Corrective Action Plans

Identification Number: 2024-001 Finding: Procurement, Suspension and Debarment Corrective Actions Taken or Planned: The Armed Services YMCA (ASYMCA) acknowledges the control deficiency identified in the area of procurement policy and is actively addressing it to ensure full compliance with 2 CFR § 200.318 (formerly referenced as 2 CFR 300.218), which governs procurement standards for non-federal entities receiving federal awards. 1. Policy Development and Alignment with Federal Regulations ASYMCA Finance is currently compiling and formalizing procurement procedures in accordance with 2 CFR § 200.318. This initiative will result in a comprehensive, board-approved procurement policy that ensures compliance with federal requirements and strengthens internal controls. 2. Existing Policies and Controls ASYMCA already maintains consistent, documented, and approved policies in several key areas of procurement and financial management, including: • Authority of Responsibility: Delegation of authority for designating funds and obligating ASYMCA for purchases, including spending thresholds and approved personnel. • Procurement Standards: General procurement principles and internal controls. • Professional Services and Consulting Agreements • Purchase of Capital Items • Signature Authority • Legal Review • Unbudgeted Expenditures • Record Retention • Policy Enforcement and Consequences • Procedures for Invoicing, Payment Processing, and Reimbursements (Travel and Non-Travel) • Requesting New Vendors • Competition: Requirements for full and open competition in vendor selection.   3. Areas for Expansion and Integration To ensure full compliance with federal procurement standards, ASYMCA will expand its current policies to include the following areas: • Conflict of Interest: Clear guidelines to prevent personal or organizational conflicts in procurement decisions. • Methods of Procurement: Defined procedures for micro-purchases, small purchases, sealed bids, competitive proposals, and non-competitive proposals. • Purchase/License of Technology or Software: Standards for evaluating and acquiring digital tools and platforms. • Indirect Cost: Clarification of treatment and allocation of indirect costs in procurement. • Methods of Procurement (as per federal thresholds) • Contracting with Small and Minority Businesses and Women’s Business Enterprises • Contract Cost and Price Analysis • Federal Awarding Agency Requirements 4. Implementation Timeline ASYMCA is committed to finalizing, approving, and implementing the updated procurement policy the end of the 2025 reporting period. This will include: • Internal review and legal vetting (if necessary) • Board and/or Audit Committee approval • Staff training and dissemination of the policy • Integration into operational procedures for all federally funded and non-federally funded projects Conclusion ASYMCA is committed to maintaining the highest standards of accountability, transparency, and regulatory compliance. The actions outlined above demonstrate a proactive and structured approach to addressing the control deficiency and ensuring that all procurement activities are conducted in accordance with applicable federal regulations. Anticipated completion date: December 31, 2025 Responsible Contact Person: Laura Tate-Smith, Chief Financial Officer

Corrective Action Planned: The USGA will enhance the procedures within its Policy for the Acquisition of Goods & Services relating to procurements utilizing Federal funding. In particular, the Policy will be amended so that adequate documentation is retained to ensure compliance with the requirements for the procurement methods described in 2 CFR §200.320. Further, the updated Policy will include additional requirements to ensure that applicable documentation of the USGA’s suspension and debarment verification procedures is retained and attached to any related purchase order in the USGA’s ERP system. At the time of the Policy’s approval by the USGA’s Executive Leadership team, the document will be shared with all employees and posted on our internal shared site where Finance related policies are stored and may be referred to. The USGA’s Finance/Accounting Department will be responsible for identifying grants to which the updated Policy applies and to assist with retaining the relevant documentation. The USGA’s Finance/Accounting Department will also develop a unique coding/project identifier to assist with ensuring that the request to purchase via a Purchase Order (PO) is visibly different than a generic PO when Federal funding is involved.

The County Board should draft and approve policies and procedures for the procurement of contractors per the Compliance Supplement, Code of Federal Regulations, United States Codes, and Federal Acquisition Regulations to ensure the proper advertisement and selection of contractors and consultants, and to prevent conflicts of interest during the selection of contractors and consultants. Management Response: Management will draft and approve the recommended procurement policies and procedures and disseminate the information to department heads and County employees during the fall of 2025.

