Corrective Action Plans

FINDING 2024-003 Finding Subject: Water and Waste Disposal Systems for Rural Communities - Procurement Contact Person Responsible for Corrective Action: David M. Kennard Contact Phone Number and Email Address: 812-677-3959 clerk@princetoncity.com Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Management will establish a proper system of internal controls to ensure expenditures made from federal awards use the appropriate procurement method and retain the documentation to support the procurement methods used in order to ensure compliance with the terms and conditions of the federal awards. Anticipated Completion Date: The corrective action plan will go into effect immediately.

Program: Continuum of Care Federal Financial Assistance Listing No.:14.267 Federal Agency: U.S. Department of Housing and Urban Development Pass-through: Sacramento Steps Forward Award Year: 2024 Compliance Requirement: Procurement, Suspension and Debarment Grant Award Number: CA0955L9T032209, CA0955L9T032310, CA0143L9T032215, CA0143L9T032316, CA1303L9T032208, CA1303L9T032309 Finding Summary: The Organization's procurement policy did not include all the required elements as outlined in the Uniform Guidance. Repeat Finding from Prior Years: Yes, Finding 2023-003. Management's Response: We concur. Views of Responsible Officials and Corrective Action: • Management has updated policies and procedures to ensure they confirm to the Uniform Guidance regarding procurement, suspension and debarment (2 CFR 200.317 through 200.327, 2 CFR 180). • Train grant staff on new policies and procedures. Name of Responsible Person: Projected Implementation Date: Bryan Wagner, CFO Date 8-21-2025

Federal Program Name: Mental and Behavioral Health Education and Training Grants Federal Agency: U.S. Department of Health and Human Services Federal Assistant Listing and Title Number: 93.732 Award Year: January 1, 2024 to December 31, 2024 Criteria or Specific Requirement: Procurement, Suspension and Debarment Condition: The District is required to follow their own documented procurement procedures which conform to the Uniform Guidance procurement standards. Correction Action Planned: The first contract in question was for a vendor (Healthsource Solutions) already under contract with Lubbock County Hospital District dba University Medical Center prior to the grant application. The vendor in question had been used since at least 2010, with the most recent contract for the current wellness portal (Wellness +) beginning in 2017. Because of the success of the wellness portal and established relationship with the vendor, University Medical Center included expansion of existing platforms and additional services provided by Healthsource Solutions as a large component of the Methodology/Approach in the proposed activities of the grant narrative submitted. Use of this vendor and its applications were specifically outlined in the grant project narrative and a critical component of meeting grant objectives. The second contract in question was for the Evaluation Group which provided specific services around grant program evaluation. This vendor was included in the original grant application and selected via the grant consultant used during the grant application process. University Medical Center follows the Lubbock County Purchasing Guidelines, which conform to the Uniform Guidance procurement standards. University Medical Center has reviewed the specified requirements of the Office of Management and Budget Uniform Guidance for procurement standards, specifically related to noncompetitive procurement and concurs that formal procurement methods were not used for expansion of new services with this existing vendor or adequate documentation was provided for noncompetitive procurement. In order to ensure compliance with the Uniform Guidance, the University Medical Center will provide training to existing grant Program Managers on Uniform Guidance procurement standards. Additionally, if a new grant is being pursued the grant committee should receive training on Uniform Guidance procurement standards before completing grant applications. On existing or future grants, any potential contracts or purchases over $75,000 should be reviewed by the grant Program Manager (or Grant Committee lead if a Program Manager has yet been assigned) to ensure all procurement guidelines are followed and sufficient documentation is obtained prior to purchase or contract execution. Contact Person (s) Responsible for Corrective Action: Aaron Davis, VP & Chief Experience Officer Anticipated Completion Date: The Corrective Action will be immediately implemented in response to the auditors’ recommendation.

Effective immediately, the Chief Financial Analyst has established a new schedule for monthly financial statements at Westward Heights Care Center. Monthly financial statements will be completed and provided to the Administrator by approximately the 20th of each month. This schedule ensures adequate time to prepare quarterly reports for submission to the USDA. Once the quarterly financials are finalized, the USDA report will be submitted no later than the last day of the month. This plan will also be added to the calendar with reminders set for the Administor to ensure timely review and submission.

