Corrective Action Plans

FEDERAL AWARDS – CORRECTIVE ACTION PLAN REFERENCE # 2022-001 PROCUREMENT SUSPENSION AND DEBARMENT – MATERIAL WEAKNESS- NON-COMPLIANCE Program Name/ALN Emergency Solutions Grant Program (ALN # 14.231) Criteria: As per § 200.318 General procurement standards. (a) The Non-Federal entity must have and use documented procurement procedures, consistent with State, local, and tribal laws and regulations and the standards of this section, for the acquisition of property or services required under a Federal award or subaward. The non-Federal entity's documented procurement procedures must conform to the procurement standards identified in §§ 200.317 through 200.327. (d) The Non-Federal entity must maintain records sufficient to detail the history of procurement. These records will include, but are not necessarily limited to, the following: Rationale for the method of procurement, selection of contract type, contractor selection or rejection, and the basis for the contract price. Condition/Context: Condition: Based on our review of the Procurement compliance requirements, we noted that the Division has written procurement policies and competitive policies as required by CFR § 200.318 General procurement standards. We selected five (5) vendors for procurement Suspension and Debarment compliance testing of total population of 5 vendors subject to procurement and we were not provided with Procurement comparative bids therefore, we were unable: • To verify that the procurement method used was appropriate based on the dollar amount and conditions specified in 2 CFR section 200.320. • To Verify that procurements provide full and open competition (2 CFR section 200.319 and 48 CFR section 52.244-5). Questioned Costs: Cannot be determined Recommendation: We recommend that the Division must: (1) Use documented procurement procedures, consistent with State, and local, laws and regulations and the standards, for the acquisition of property or services required under a federal award or subaward. (2) The Division must maintain records sufficient to detail the history of procurement. These records should include, but are not necessarily limited to, the following: Rationale for the method of procurement, selection of contract type, contractor selection or rejection, and the basis for the contract price. Corrective Action Plan: The Division will work with Territorial Headquarters to document procedures as outlined in the Recommendations above. Step 1 Action Date: Ongoing Final Implementation Date: 12/31/2023 Name and Phone # Of Person Responsible for Implementation: Jeanne Stromberg, Major, Divisional Finance Secretary (916) 563-3710

The County will make sure that all federal documentation is maintained by each district for inspection and will ensure it is accurately reported on the SEFA.

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.

Corrective Action Plan for Finding 2022-003 We are in receipt of the Findings Required to be Reported by Uniform Guidance, regarding procurement, suspension and debarment. Management agrees with the finding. An official procurement policy is drafted and will be adopted by the District in January 2026. A monthly meeting to include representatives of administration and finance will be held to ensure procedures detailed in the procurement policy are being followed going forward. The hospital CFO, Lewis Robbins, will oversee this to ensure that this is accomplished. The Corrective Action Plan will be implemented by September 30, 2026.

The Sun Prairie Village County Water and Sewer District did not provide a corrective action plan.

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

Corrective Action: Management of the Institute did not provide any planned corrective actions for this finding. Person Responsible: Management of the Institute did not identify an individual responsible for corrective action for this finding. Completion Date: Management of the Institute has not established a completion date for corrective action for this finding.

November 17, 2022 To: U.S. Department of Agriculture, Passed-through Commonwealth of Massachusetts, Department of Elementary and Secondary Education (DESE). From: Mystic Valley Regional Charter School (MVRCS) respectfully submits the following corrective action plan for the year ended June 30, 2022. Name and address of independent public accounting firm: AAFCPAs, Inc. 50 Washington St, Westborough MA 01581 Audit period: June 30, 2022 The findings from the June 30, 2022 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS-FEDERAL AWARD PROGRAMS AUDITS SIGNIFICANT DEFICIENCY U.S. Department of Agriculture (Passed-through Commonwealth of Massachusetts, Department of Elementary and Secondary Education): 2022-001 Child Nutrition Cluster: CFDA No. 10.55 Written Procurement Policy Recommendation: MVRCS should revise their written procurement policy to comply with current standards under the Uniform Guidance. Actions taken: MVRCS is updating it's procurement policy and will submit to it's Board at the next meeting for review and approval. If there are any questions regarding this plan, please call Rick Veilleux at 781-974-5671. Sincerely yours, Richveller Rick Veilleux, Assistant Superintendent-Finance & Operations]

Action Item Title 2022-003 – Procurement Policies and Covered Transactions Compliance Requirement Procurement, Suspension, and Debarment Status (Open: In-process) Condition: General Procurement Standards - Written Policies – 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. Suspension and Debarment - Covered Transaction – From a population of nineteen disbursements, we selected nine disbursements to ascertain compliance with 2 CFR section 180.220 by examining the procurement documents provided by the Corporation. From that sample, we identified nine instances in which the SAM.gov registration verification process was not performed. Of the nine instances, we found eight suppliers properly registered, but one supplier appears as validated as unique and existing but not registered in SAM.gov. Identified root cause: Lack of understanding of procurement compliance requirements for federal awards. Fiscal year 2023 was the first year for the Corporation to be subjected to a single audit compliance requirement for receiving and expending COVID-19 public health emergency programs Grantee resolution plan: General Procurement Standards - Written Policies – With the implementation of Law No. 73 of 2019, previous processes established by regulation are repealed and rendered ineffective. In addition, the Corporation will adopt procurement policies in compliance with the federal regulations. Suspension and Debarment - Covered Transaction - Currently, the Corporation is verifying and requesting all suppliers with contracts of $25,000 and over with evidence of being active at SAM.gov. Also, the Corporation is verifying if the supplier is suspended or debarred to do business with the Federal government. Completion Date: General Procurement Standards - Written Policies – By June 30, 2025 Suspension and Debarment - Covered Transaction – Corrected in FY2023. 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