Finding 2024-003 – Material Weakness Award No.: AL No. 15.555 and AL No. 15.074 Federal Grantor: U.S. Department of the Interior, Bureau of Reclamation. AL No. 15.074 Passed-through the Del Puerto Water District. Compliance Requirement: Procurement, Suspension and Debarment. Condition: The following conditions were noted during the single audit: • The District was not able to provide evidence that procurements for the Mendota Pool Fish Screen and Control Structure Project and Poso Canal Bridge Replacement Project design contractors under AL 15.555 met the requirements for adequate price competition and was unable to provide documentation confirming the sole-source solicitations met the requirements of Uniform Guidance. Specifically the District was unable to provide evidence it received enough statements of qualification to have adequate price competition or complied with one or more provisions of Section 200.210(c) that allows a sole source agreement to occur. It would appear the District would need evidence that the grantor approved the sole source procurement, but was not able to provide documentation of approvals of sole source procurements by the grantors. The District also was unable to provide documentation of the advertisement of the solicitation of requests for qualifications for the Fish Screen and Control Structure Project. • The District was not able to provide adequate documentation that the Mendota Pool Fish Screen and Control Structure Project contract under AL 15.555 and Orestimba Creek Recharge and Recovery Expansion Project contract under AL 15.074 complied with Section 200.327 and appendix II to this part requiring federal contract provisions to be included in the approved contract. This resulted in the District not having evidence that the contractor certified it was in compliance with all required federal provisions. Criteria: Uniform Guidance states the following: • Section 200.318(i) states that “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, contractors selection or rejection, and the basis for the contract price.” • Section 300.320(c) states “There are specific circumstances in which the recipient or subrecipient may use a noncompetitive procurement method. The noncompetitive procurement method may only be used if one of the following circumstances applies: (1) The aggregate amount of the procurement transaction does not exceed the micro-purchase threshold (see paragraph (a)(1) of this section); (2) The procurement transaction can only be fulfilled by a single source; (3) The public exigency or emergency for the requirement will not permit a delay resulting from providing public notice of a competitive solicitation; (4) The recipient or subrecipient requests in writing to use a noncompetitive procurement method, and the Federal agency or pass-through entity provides written approval; or (5) After soliciting several sources, competition is determined inadequate. • The provisions of the Brooks Act (49 United State Code, Section 1104) require local agencies to award federally funded engineering and design related contracts, otherwise know as A&E contracts, on the basis of fair and open competitive negotiations, demonstrated competence, and professional qualifications (23 Code of Federal Regulations (CFR), Part 172) at a fair and reasonable price (48 CFR 31.201-3). Both federal regulation and California state law (Government Code 4525-4529 et a) require selection of A&E consultant services on the basis of demonstrated competence and professional qualifications. Procurement by noncompetitive proposals may be used only when the award of a contract is infeasible under small purchase procedures, sealed bids or competitive proposals, as cited above. • Section 200.327 states “The non-federal entity’s contracts must contain the applicable provisions described in appendix II to this part.” Appendix II contains requirements to include in federally funded contracts termination for cause and convenience provisions, Equal Employment Opportunity provisions, Davis-Bacon Act provisions, Contract Work Hours and Safety Standards Act provisions, Clean Air Act provisions, debarment and suspension provisions, Byrd Anti-Lobbying Amendment provisions, and other provisions, as applicable. Cause: The current staff was not able to find procurement documentation prepared before they were hired. Effect: The District was unable to provide evidence that it was in compliance with the requirement to maintain documentation indicating the procurement was in compliance with Uniform Guidance Sections 200.318 to 200.327 and appendix II to this part. Context: The original procurement for the consulting firm for the Mendota Pool Fish Screens and Control Structure project was performed in September 2018 and awarded in late October 2018. This procurement precedes the current staff. Staff indicated the grantor approved the Mendota Pool Fish Screen and Control Structure Project sole source procurement and the Board Resolution approving the agreement indicated the grantor approved the sole source procurement, but staff was not able to provide proof of written approval by the grantor. Recommendation: We recommend management implement additional controls over the procurement process that ensures each procurement complies with Uniform Guidance Section 200.318 to 200.326, including training of staff working on procurements of the documentation retention and other requirements under the Uniform Guidance. We further recommend the District establish a procurement folder on its server with subfolder for each individual procurement where documentation of each procurement is maintained, including advertising of the procurement, requests for proposals/qualifications with language that satisfies Uniform Guidance requirements, proposals received, executed contracts, certifications of compliance with federal contracting provisions by the contractor if not part of the proposal or executed contracts, documented quantitative and qualitative analysis indicating why the recommended bid was selected for approval, management report to board recommending which bid should be approved, board resolution approving the winning bid and for contracts under $250,000 a memo or form documenting bids received and reason for selecting the bid, including reasons for not selecting the lowest bid if applicable. If a sole source procurement method is used, documentation showing the sole source procurement is allowable under criteria listed in Section 300.320(c) should be retained. Views of Responsible Officials and Planned Corrective Actions: Management will keep procurement folders on each procurement in the future that includes the confirmation in the recommendation and will consult with Reclamation on whether a contract amendment is necessary to document the federal contract. Estimated Completion Date of Corrective Action: Future procurement projects