2024 -002 Documentation of Procurement History Corrective Action Plan: The Standard Operating Procedures currently outlines procurement based on Uniform Guidance. Additional procedures will be implemented to ensure compliance with the policy. An internal Procurement Checklist and Pre-Award Review Form prepared by the Chief Operating Officer will be implemented to ensure compliance is documented before federal funds are expended. That document will be reviewed and approved by the President / CEO. All procurements over the simplified acquisition threshold will be reviewed by the Chief Operating Officer for compliance before a purchase order is issued or a quote is approved. All vendors solicited for proposal on procurements over the simplified acquisition threshold will be discussed during board meetings and documented in board meeting minutes. Personnel Responsible for Corrective Action: Alison Elder, CFO Anticipated Completion Date: May 2025

Management has since developed and formally implemented a written procurement policy that meets the standards of 2 CFR 200 Subpart D, including required controls over procurement and suspension and debarment. The policy is effective as of the date of this corrective action plan. Management will review the policy periodically to ensure ongoing compliance with federal requirements.

Recommendation Quivira should implement procedures and controls to ensure that the federal reports are reconciled, reviewed for accuracy and completeness before submission. Views of Responsible Officials and Planned Corrective Action Management agrees that, despite regular reviews of SF-425 reports for accuracy and completeness, current steps were not adequate to ensure federal reports are reconciled and reviewed for accuracy and completeness before submission. This finding is directly connected to 2024-001, and the same action steps will address this finding. To correct for this significant deficiency, Quivira Coalition will: Action Step Detail Date Responsible Party Develop a new, compliant method to allocate personnel costs for federal billing and reporting. Stop using the timekeeping system (Harvest) for allocation. The new method must properly reflect actual paid salaries, paid fringe, and actual time spent. 12/31/2025 Accounting Firm Update reporting process to reconcile all costs reported on the SF-425 to the general ledger (instead of the timekeeping system) using the new federal grants billing process. Keep detailed records of the reconciliation. 12/31/2025 Accounting Firm Implement a monthly reconciliation process between the time and expense system (Harvest) and the QuickBooks general ledger to reconcile all non-personnel expenses. 1/30/2026 Operations Director Document the grant management process, including new reporting processes, required reconciliations, monitoring policies, and allowable cost management to ensure consistency across the organization. 2/28/2026 Operations Director Update policies and procedures to require that expenses reported on the SEFA form come directly from the accounting system to ensure this continues. 1/30/2026 Operations Director Update policies and procedures to require an annual reconciliation between the SF-425 and SEFA reports to ensure this continues. This occurs before submitting the SEFA report. 1/30/2026 Operations Director Reconcile all grant programs active in 2024 using updated processes and resolve any discrepancies with federal reports or billing. 1/30/2026 Initial Review - Operations Director & Grants Manager Secondary Review & Corrections (if needed) - Accounting Firm Develop a plan to ensure regular and sufficient training on Uniform Guidance tracking regulatory changes, and how to implement changes. Update policies and procedures. 11/30/2025 Operations Director & Executive Director Update policies and procedures to require an additional level of review and approval for SF-425 and SEFA reports and reconciliations for accuracy and completeness before they are submitted. 12/31/2025 Operations Director with final approval from the Executive Director

Finding 2024 002 – Activities Allowed or Unallowed and Allowable Costs/ Cost Principles, and Procurement Federal Agency: U.S. Department of Transportation Program Name (ALN): Public Transportation Emergency Relief Program (ALN 20.527) Federal Grant Numbers: NJ 44 X004 02 (Federal fiscal years 2012–2025) Contact Person: Fatima Castellanos, PATH, Finance & Business Planning Manager, 201-216-6459. Corrective Action: Although federal funds were not received for this expenditure, PATH acknowledges an internal control deficiency regarding the recognition of grant funding for work performed under standard nonfederal engineering call-in contracts. PATH will continue to work collaboratively with the Engineering and Procurement Departments to strengthen internal communications and reinforce adherence to established protocols governing capital projects that are eligible for federal funding. Procurement will provide and document targeted procurement training for awareness to Engineering and PATH staff on adhering to procurement protocols during the execution of contract work that is anticipated to receive federal funding. Anticipated Completion Date: Changes to the controls and processes will be implemented and training provided in the fourth quarter of 2025.

Finding # 2025-001 Type: Immaterial noncompliance U.S. Department of Commerce, National Oceanic and Atmospheric Administration Assistance Listing #11.441 Finding: The Organization’s fiscal policies and procedures do not meet the required federal standards for procurement set out at 2 CFR sections 200.318 through 200.327. The Organization's procurement policy must have documented procurement procedures, consistent with state, local, and tribal laws and regulations for the acquisition of property or services required under a federal award or subaward. The Organization should maintain records sufficient to detail the history of procurement. Corrective Action: Management will work on revising the Organization’s procurement policies to incorporate the necessary provisions. Anticipated Completion Date December 2025

