Corrective Action Plans

Significant Deficiency over Procurement Contact Person Responsible for the Corrective Action Plan: William Roberson, Financial Services Director Corrective Action Plan: The County identified a problem during the fiscal year, corrected the issue during the fiscal year, and shared the information with the audit team. Procurement for the new radio read water meters began with informal solicitation of pricing during the prior administration which ended in February 2023. The lack of formal procurement was identified as an issue by the interim county manager and recommended that the County reject the three informal bids. Subsequently, the County initiated a formal procurement process and is documented in meeting minutes, and a copy of County Administration’s memorandum to the Board of Commissioners was shared with the audit staff early in the audit process. The project was approved and contract awarded on July 5, 2024. Anticipated Completion Date: Completed

Recommendation: During our review of the organization's procurement processes, it was noted that the organization does not have a procurement policy that complies with federal requirements. Specifically, the policy does not address key elements such as competition, cost or price analysis, and documentation requirements as outlined in federal regulations. We recommend that the Organization develop and implement a procurement policy that complies with federal requirements, including provisions for competition, cost or price analysis, and proper documentation. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management has reviewed the federal law and standards identified in 2 CFR 200.318 through 2 CFR 200.327. A procurement policy that aligns with these federal requirements is currently being developed. The policy is expected to be adopted and in place in the coming months. Name(s) of the contact person(s) responsible for corrective action: Angela Woods Planned completion date for corrective action plan: June 2, 2025

A procurement policy will be prepared 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 responsible Debbie Pinnock, Yolanda Adams Completion Date Plan to be implemented as soon as possible.

Management Response: The Mifflinburg Area School District agrees with the finding. The SFA has updated Policy #626 Procurement - Federal Programs. The SFA has removed the RFP reference from the informal procurement method. The SFA reviewed the bidding requirements and will adhere to the policy. This policy was approved by the School Board in May 2024. The SFA has updated future produce solicitations to include the following: Pricing will be a cost-plus fixed fee structure. All prices bid for all products will be net, Free on Board (F.O.B.). SFA will consider individual product price changes both as part of a renewal to the awarded contract and during the contract year. Product price changes may not exceed the U.S. Department of Labor-Bureau of Labor statistics Northeast region not seasonally adjusted consumer price index percentage change annual average for the previous 12 months. Vendors must submit both the supplier charge and the fixed fee, which much be listed separately. Additionally, the SFA implemented a formal requisition process in the Food Service department, in which pricing would be entered into the requisition and verified against the bid or other respective documents, then submitted for approval. The SFA employees responsible were trained in this procedure. Individual Responsible: Superintendent, Business Manager, Food Service Director Anticipated Completion Date: May 31, 2024

NONCOMPLIANCE WITH PROCUREMENT AND SUSPENSION AND DEBARMENT REQUIREMENTS, CORONAVIRUS STATE AND LOCAL FISCAL RECOVERY FUNDS, AL No. 21.027, DIRECT ALLOCATION Name of contact person: Peri Whiteclay Corrective Action: Checking the SAM system was added to the county’s grant management procedures after the audit of fiscal year 2023. Proposed Completion Date: Completed.

Identifying Number: SA 2024-002 Description of Finding: During the audit, MARTA was unable to provide purchase order documentation or contract for eight samples that are above $500. Per current procurement policy, "Purchases of supplies, services, and equipment costing more than five hundred ($500) shall be made by purchase order, unless authorized by a signed contract or Mountain Transit Board Approval". During the audit, MARTA was unable to provide supporting documentation to demonstrate that the required price or rate quotations for those purchases or contracts with contract amounts above $10,000 were obtained from an adequate number of qualified sources and maintained the documentation to support its conclusion. These were noted for two samples tested. The expenditure paid ranged from $10,000 to $36,000 in 2024. During the audit, MARTA was unable to provide supporting documentation to demonstrate that the process of verifying if vendors are not suspended or debarred were performed on two vendors tested. The expenditure paid to these vendors ranged from $109,000 to $647,000 in 2024. Corrective Actions Taken or Planned: We are in the process of updating our Procurement Policy. We will ensure that we follow these updated policies and procedures to address compliance and documentation requirements for small and micro-purchases, sole-source, and informal processes. The updated Procurement Policy will be brought to our October 2025 Board of Directors meeting for Board review or approval. Personnel responsible for implementation: Sean Gillingham, Finance Manager Anticipated completion date: October 2025