Management Response #2022-010: Due to the staff shortages and turnover in FY2020-2022 the company did not have adequate personnel in place to monitor or document grant activity. Formal documentation of policies and procedures were also deficient. Additionally, documents were not stored centrally, which made it extremely difficult to find supporting documentation. Corrective Action Plan: In mid-2023, the company established policies and procedures that formally document the current compliance practices that are in place for dissemination and training throughout the organization. Detailed in the procedures was a hard stop by the manager of procurement that would require three bids prior to a purchase order being created. Once a vendor is selected, the manager of the procurement will send the vendor information to the compliance department to check for debarments and federal eligibility requirements. Added to the procedures is the creation of a central repository platform to keep all bids and price analysis performed for each vendor. To further enhance compliance, all Accounts Payable invoices that are designated for grant funding are routed for approval to the respective grants program manager prior to payment being made via the WorkPlace software. Responsible Party: Tamara Barnes, CFO

Corrective Action Planned: The City Clerk and Mayor, with help from the Treasurer, will develop and implement documented procurement procedures that conform to the procurement standards relating to Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) 200.317 through 200.327 Name(s) of Contact Person(s) Responsible for Corrective Action: City Clerk, Kami Hoerning. City Treasurer, Karen Kipp. City Mayor, John McGinley. Anticipated Completion Date: Summer 2024

Suspension and Debarment Not Verified Prior to Awarding ContractsState Agency: Governor?s Office of Planning and BudgetFederal Program: Coronavirus State and Local Fiscal Recovery FundsGOPB will review its September 2022 guidance on requirements for SLFRF agreements and reissue the document to remind agencies of the need to perform timely suspension and debarment checks. GOPB will also provide training to agencies and remind them to include a suspension and debarment clause in contract agreements. GOPB will update the reference guide for agencies with standardized language about suspension and debarment checks to be used in new agreements. GOPB will include this review in its regular monitoring activities and sample contract agreements to verify inclusion of the appropriate contractual provisions.Contact Person: Darcy Jaimez, Fiscal Grant Manager, 385-377-3373Anticipated Correction Date: April 30, 2023

Improve the Timeliness and Accuracy of Financial and Programmatic Reports21.023, 21.027 Emergency Rental Assistance Program, Coronavirus State and Local Fiscal Recovery FundsName of contact person: Connie DeKemper, Finance DirectorAnticipated completion date: 6/30/2023The Finance Department has corrected the issue of late reporting by working with the subrecipient and developing processes to accurately and timely report on the requirements of the grant. The US Treasury has developed an extension request process to allow for the collection of additional data due to changing requirements. The Finance Department has submitted its closeout data accurately and timely for the Emergency Rental Assistance Program correcting any reporting errors.Improve the Timeliness and Accuracy of Financial and Programmatic Reports93.224, 93.527 Health Center Program ClusterName of contact person: Tracy Pytlakowski, Community Health Center of Yavapai Finance ManagerAnticipated completion date: 4/17/2023The Community Health Center of Yavapai has corrected the late reporting of its federal funding by ensuring that reports are prepared as soon as possible so that unforeseen staffing absences do not affect the ability to meet timely reporting requirements. The quarterly report that was submitted late is no longer required by the grantor.

FINDING 2022-001Contact Person Responsible for Corrective Action: Mayor Terry AmickContact Phone Number: 812-752-3169Views of Responsible Official: I concur with the findings.Description of Corrective Action Plan: The City plans to review existing policies and procedures andmake any needed changes to endure that they are in compliance with the federal compliancerequirements for procurement as well as suspension and debarment. Furthermore, controls will beestablished to ensure that the City?s policies related to compliance with the federal compliancerequirements for procurement as well as suspension and debarment are followed.Anticipated Completion Date: December 31, 2023

US Department of the Treasury - COVID-19 - Coronavirus State and Local Fiscal Recovery Funds (ARPA) (ALN 21.027) Recommendation: We recommend that the City establish procedures to ensure that their purchasing policy follows Uniform Guidance procurement standards. Action Taken: The City does follow Uniform Guidance procurement standards. In this instance, a vendor was selected under an emergency contract basis utilizing our waiver of bids policy. The entire country was awarded ARPA funds with water and sewer lining replacement being an allowable use of these funds. Due to the fact that there are a very limited number of vendors who provide this service, and the fact that there would be a significant number of municipalities seeking this service with the influx of ARPA dollars, as well as the fact that due to supply and demand, the cost for these services were escalating rapidly, the City wanted to be one of the first to engage with a contractor in order to secure a vendor in a timely manner before we would be unable to do so since the projects are long term projects and there was a time limit on when this money would need to be spent. Therefore, we knew it would not be possible to conduct our own bid. We choose a vendor off the COSTARS contract. I have attached a copy of the ordinance where we explained to Council our concern for our securing a vendor and our need to act quickly, which is why we originally initiated the purchase from City funds, before ARPA funds were distributed, and then replaced the City funds with ARPA funds once they were received.