purchases or contracts exceeding $20,000 2. For any purchase or contract exceeding $250,000, a formal bidding process is required. BELIEVE Schools has adopted resources provided by the Indiana Department of Education: a. Procurement Checklist b. Procurement Plan Template (accessible through DOE) This protocol has been incorporated into the Standard Operating Procedures and School Handbooks, with all relevant stakeholders duly informed on February 16th, 2024.

Recommendation: We recommend that the Organization establish and maintain effective internal controls over procurement requirements. Action Taken: All purchases at One City Schools already require a second approver before invoices are paid. At the November 2023 Board meeting, One City Schools adopted new procurement policies that meet the federal requirements including effective internal controls.

Correctice action plan: The procurement policy will be evaluated and followed with reference to the appropriate Federal, State, and local laws, regulations, and standards. All staff charged with initiating and approving purchases under federal grant programs will use the documented policy. Individual(s) responsible: Allison Hayes, Debbie Pinnock, Yolana Adams Completion Date: Plan to be implemented as soon as possible.

YPIC has created a schedule to document the due dates of various reporting requirements for its grants

Contact: Reginald Gregory Title: Executive Director/Controller Phone Number: 202-772-4300 Estimated completion date: June 30, 2024 Corrective Action: Management will continue to stress the importance of following the detailed procedures for preparation and review of the SEFA. Responsibility for compiling the SEFA was assigned to a Senior Program Accounting Manager who is tasked with assuring the SEFA and all 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).

December 14, 2023 Donovan CPAs 9292 N. Meridian Street, Suite 150 Indianapolis, IN 46260 To Whom It May Concern, Liberty Grove Schools will take the following corrective action to address the FY2023 Single Audit Report finding: We will take corrective action to ensure our procurement policy is updated and in line with the audit requirements of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements forFederal Awards (“Uniform Guidance”), specifically 2023-001. In addition, Morrise Harbour, Founder & Executive Director of Liberty Grove Schools, will ensure this updated procurement policy is implemented and approved by our Board of Directors. Sincerely, Morrise Harbour Founder & Executive Director

Finding 2023-005 Department of Health and Human Services Federal Financial Assistance Listing #93.697 COVID-19 Testing and Mitigation for Rural Health Clinics Procurement, Suspension, and Debarment Material Weakness in Internal Control over Compliance and Material Noncompliance Finding Summary: The Health System did not obtain quotes from multiple vendors as it relates to the procurement and purchasing of flooring which was over the micro-purchase threshold. In addition, the Health System did not have a written procurement policy or written standards of conduct policy related to procurement. Responsible Individuals: Diana Swindler, CFO Corrective Action Plan: Tri Valley Health System will implement a procurement policy and standards of conduct policy related to procurement, implement internal control processes to ensure compliance with their procurement policy, and retain documentation to support procurement, suspension and debarment procedures performed. Anticipated Completion Date: 01/31/2024

Finding 2023-003 Reporting – Material Weakness in Internal Control Over Compliance Federal/State Agency Name: Department of Justice and State of South Dakota Department of Public Safety Program Name: Crime Victim Assistance FFAL # 16.575, 2022-COMBO-00022 Finding Summary: The Victims’ Service final financial report was not completed until requested by the auditors. Responsible Persons: Shannon Clark, Chief Financial Officer Lynn Peterson, Controller Michelle Tarrell, Finance Administrator Corrective Action Plan: A Finance Administrator has been designated for each Federal Financial Assistance Program. The Controller and Finance Administrator(s) will monitor and ensure reporting requirements are timely completed. Anticipated Completion Date: June 30, 2024

Recommendation: JTCHS should review federal procurement guidelines and revise its procurement policy to be in compliance with the federal procurement guidelines. Responsible Official’s Response: Management will review adopt a procurement policy in accordance with the Uniform Guidance. Planned Implementation Date of Corrective Action Plan: Management has started revising its policy and expects to have a revised procurement policy during fiscal year ending January 31, 2024.

Finding No.: 2022-029 AL Program: 21.027 - Coronavirus State and Local Fiscal Recovery Funds Area: Procurement and Suspension and Debarment Questioned Costs: $12,244,415 Contact Peron(s): Tracy B. Norita, Secretary of Finance / Geraldine Cruz, Procurement Services Director Corrective Action Plan: Condition 1&3: The Procurement Services Division agrees with this finding. The Division will revise CNMI’s procurement regulations to ensure alignment with federal procurement standards as outlined in 2 CFR Part 200, particularly the small purchase threshold requirements and competitive procurement procedures. Proposed Completion Date: Policy updates drafted by December 31, 2025 and adopted by March 31, 2026. Condition 2&5: The Procurement Services Division agrees with this finding. To address the lack of consistent verification of vendor eligibility under federal debarment and suspension requirements (2 CFR §180.300), a policy will be implemented requiring all agencies to submit debarment verification documentation at the time of vendor selection. Acceptable documentation may include (1) a printout or screenshot from the SAM.gov Exclusions database, confirming that the vendor is not debarred or suspended, (2) a signed certification from the vendor attesting to their eligibility, or (3) a signed contract clause or provision that explicitly states the vendor is not excluded from federal transactions and complies with applicable debarment regulations. Procurement procedures and standard forms will be revised to include debarment verification as a mandatory step prior to any purchase approval involving federal funds. Procurement Services will ensure that debarment verification documents are maintained in the official procurement file for each transaction involving federal funds. Proposed Completion Date: October 1, 2025 Condition 4&6: The Procurement Services Division respectfully disagrees with this finding. Due to internal scheduling constraints and the compressed timeline required to complete the FY22 audit, the requested documents were not submitted by the specified deadline, resulting in this finding. However, the Division maintains all relevant supporting documentation and is prepared to provide it upon request from the Grantor. Proposed Completion Date: Ongoing