Identifying Number: SA 2024-001 Description of Finding: MARTA does not have comprehensive written policies and procedures concerning the following key compliance areas which are required by the Uniform Guidance: Equipment and Real Property Management MARTA has an Asset Inventory Policy and Procedures, however, it does not clearly define the policies and procedures that are in place for the use, management and disposition of equipment acquired under a Federal award in accordance with 2 CFR sections 200.313(c) through (e). Cash Management MARTA does not have written procedures to implement the requirements of 2 CFR 200.305 Federal Payment. Procurement, Suspension and Debarment MARTA has a Procurement policy, however, documented procedures are not well- defined regarding the purchase process for different types of procurement, obtaining quotations, bidding, and procedures for verifying that an entity with which it plans to enter into a covered transaction is not debarred, suspended, or otherwise excluded. Corrective Actions Taken or Planned: We have an Asset Inventory Policy and Procedures in which the purpose is to ensure that fixed assets are properly accounted for, identified, and tracked. We also have Cash Handling Policy and Procedures which addresses safeguarding public funds and maximizing resources available. This is designed to reduce the risks associated with the collection, receipts storage and reporting of cash transactions and to safeguard and maintain the security and integrity of MARTA's fiscal assets. We are in the process of updating our Procurement Policy. We will review and update these policies and/or create new policies to make sure we are compliant with the Uniform Guidance. The updated or newly created policies will be brought to our October 2025 Board of Directors meeting for Board review or approval. Personnel responsible for implementation: Sean Gillingham, Finance Manager Anticipated completion date: October 2025

The City staff will be stricter in following its established internal control procedures to ensure that all reporting requirements are met and submitted timely. The City will also establish access to the Integrated Disbursement and Information System (IDIS) for another member of the Finance Department in a backup capacity. Where applicable, the City will request an extension from the funding agency and maintain a record of the approval when a report cannot be submitted by the due date.

Federal Award Finding: 2024-002 Material Weakness in Compliance and Internal Control over Procurement and Suspension and Debarment Name and Contact Person: Adrienne Gaines, Executive Director Corrective Action: WISH has evaluated the processes and procedures regarding procurement and suspension and debarment, as well as the processes for maintaining records supporting all procurement activity. Management will appoint an individual to oversee this. Proposed Completion Date: June 30, 2025

Reporting - FSRS Opioid STR - FSRS were not timely submitted resulting in noncompliance with the reporting requirement. Corrective Action Plan: ADAD will meet with the program staff to complete the implementation of the policies and procedures relating to the reporting of subawards to the new FSRS system to comply with the Federal reporting requirements. Implementation Date: July 1, 2025 Responding Official: John Valera and Melanie Muraoka, Administrative Officer/Alcohol and Drug Abuse Division

Corrective Action Plan Procurement – Finding 2024-003 Roof Above will amend the procurement policy to document the criteria for vendor selection, including bids, quotes, and sole source justification and follow the policy when contracting with new vendors using federal funding. Contact person responsible for corrective action: Kaedon Grinnell, Chief Program Officer Anticipated completion date: March 31, 2025

FINDING 2024-004 Finding Subject: Child Nutrition Cluster – Procurement and Suspension and Debarment Contact Person Responsible for Corrective Action: Kelli Keith Contact Phone Number and Email Address: 812-438-2655, kkeith@risingsun.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: We had never been instructed to do price quotes for items purchased from the HPS Purchasing Co-Op before. In the future, we will obtain price quotes when purchasing from HPS when purchases are above the micro-purchasing threshold. Or we will find a different purchasing avenue and will not use HPS. The cafeteria director is currently discussing this with each of the cafeteria supervisors to decide which avenue they will use to avoid the finding in the future. Going forward, for any vendor expected to equal or exceed $25,000 that is paid from school lunch funds (or any federal funds for that matter), someone at the school corporation will verify those vendors aren’t suspended or debarred. Anticipated Completion Date: 08/01/2025: The next school year.