Federal Program: Head Start – ALN 93.600 / 93.356 Awarding Agency: U.S. Department of Health and Human Services (DHHS), Administration for Children and Families (ACF) Finding Reference Number: 2024-001 Condition The SF-425 Federal Financial Report for the period ending December 31, 2024, which was due on January 30, 2025, was submitted late on February 7, 2025. Corrective Action Plan Christian Military Academy, Inc. acknowledges this finding and has implemented corrective measures to ensure compliance with future reporting deadlines: 1. Enhanced Monitoring of PMS Submissions – A reporting calendar with reminders has been established to track all SF-425 deadlines and submission confirmations through the Payment Management System (PMS). 2. Secondary Reviewer – A second staff member has been assigned to review and confirm timely report submissions before each deadline. 3. System Contingency Plan – In the event of PMS malfunctions or access issues, management will immediately notify DHHS/ACF program officers in writing and retain evidence of the communication on or before the due date. 4. Staff Training – Fiscal staff responsible for federal reporting have been trained on the importance of timely submission and the procedures to follow in case of technical issues. Responsible Official Maribel Batista Marrero Christian Military Academy, Inc. Anticipated Completion Date The corrective actions have been implemented as of October 2025 and will remain in place on an ongoing basis.

Individual(s) Responsible: LaNita Perez, Controller and AP Specialist Action: Management will ensure that all procurement transactions comply with established policies and procedures. Competitive bidding, documentation of procurement methods, justification for sole-source contracts, and price/cost analyses will be required for all applicable purchases. Staff will receive training on procurement requirements under Uniform Guidance. Management will monitor procurement activities and verify that each purchase is supported by proper documentation. Compliance with policies and procedures will be checked regularly. Anticipated Completion Date: December 31, 2025

Management Response #2024-003: Previously, the Corporation faced challenges in effectively monitoring and documenting grant activity due to limited formal processes. Documentation of policies and procedures was insufficient, and supporting materials were not stored in a centralized location, making information retrieval difficult. Since then, processes have improved, with enhanced documentation practices and better organization of grant-related records to support more efficient oversight and compliance. Corrective Action Plan: The Corporation has implemented the following corrective measures: • The Corporation established comprehensive, formal policies and procedures that document the current compliance practices. These procedures have been disseminated across the organization and incorporated into training programs to ensure all employees are aligned with the updated standards. • A procedure enhancement has been implemented in the procurement process, which requires the procurement manager to obtain three bids prior to the creation of certain purchase orders. This ensures competitive bidding and transparency in vendor selection. • Once a vendor is selected, the procurement manager will forward the vendor’s details to the compliance department. The compliance team will then verify the vendor's debarment status and federal eligibility to ensure compliance with all regulatory requirements. • A central repository platform has been created to store all vendor bids, price analyses, and related procurement documentation. This ensures that all relevant information is easily accessible and properly organized. • All accounts payable invoices designated for grant funding are now routed for prior approval to the respective grant program manager via the WorkPlace software before any payments are processed. This ensures proper oversight and alignment with grant requirements. These corrective actions aim to strengthen compliance, improve document management, and streamline oversight processes to prevent future issues related to grant monitoring and procurement. Management expects to be completed by December 31, 2026. Responsible Party: Tamara Barnes, CFO

Corrective Action Plan The Program will develop an internal procurement policy with reference to the appropriate Federal, State, and local laws, regulations, and standards. The documented policy will be used when initiating and approving purchases under Federal grant programs, so they can ensure that they are in compliance with Uniform Guidance. Individual(s) Responsible Sherry Bradley Completion Date Discussion is ongoing regarding the plan; it will be implemented by the end of 2025.

Management has reviewed the finding above and concurs. A corrective action plan addressing the deficiencies will be completed and submitted within 60 days of the report.

Management has reviewed the finding above and concurs. A corrective action plan addressing the deficiencies will be completed and submitted within 60 days of the report.

Finding 2024-002 Drinking Water State Revolving Fund - Procurement Contact Person Responsible for Corrective Action: JoAnn Collins/Clerk Treasurer Contact Phone Number and Email Address: 574-653-2112 kewanna@fourway.net Views of Responsible Officials: We concur with the finding Description of Corrective Action Plan: We will update our procurement policy and implement a system of internal controls to ensure a purchasing policy is in place and quotes are obtained for small purchases. Anticipated Completion Date: A policy and internal controls will be in place by January 1, 2026

FINDING 2024-003 Finding Subject: Drinking Water State Revolving Fund - Procurement and Suspension and Debarment Contact Person Responsible for Corrective Action: Tyler Pearson, Clerk-Treasurer Contact Phone Number and Email Address: 574-739-1416 clerktreasurer@cityoflogansport.org Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: We will develop and implement a formal process for verifying that vendors are not suspended, debarred, or otherwise excluded from receiving federal funds before entering into contracts or transactions that meet or exceed the $25,000 threshold. The City will develop a purchasing policy that reflects the applicable state laws and regulations related to procurement. The City will also maintain proper documentation to support the appropriate procurement method. Anticipated Completion Date: December 31,2025