Finding: Procurement, Suspension and Debarment: Special Education – Special Olympics Education Programs The recipient must maintain and use documented (written) procedures for procurement transactions under a Federal Award or subaward, including for acquisition of property or services. These documented procedures must be consistent with applicable State, and local laws and regulations, provided that the procurements conform to applicable federal statutes and the procurement requirements identified in the Uniform Guidance (2 CFR 200.317-200.327). The Organization has a written purchasing policy in place, but it does not include all required elements for a procurement policy in accordance with Federal statutes . Views of Responsible Officials and Planned Corrective Actions: Management is in agreement with this finding. Management will review the organization’s current Procurement Policy and make adjustments to the policy to ensure that it contains the required criteria to meet the federal procurement guidelines. An updated copy of the organization's Procurement Policy will be finalized by Oct 31, 2025. This policy will be reviewed regularly to ensure that it remains in compliance with federal procurement guidelines. Responsible Official: Greg Vanselow, Chief Operating Officer Completion Date: Oct 31, 2025

The city has updated and implemented its procurement process in FY25 to ensure that expenditures for vendors that exceed $10,000 and sole source contracts follow the correct procurement policies and procedures in accordance to MGL 30B.

The City will update it’s polices and procedures to help ensure the procurement standards are followed when expending federal monies.

Correction action • Finance team is in the process of implementing a new financial accounting (Grants Management System, Sage) system to ensure that coding for grants are accurately tracked. Internal reports will be built to provide monthly analysis of individual grants. Finance will work with program staff to ensure timely and accurate budget to actuals review and reconciliations. • Finance will contact Grant Manager responsible for each grant to develop plan of action for returning any overdrawn funds. Responsible Person • Associate Director - Finance Anticipated completion date • September 30, 2025

FINDING 2024-03 Finding Subject: Water and Waste Disposal System for Rural Communities - Procurement and Suspension and Debarment Contact Person Responsible for Corrective Action: Beth Jones Contact Phone Number and Email Address: 812 723-2739, clerk@paoli.in.gov Views of Responsible Officials: We concur with the findings Description of Corrective Action Plan: The Clerk Treasurer will work with the council and town attorney to make sure we are following the procurement policy and that we are compliant with the Federal and State guidelines. If a new project or a current project is being extended to a significant amount; during a council meeting, we will state that we are retaining a certain vendor for the project and explain why we are using that vendor. Anticipated Completion Date: August 1, 2025

CORRECTIVE ACTION PLAN FISCAL YEAR OF FINDING: June 30, 2024 AUDITOR FINDING: 2024-004 Procurement and Suspension & Debarment Assistance Listing No. 21.027 COVID-19 Coronavirus State and Local Fiscal Recovery Funds In accordance with 2 CFR 200.318, non-Federal entities must have and use documented procurement procedures, consistent with State and local 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 2 CFR 200.317 through 200.327. The Organization's procurement policy requires obtaining three competitive bids for purchases in excess of $5,000 before purchase order is placed. In addition, it states that CFR 200's procurement standards are the guiding legislation. The Organization did not have adequate documentation to support the Organizations procurement decisions and did not have adequate internal controls in place which resulted in a purchase without adherence to the Organization's own procurement policies and the Uniform Guidance. CLIENT PLANNED ACTION: 1. SummitStone will review and align its procurement policy with Uniform Guidance compliance requirements for procurement records per 2 CFR 200.318 (i) Procurement records as well as 2 CFR § 200.214 Suspension and debarment requirements. 2. SummitStone will provide the necessary training on Uniform Guidance procurement compliance requirements to its procurement personnel and other authorized purchasers within the organization. 3. SummitStone will update its purchasing procedures and record keeping thereof, to ensure that competitive bids are obtained prior to contract / purchase order issuance / q CLIENT RESPONSIBLE PARTY: John Dowling, Chief Financial Officer Sarah Bystrom, Director of Compliance COMPLETION DATE: September 30, 2025