CORRECTIVE ACTION PLAN (CONCERNING FINDING 2024-001-RF3-407-3.0) Contact Person Responsible for Corrective Action: Judy L Hayward Corrective Action Plan: The Royalton Fire District 1 will take the following actions to address finding 2024-01. We will prepare and adopt a federal procurement policy, Anticipated Completion Date: June 30, 2025.

FINDING 2024-012 Subject: Special Education Cluster (IDEA) - Procurement and Suspension and Debarment Federal Agency: Department of Education Federal Programs: Special Education Grants to States, COVID-19 - Special Education Grants to States, Special Education Preschool Grants, COVID-19 - Special Education Preschool Grants Assistance Listing Numbers: 84.027, 84.027X, 84.173, 84.173X Federal Award Numbers and Years (or Other Identifying Numbers): 22611-027-PN01, 22611-027-ARP, 22619-027- ARP, 23611-027-PN01, 23619-027-PN01 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Procurement and Suspension and Debarment Audit Findings: Material Weakness, Modified Opinion Contact Person Responsible for Corrective Action: Beth Husband/Alexandria Eckert Contact Phone Number 260-356-8312 Email Address: bhusband@hccsc.k12.in.us/aeckert@hccsc.k12.in.us Views of Responsible Officials: We concur with the finding Description of Corrective Action Plan: All future expenditures triggering procurement and suspension and debarment requirements will include implementing the following procurement policies: Reference Procurement Standards 2 CFR 200.318 Districts may not enter into contracts with entities that have been suspended or debarred from participating in contracts with federal funds. For contracts over $25,000, districts must verify a contractor is not excluded or disqualified. Contractors must be verified in one of three ways: 1. Checking the System for Award Management (SAM) (www.SAM.gov) 2. Collecting a certificate from that contractor. 3. Adding a clause or condition to the covered transaction with that contractor. (Recommended) **Proper verification and documentation must be sent to the LEA for audit purposes. Methods of Procurement Where specific EDGAR/UG thresholds apply, Districts must meet baseline requirements for procurement. If State or local rules have more restrictive thresholds, the most restrictive rule must be followed. Anticipated Completion Date: All expenditures initiated after March 26, 2025

We will give instructions to the Contract Division to use a contract model that includes all the required federal clauses for contracts formalized that are subsidized with federal funds

Name of Contact Person: Darla Hawkins, City Treasurer, City of Sheridan, Wyoming Corrective Action Plan: Due to personnel changes, obtaining authorization to access the reporting site proved to be a challenging and time-consuming process. To prevent similar issues in the future, a cross-training program and centralized task list are being developed to ensure multiple staff members are familiar with all tasks and have backup access to logins when available. Proposed Completion Date: June 30, 2025

The corrective action plan listed below is response to the San Bernardino Valley Municipal Water District’s single audit report for the fiscal year ending June 30, 2024, prepared by Rogers, Anderson, Malody and Scott, CPA’s 2024-001 - Lack of Internal Controls Over the Reporting Process Significant Deficiency Reclamation States Emergency Drought Relief Program, AL 15.514 Recommendation: We recommend that the District develop and implement formal policies and procedures to ensure that federal reports are reviewed for accuracy, completeness, and timeliness prior to submission. Management should assign responsibility for report preparation and review, implement checklists or reconciliation processes, and provide training to sta􀆯 involved in federal reporting. Corrective Action: To ensure compliance for future reporting, the District has implemented procedures that prior to submission of grant reporting, the accounting department will approve the report for all grant expenditures. In addition, the District has arranged for sta􀆯 training for employees involved with federal grants and reporting. Person Responsible for Corrective Action: Chief Financial O􀆯icer Senior Accountant Project Managers (Various Departments) Anticipated Completion Date for Corrective Action: Corrective Action is immediately implemented in response to the auditors’ recommendation.