Following the close of the 2023 audit in October 2024, 9/11 Day implemented a strengthened procurement process for all large vendors, including the adoption of a formal procurement policy that complies with federal guidelines. A vendor log and checklist system has been established to document the receipt of RFPs, the rationale and method of procurement, and decisions on whether to move forward with a vendor. Although 9/11 Day has, and does verify whether vendors and subgrantees are permitted to receive federal funds, we have now updated our policy to retain printed verification of each vendor’s/subgrantee’s eligibility to receive federal funds, including confirmation that these organizations are not suspended or debarred. These documents will be retained in the procurement file for each vendor/subgrantee. These steps ensure compliance with 2 CFR 200.318 and provide clear documentation and oversight for all procurement activities.

FINDING 2024-003 Finding Subject: Water and Waste Disposal Systems for Rural Communities - Procurement and Suspension and Debarment Contact Person Responsible for Corrective Action: Timothy Detrick – Clerk-Treasurer Contact Phone Number and Email Address: treasurer@townoffrankton.in.gov Views of Responsible Officials: Concur with the finding Description of Corrective Action Plan: I’ve already spoken with our Council President regarding the creation of an ordinance to establish a formal Procurement Policy, that mimics state law that’s already established. This ordinance will ensure that all new contracts entered into by the Town comply with Build America, Buy America (BABA) requirements. The ordinance will also ensure that the Town verifies both current and prospective vendors through the SAM.gov website to confirm their eligibility to receive federal funding. The ordinance will have in it that BABA must be follow and the town will verify that the contract is in good standing with the state but checking the SAM.gov website. Once check an affidavit will be made stating that that are in good standing, and signed by the council president and Clerk-Treasurer. Anticipated Completion Date: End of 2025 Date December 31st, 2025 INDIANA STATE

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 Health System is committed to implementing internal controls to ensure procurement related to federal awards follow 2 CFR section 200.318 to 200.327. The Health System will create a 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. Contact Person: Daniel Cooper, Vice President of Finance and Accounting Expected Completion Date: December 31, 2025

Management will continue strengthen its processes and internal control to ensure that report of expenditures is reviewed by Finance prior to submission and only includes expenditures incurred in the period. Purchase orders will no longer be included in any submissions. Management will amend its procurement policy to ensure the policy includes the required regulations as outlined in the Code of Federal Regulations in relation to Federal Awards and that all relevant documentation will be retained.

FINDING 2024-002 Material Weakness-Procurement, Suspension, Debarment Contact Person Responsible for Corrective Action: Brittany Couse Contact Phone Number: 765-677-2014 Views of Responsible Official: Agree with finding Description of Corrective Action Plan: The Clerk Treasurer's Office will continue to check the System for Awards Management quarterly to verify any contractor is not debarred. Further, the office will now check for contracts that exceed the $25,000 threshold that require such inquiry. Anticipated Completion Date: Immediate

WRTP has reviewed the organization’s fiscal policy manual including all subsections regarding contractual provisions and procurement. Additional training has been provided and completed by management and staff. The fiscal policy manual procurement section will undergo further review by a third party and if recommended, will be updated and presented to the Finance Committee of the Board of Directors.

FINDING 2024-003 Finding Subject: Highway Planning and Construction - Procurement Contact Person Responsible for Corrective Action: Chance Bender, Highway Superintendent Contact Phone Number and Email Address: (812) 338-2162 / chancebender@crawfordcounty.in.gov Views of Responsible Officials: We concur with the findings of this report. Description of Corrective Action Plan: The County Highway Department has implemented a new filing system to help ensure that audit documentation is being maintained for all federal requirements. The County will maintain documentation of all bids and Letter of Interests (LOIs) received from vendors for each project for review. These files are maintained in their own folder with the DES# and project description on the outside. The County will also maintain documentation of the LPA Selection Review Checklist for each project for review. The County Highway Superintendent is responsible for maintaining all the files and the administrator will review/sign the checklist to ensure all the files are properly maintained. In addition, the County is currently working with the County's attorney to develop a procurement policy that includes federal regulations. Anticipated Completion Date: September 2025

Management agrees with the finding. Management has downloaded 2 CFP Part 200 for review and to familiarize. Assistance has been requested to develop additional policies in accordance with the Uniform Guidance. Policies will be reviewed and approved by the Board regularly. Contact Person: Renee LaFleur, Executive Director Anticipated Date of Completion: December 31, 2025