SINGLE AUDIT FOR THE YEAR ENDED SEPTEMBER 30, 2024 CORRECTIVE ACTION PLAN FEDERAL AWARD FINDINGS - Fiscal Year 2024 Finding Number: 2024-001 Procurement Assistance Listing Number: 93.696 Assistance Listing Title: Certified Community Behavioral Health Clinics N ame of Federal Agency: Substance Abuse and Mental Health Services Administration Federal Award Identification Number: H79SM089299 Fiscal Year of Initial Finding: 2024 • Name of the contact person: Tina Boyer, CFO • Corrective Action Plan: Management agrees with this recommendation. VBCMH management will review and update policies and procedures to ensure that allfederal requirements are followed. Anticipated Completion Date: Fiscal Year 2025

Finding: 2024-036 -A review of 25 FY 24 Disaster Grants payments found that 14 payments (56 percent) lacked required supporting documentation. Specifically, six payments lacked pay policy and/or fringe benefit calculations and eight payments lacked procurement contracts that included all federal requirements. Additionally, two of the eight payments lacked a complete or signed contract on file. Questioned Costs: AL - 97.036: $96,758; AL - 97.036 COVID-19: $2,159 Assistance Listing Number: 97.036 Assistance Listing Title: Disaster Grants — Public Assistance (Presidentially Declared Disasters) Views of Responsible Officials (state whether your agency agrees or disagrees with the finding; if you disagree, briefly explain why): DMVA concurs with the finding. Corrective Action (corrective action planned): To ensure compliance with federal regulations and effective management of federal awards, the Finance Office in conjunction with the Homeland Security Director will develop and implement written procedures that provide a clear framework for managing federal awards and ensure compliance with federal regulations. DMVA will: • Clearly outline federal requirements under 2 CFR 200.327, 2 CFR 200 .403(g), and Homeland Security Acquisition Regulation Class Deviation 15-01. • Specify the documentation required to support reimbursement requests, including expectations related to discrepancies and follow-up actions. • Outline the procedures for Homeland Security for reviewing and certifying work completed by contractors, where applicable, prior to reimbursement to subrecipients. Completion Date (list anticipated completion date): October 31, 2025 Agency Contact (name of person responsible for corrective action): Bryan Fisher