Finding 2024-003 Contact Person Responsible for Corrective Action Plan: Brenda Layne, Food Service Director Contact Phone Number: 765-289-7323 We concur with the finding. Corrective Action plan: As of 3/1/25. Cindy will look the company up on Sam.gov. and the Food Service Director will look it over and both of us will initial and keep a copy on file. Anticipated Completion Date: March 2025

Finding Reference 2024-06 Corrective Action Plan: The Authority will revise its procurement policies and procedures to ensure that all federally funded projects undergo the appropriate competitive procurement processes. This will include consistent and standard guidelines for project scope determination, bidding process, and documentation requirements. Responsible: Eng. Maria Ayala Rivera, Construction Office Director Planned Implementation Date: December 31, 2025

Identifying Number: 2024-001 Audit Finding: Accounting for Pharmacy 340B Drug Pricing Program Transactions. While testing the 340B Program, revenue and accounts receivable, we identified the following errors: • The Organization overstated 340B Program accounts receivable and revenue by double-counting a 340B Program transaction in the amount of $213,887. • The Organization understated 340B Program accounts receivable and revenue by $45,038 by not properly recording a transaction with a pharmacy. • The Organization overstated 340B Program revenue and professional services expense by $1,111,252 by posting an incorrect adjustment to true-up revenue and expense for dispensing, processing and administrative fees associated with the 340B Program. Corrective Action Taken: The Controller will utilize program data reports to perform reconciliations periodically. The reconciliations will be reviewed by the VP of Finance and stored. Additionally, the Revenue Cycle Manager and the VP of Finance will assist and monitor TPA’s setup and conditions for proper program management. This will be implemented by June 30, 2025. Identifying Number: 2024-002 Audit Finding: Inadequate Internal Controls Over Payroll Transactions. In May 2024, the Organization failed to restrict the modification of payroll reports subsequent to approval. There was no final check performed to ensure that the final submitted payroll report agreed with the approved version. Corrective Action Taken: By June 2024, the Finance Director created additional checks and balances to ensure integrity of payroll. The Director will provide a trend analysis of payroll data for each payroll for the approval process. The analysis will show changes in employee pay and trends. We will also compare the final payroll totals with the website verification after submission to ensure the totals reviewed match what was submitted. Identifying Number: 2024-003 Audit Finding: While testing the procurement requirement for micro purchases, we noted there was one sample selection for which the Organization did not have documentation to support whether the procurement method used was appropriate. Corrective Action Taken: By June 30, 2025, the Operations team and the Accounts Payable Coordinator will maintain a centralized database of vendor contracts, bids, and other information regarding purchases. To ensure continuity through changes in personnel, Tapestry will store the data on the shared drives, allowing for a repository to persist over time. Purchases, contracts, and associated back up will be monitored by both Operations and Finance teams and will be assisted by Office Managers who may perform some ordering.

Contact Person Mark Bell Director of Finance vcc.m.bell@ontrackroguevalley.org Explanation and Specific Reasons for Disagreement With the Audit Finding or That Corrective Action is not Required (if Applicable) No disagreement. Corrective Action Planned 1. Develop and Implement a Formal Procurement Policy o A written procurement policy will be developed that aligns with 2 CFR 200.317 - 200.327, ensuring compliance with federal, state, and local regulations. 2. Enhance Internal Controls for Procurement Compliance o All procurement transactions will be reviewed and approved by designated personnel to verify compliance before finalizing agreements. o A procurement checklist will be used for each transaction to ensure that required documentation is maintained. 3. Mandatory Suspension and Debarment Verification o The Organization will implement procedures to verify all vendors against the System for Award Management (SAM.gov) database before entering into contracts. o Documentation of suspension and debarment searches will be retained in the procurement files. Anticipated Completion Date September 30, 2025