The Government concurs with the auditor's findings and recommendations. The Government has since updated its procurement laws and has 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. The Government, in late January and early February 2025, conducted the Government-wide training on the updated procurement laws and re-established expectations as it pertains to processes and maintaining full and open competition. The Government has begun providing User Agencies with access to GVIBUY to enable them to perform informal solicitations in the eProcurement system. Further targeted training on this process will continue over time, ensuring User Agencies prioritize full and open competition in their procurement activities and will give the Department of Property and Procurement more oversight and compliance powers.

I believe this has to do with the sewer project. I was thrown into the middle of this. I don’t believe proper records were started or kept by the former Fiscal Officer. I only have what happened since I was here.

2022-008 Procurement Policy and Procedures Finding: Under Uniform Grant Guidance (2 CFR 200.318 through 200.327) non-federal entities other than states must follow the procurement standards set out in 2 CFR sections 200.318 through 200.327. They must use their own documented procurement procedures, which reflect applicable state and local laws and regulations, provided that the procurements conform to applicable federal statutes and the procurement requirements identified in 2 CFR Part 200. The Corporation does not maintain a formal procurement policy and procedures that meets the requirements of the Uniform Guidance, including procedures addressing allowable costs exceeding the small purchase threshold. The lack of such a formal policy increases the risk that purchases are made that do not comply with Uniform Guidance requirements. Corrective Actions Taken or Planned: While Saint Anthony Hospital has a procurement policy in place, we needed to order computers within a certain timeframe in order to secure funds from the grant and utilized our main supplier. Thus, we did not get more than 1 quote for the computers. 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. Name of contact person responsible for corrective action: Cindy Cisneros, Grant and Partnership Specialist

RECOMMENDATION: The School should adopt written reconciliation and tie-in procedures into its financial policies and procedures manual. Action Taken: The School agrees with this finding and will implement this recommendation within 120 days of this audit report.

Finding Number: 2022-006 Condition: Policies and procedures in place over procurement, suspension, and debarment are not in conformance with Uniform Guidance. Additionally, the Organization did not procure in accordance with the regulations, including maintaining records sufficient to detail the history of each procurement transaction nor did they comply with suspension and debarment rules. Planned Corrective Action: Management will implement written policies and procedures over procurement, suspension, and disabarment that conform with Uniform Guidance Contact person responsible for corrective action: Chief Financial Officer Anticipated Completion Date: 06/30/2025

Assistance Listing Number 21.027 Noncompliance Over Procurement and Suspension/Debarment - Major Federal Program - Coronavirus State and Local Fiscal Recovery Funds Muskogee County has hired an internal grant administrator to assist in keeping the county compliant with all local, state, and federal requirements. Efforts will be made going forward to ensure that all grant funds are properly expended. This includes that all expenditures are properly documented and that all vendors are ferderally eligible to perform services

The City has identified federal grants subject to the Uniform Guidance and will develop written policies and procedures which include the relevant provisions required by 2 CFR § 200.318 through 2 CFR § 200.326 Contract provisions.

Finding Number: 2022-004 Condition: WakeMed does not have a written policy in place over procurement methods which covers 2 CFR 200.317 - 200.327, nor did WakeMed follow required procurement guidelines. Planned Corrective Action: WakeMed is in the process of updating their existing procurement policy to include the relevant sections from the Code of Federal Regulations and will provide education to the areas involved in procurement and use of federal funds on these requirements. Contact person responsible for corrective action: Lynn Bailey Anticipated Completion Date: 12/5/2024

Description of Finding: Lack of documentation on sole source contracts and verification of vendors Statement of Concurrence or Nonconcurrence: The California Asian Pacific Chamber of Commerce (CalAsian) agrees with the finding. Corrective Action: CalAsian understands the serious nature of this finding and the compliance required with 2 CFR sections 200.318 through 200.327, as well as Part 1326 for vendor exclusions. The Interim Controller and Director of Finance will be revising procedures to document requirements for all procurement activities, regardless of type. We also understand these findings are repetitive from the 2021 audit; however, due to catch-up of the prior year audits, we were unable to address these issues prior to completion of the 2022 audit. This delay was caused by a change in auditors as our previous auditor did not have the capacity to retain us as clients due to staff shortages related to COVID. Resolution of this issue began in 2024 as staff were trained and provided the updated procedure to ensure all procurement activities adhere to the company policies. Continuing education will be provided in 2025 to ensure continued compliance with these policies. In 2025, a formal procurement system in the new ERP structure will be implemented and utilized for vendor quotes, requisitions and POs to ensure compliance. Periodic reviews of the procurement activities will be performed to ensure compliance with these procedures to mitigate the risk of continued deficiencies. Name of Contact Person: Ryan Fong, Director of Finance, 916-446-7883, rfong@calasiancc.org Pat Fong Kushida, President & CEO, 916-446-7883, patfongkushida@calasiancc.org Projected Completion Date: December 2024

AIRS management has started the process of creating new and updated policies and procedures related to financial reporting, activities, including written procurement standards, written standards of conflict of interest and others as required under Uniform Guidance