Finding 2024-005 – Procurement Policy (Repeat Finding 2023-004) Condition: During our review of the Coalition's Policies and Procedures, we determined that the Coalition's Procurement policy does not comply with 2 CFR, Part §200.317 - §200.327 In response to the finding related to non-compliance with procurement policies and procedures under Uniform Guidance 2 CFR §200.317 – §200.327, the Nebraska Urban Indian Health Coalition (NUIHC) is committed to ensuring full compliance with all applicable federal, state, local, and tribal procurement requirements. To address this finding and strengthen internal practices, the Coalition will implement the following corrective actions: 1. Procurement Policy Review with External Expertise: NUIHC has contracted with an external consultant with expertise in federal procurement regulations to assist in conducting a thorough review of the organization’s current procurement policies and procedures. This partnership will help ensure that all updates reflect the specific requirements of 2 CFR §200.317 – §200.327 and incorporate best practices in compliance, documentation, and oversight. 2. Update and Alignment of Procedures: With the support of the external contractor, NUIHC will update detailed procurement procedures to ensure they align with Uniform Guidance and any applicable state, local, or tribal procurement laws. Clear step-by-step procedures will be documented for each procurement method (e.g., micro-purchases, small purchases, sealed bids, competitive proposals, and non-competitive proposals). 3. Ongoing Education and Training: NUIHC will implement a continued education and training program for all staff involved in procurement activities. In addition to the initial training on updated policies, refresher training will be offered annually and included as part of new employee onboarding. This will ensure sustained awareness of procurement responsibilities and regulatory compliance. 4. Internal Controls and Review Process: A formal internal control process will be implemented to verify compliance with updated procurement policies. This includes a procurement checklist, mandatory pre-approval protocols, and supporting documentation requirements for every procurement action. 5. Monitoring and Quarterly Compliance Checks: The Coalition will continue conducting quarterly internal audits of procurement activities to ensure adherence to policy, detect potential issues early, and implement timely corrective actions. Findings will be reported to leadership and the Board of Directors as part of ongoing compliance oversight. Timeline for Implementation: • External Consultant Engagement: Completed – May 2025 • Policy and Procedure Review: To be completed by July 31, 2025 • Initial Staff Training: To be conducted by August 15, 2025 • Internal Controls & Monitoring: To be fully implemented by August 31, 2025 • Ongoing Training and Quarterly Reviews: Begin Q3 2025 and continue thereafter Anticipated Full Compliance Date: August 31, 2025 Corrective Action Plan Finding 2024-005 – procurement Policy (Repeat Finding 2023-004) Responsible Party: Chief Financial Officer, Carlett Gregory

Condition: A weakness existed in the overall reconciliation/tie-in procedures performed over the Tribe’s financial statement accounts for the fiscal year ended September 30, 2024. Financial accounts were either reconciled untimely or in some cases, accounts were not reconciled at all. Most of these accounts should be reconciled on a monthly basis. The major areas where reconciliation procedures were weak included: A)   Beginning Balances B)    Account Receivables C)    Grant Receivables/Unearned Revenues D)   Accounts Payable E)    Payroll and Other Current Liabilities Recommendation: The Tribe should adopt written reconciliation and tie-in procedures into its financial policies and procedures manual. Action Taken: We agree with the auditor’s recommendation. We expect this to be complete within 120 days past the issuance of this report

Condition: Prisma Health's written procurement policy and procedures are not compliant with the requirements of the Uniform Guidance (2 CFR Part 200). This includes the absence of a documented policy outlining the different procurement methods, related thresholds, necessary documentation, and steps to ensure full and open competition when using federal funds. Planned Corrective Action: Prisma Health acknowledges this finding and will develop and implement a Uniform Guidance compliant procurement policy within the next month. The policy will be reviewed and approved by the CFO, head of Procurement and representatives of the Grants team. Contact person responsible for corrective action: Matt Elsey, Executive Vice President and CFO Anticipated Completion Date: 7/31/2025

2024-03: Lack of Procurement Policy Contact Person Heather Ferebee Corrective Action Plan A procurement policy will be developed and approved by the City Council. Completion Date 2025

Create a detailed, step-by-step process for federal procurement to ensure compliance and awareness among all staff responsible for spending and reporting federal funds. Washington Local Schools - Federal Grants Management Process Moving forward, the district will perform a cost/price analysis for procurement in excess of $250,000.

Create a detailed, step-by-step process for federal procurement to ensure compliance and awareness among all staff responsible for spending and reporting federal funds. Washington Local Schools - Federal Grants Management Process The district has also since enrolled with Bonefish, a partner of OASBO and Ohio Schools Council (OSC) to satisfy all requirements of securing vendors/entities using the Federal government’s System for Award Management (SAM). This will create the proper internal controls that were lacking.

Corrective Action Plan Actions Planned – The City will hold pre-meetings with grant administrators to ensure all federal compliance requirements are met including verifying suspension and debarment. Official Responsible – Amy Sevig, Deputy Finance Manager Planned Completion Date – December 31, 2025 Disagreement With or Explanation of Finding – The City agrees with this finding. Plan to Monitor – Janet Burns, Grant Coordinator Accountant, will oversee the process to ensure pre-meetings are set up with grant administrators and the City is in compliance with all federal grant requirements.