Finding No. 2024-004: Segregation of Duties and Oversight – Material Weakness in Internal Control over Financial Reporting Contact for Corrective Action: Matt Bergheiser, President The finance department will institute a monthly financial reporting package to be sent to the President of the organization which will include the monthly financial statements, general ledger detail, a listing of all journal entries made, significant accounts reconciliations, aged payables and receivables, and any significant adjustments in the previous period. Report will also include an update to the Schedule of Federal Awards and other significant grant reporting done in conjunction with the development team. President will review and approve the packet monthly. Expected Completion Date: 3/31/2025

Condition: During the audit, the auditors noted three of seven monthly Federal Financial Reports were filed late. Specifically, the July 2023, August 2023 and May 2024 reports were filed later than 30 days as required under the County’s contract. Recommendation: The auditors recommended that the County improve internal controls over grant reporting that includes a process that identifies reporting requirements, including reporting deadlines, and monitors timely grant reporting. Corrective Action Planned: The County Community Services department will improve the timeliness and accuracy of grant reporting by implementing the following measures. An automated task list will be implemented to clearly identify billing report due dates, responsible staff, report recipients, and the required reporting frequency. This system will enhance accountability and help ensure deadlines are consistently met. A separate automated task will be established to ensure Community Services receives accurate and timely billing reports from grantors. This proactive approach will help identify and resolve potential delays before they impact reporting compliance. If unforeseen circumstances impact reporting timelines Community Services will utilize internal departmental data to prepare preliminary billing reports to prevent delays and reconcile to final reporting when available. Additionally, Community Services will proactively communicate with grantors in the event of anticipated delays to maintain transparency and compliance. The County Finance department had already partially addressed this at the beginning of fiscal year 2025 with enhanced data gathering of grant reporting requirements and deadlines for each grant. This data is gathered prior to grant acceptance. The County Finance department will improve its process by providing frequent reminders at a standard frequency to all department directors and those who are directly responsible for grant reporting to follow the grantor reporting requirements. Additionally, these periodic communications will request that department directors confirm the accuracy of department grant contacts and provide updated contact information as needed. Contact Name: Christina Register, Assistant Director Community Services Anticipated Completion Date: June 30, 2025

CORRECTIVE ACTION PLAN March 17, 2025 Health Resources and Services Administration 5600 Fishers Lane Rockville, MD 20857 The Gavin Foundation, Inc. respectively submits the following corrective action plan for the year ended June 30, 2024. CohnReznick LLP 350 Granite Street, Suite 1200 Braintree, MA 02184 Audit Period: June 30, 2024 The finding from the June 30, 2024 schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. FINDING - FEDERAL AWARD PROGRAM AUDIT U.S. Department of Health and Human Services 2024-001 Congressional Directives - Assistance Listing No. 93.493 SIGNIFICANT DEFICIENCY Recommendation Management should establish procedures to ensure contract files include the history of procurements and the documentation is maintained. Action Taken The organization performed procurement procedures, including soliciting bids/proposals from multiple contractors, evaluating them and selecting the contractor based on their procurement procedures. However, as the project was completed we maintained the contracts related to the contractor selected but inadvertently disposed of the documentation related to the procurement process. We have met with employees responsible for completion and filing of the procurement documentation and discussed the importance of not only completing the documentation, but also the importance of its proper filing. We have updated our procedures to ensure procurement history is adequately documented and maintained in the contract files. These actions were implemented (or are anticipated to be implemented) effective March 17, 2025. If the Health Resources and Services Administration has questions regarding this plan, please call Peter Barbuto at (857) 496-7341. Sincerely yours, Peter Barbuto, CEO The Gavin Foundation, Inc.

The Service Center will be sure to follow the federal procurement requirements pursuant to Policy 6325 and verify that appropriate controls and compliance with federal requirements are maintained with documentation supporting the procurement types.