Finding 2024-001: Procurement, Suspension and Debarment Corrective Action: Management agrees with the finding. In fiscal year 2024 the Laboratory charged a federal sponsored award for a procurement item, which exceeded the Laboratory’s micro-purchase threshold, without maintaining the proper documentation as required by Laboratory procurement policy. In fiscal 2025 this item was identified by the Laboratory’s Internal Audit and Sponsored Programs Accounting Offices as part of their routine review program. The transaction cost was removed by Laboratory Management from the federal award within 90 days of the item's discovery; however, because the item was identified and adjusted in 2025, the fiscal year 2024 Schedule of Expenditures of Federal Awards (SEFA) was overstated. To ensure compliance with the Laboratory’s procurement policies the Laboratory has implemented and/or will implement certain corrective actions as detailed below, in line with the recommendation: Corrective Actions Previously Implemented: 1. The Laboratory’s Internal Audit and Sponsored Program Accounting Offices will continue to conduct regular reviews of procurement items to ensure that documentation complies with Laboratory Procurement Methods Policy and Procedure, to ensure compliance with Laboratory policy, designed to ensure compliance with 2 CFR Sections 200.317 through 200.327. The audit focus will continue to be on 100% of sponsored award procurement transactions in the small purchase threshold. 2. The Laboratory Information Technology department, in collaboration with the Laboratory’s Procurement Office Director, enhanced certain systemgenerated reporting to allow for easier identification by Procurement Office personnel of charges to sponsored awards. Corrective Actions to be Implemented: 1. The Laboratory’s Sponsored Programs Accounting Office, in collaboration with its Procurement Office, will provide an annual re-education to Laboratory administrative research personnel concerning Laboratory Procurement Policies, designed to ensure compliance with 2 CFR Sections 200.317 through 200.327. 2. The Sponsored Programs Accounting Office will provide re-training for administrative staff to reinforce the Laboratory Procurement Method Policies and Procedure. 3. The Director of Procurement will streamline access and visibility of the Procurement Methods Policy and Procedure on the Laboratory’s internal website. Management intends for the re-education of administrative research personnel and retraining for administrative staff to be concluded by the end of the third quarter and/or early fourth quarter of 2025. Management intends to provide for streamlined access and visibility of Laboratory Procurement Methods Policy and Procedure on its internal website prior to the end of 2025. Names of contact person(s) responsible for corrective action: Gerard Langlais, Corporate Controller

Finding The Organization established policies and procedures over suspension and debarment, including checking all vendors against the government suspension and debarment listing. The policies and procedures for suspension and debarment were being followed, however the evidence of the search of sam.gov was not retained. Corrective Actions Taken or Planned MDIC acknowledges the importance of retaining documentation to demonstrate compliance with federal procurement requirements, specifically those related to suspension and debarment under 2 CFR 200.214. While SAM.gov checks were consistently conducted prior to vendor engagement, the absence of retained search documentation was due to internal oversight and not a failure in performing the checks. As a small organization without a centralized procurement department, we had not previously formalized the documentation requirement in our procedures. Our contracts are also reviewed by the Legal team and each contract has a language around debarment and suspension of firms. To address this finding, MDIC has taken the following corrective actions: Policy and Procedure Update As of June 2025, our procurement procedures have been updated to require documentation (PDF printout or screenshot) of each SAM.gov search to be retained in the corresponding vendor file. Procurement Checklist Enhancement Our internal procurement checklist now includes a mandatory step confirming that the SAM.gov verification has been completed and documented. Training Implementation All staff involved in procurement and contracting processes received targeted training in June 2025 to reinforce the importance of documenting compliance steps, particularly suspension and debarment verifications. Ongoing Monitoring A periodic internal review process has been introduced whereby a sample of vendor files will be reviewed quarterly to ensure documentation of SAM.gov checks is properly maintained. Contact Person Responsible Tariq Bahich Senior Director Finance Anticipated Completion Date Corrective actions were completed as of June 4, 2025, and are now fully integrated into MDIC's procurement process.

Views of Responsible Officials: BCHC is in the process of composing a formal procurement policy, which will address requirements for open competition and establish thresholds for different procurement amounts/processes. The policy will clearly outline the conditions where a noncompetitive purchase is allowable. We anticipate having this policy written by June 1 and will submit to the BCHC Board for review and approval. I

May 27, 2025 Roslund, Prestage & Company, P.C. 525 W. Warwick Drive, Suite A Alma, MI 48801 Re: Corrective Action Plan Regarding Section III: Schedule of Findings and Questioned Costs for the Fiscal Year Ended September 30, 2024, in Reference to 2024-001 Procurement It was identified in the findings of 2024-001 Procurement (repeat comment) that LCCMH had not followed proper procurement requirements and procedures regarding the agreement in reference to ALN 93.969 Certified Community Behavioral Health Clinics (CCBHC) expansion Grants. LCCMH Management has taken actions to revise policies and procedures to ensure their alignment with federal regulations, as well as providing training regarding federal procurement requirements for the relevant personnel. The Standards Committee, which is responsible for regularly reviewing Policies and Procedures and approving or recommending changes, reviewed and approved the following policy revisions at its November 19, 2024 meeting to maintain compliance with federal regulation standards. 0.1.02.65 Provider Procurement and Best Value Purchasing 01.02.85 Procuring Employment Services Providers, Independent Contractors and Network Providers. The approved policies were also presented at the LCCMH Full Board meeting on November 21, 2024. All LCCMH Staff were advised on December 2, 2024, to review the revised policies and procedures. On April 22, 2025, SAMSHA provided LCCMH written notification identifying the 2023 citation for procurement as resolved. Thank you, Brooke Sankiewicz Chief Executive Officer Lapeer County Community Mental Health (810) 667-0500 bsankiewicz lapeercmh.org

Corrective Action Plan 2024-001: Management has since performed the suspension and debarment check for each vendor for which it used the on-call services contracts available. Additionally, management will include an addendum in future contracts to ensure vendor compliance with the federal contract regulations. Anticipated Completion Date: May 2025 Contact Person: Noelle Lewis, Chief Financial Officer

Condition: Controls were not sufficient to ensure that the history of procurement decisions was documented, as required by 2 CFR 200 and management's internal policies and procedures related to procurement, suspension, and debarment. Planned Corrective Action: Management agrees with the improvement of documentation of procurement, suspension, and debarment. As noted below, purchasing policies are being followed, but were not always formally documented. Careful consideration was done in selecting the vendors to look at obtaining the best cost for the value of the service as IWS was responsible for a portion of the expenses. The findings noted three procurement contracts that were more than $50,000 that did not properly document the rationale for selection and/or sole procurement. The first contract was a single source provider for the replacement of thermostats. Other heating and air conditioning vendors would not handle the replacement of the thermostats as it was not their equipment. There was also a preventative maintenance agreement with the vendor: Phoenix Heating and Air. We will document the use of a single source contractor as allowed in our purchasing policies. We did follow the other control procedures regarding contract approvals, obtaining Certificates of Insurance and verifying completion of the work. The second contract was related to our website and marketing company: Brand Vibe. We did an open bid process, two years earlier, and renewed the contract without a formal bid process. As mentioned above, we did follow the proper approval process and verified the work was completed. The total of this contract for FY 2024 was $74,665, however only $3,600 was charged against the federal grant. Going forward, we will document the rationale for renewing the contract. The third contract was for a bi-lingual APN, with a Psych. Certificate, who was a former employee. She wanted to work part-time, and we switched her to a 1099 employee. With her experience and work record, we allowed her to transition to a part-time contractor. Our experience finding bi-lingual providers has been difficult, and the agency costs are almost double the cost paid for this contractor. The amount charged to the Trauma-Informed Centers of Care was $47,769. In the future, we will formally document the selection and use of this contractor. As noted, we did have a formal contract. and all providers are approved by the Board. Management will make necessary revisions to the existing procurement processes and controls in a timely manner to ensure that procurement decisions are documented, as required by 2 CFR Part 200. Specifically, management will ensure the history of procurement - whether obtained through quotes, formal competitive bids, or through non-competitive means – is documented, including evidence that a cost-price analysis was performed for all purchases in excess of the simplified acquisition threshold. Additionally, before entering a covered transaction with third parties, management will have a form completed by the outside parties stating they are not suspended or debarred from engaging in federal activity before entering a covered transaction. This form will be retained, and we will check and document Sam.gov, excluded parties listing. Contact person responsible for corrective action: Karen L. Williams, Chief Financial Officer Anticipated Completion Date: 06/30/2025