Audit 14751

2023-001: Lack of Internal Control Review for Allowable Costs Compliance Requirement: Activities Allowed/Unallowed & Allowable Costs Questioned Costs: None Type of Finding: Material Weakness in Internal Control over Compliance of Major Programs •Criteria: Caritas Family Solutions is responsible for implementing and maintaining a proper internal control system over allowable costs and activities allowed under the major program. •Condition: Lack of documentation of an internal control indicating formal review of timesheets of each individual funded under the grant. During the audit, it was observed that for three individuals, the timesheets for a selected payroll period lacked the necessary approval from the Host Site supervisor. •Cause: The Organization did not consistently implement a control to review the allowable costs and activities allowed allocated to the grant. The absence of Host Site supervisor approval on these timesheets may be attributed to oversight, miscommunication, or a lack of established procedures for timely approvals. •Effect: Failing to obtain Host Site supervisor approvals on timesheets raises concerns about the accuracy of reported hours worked and compliance with the major program requirements. This could result in the misallocation or misuse of grant funds. •Recommendation: The Organization should establish and communicate clear procedures for the timely approval of timesheets by Host Site supervisors and ensure that these procedures are consistentlyfollowed. •Responsible Party: Gary Huelsmann, Chief Executive Officer Management Response and Corrective Action Plan: This deficiency was also discovered during our internal investigation, and Caritas Family Solutions has implemented a new process to ensure that internal controls are in place. Program participants will only be paid for verified hours of service. An annual meeting (either oneon- one or in a group) will be held with site supervisors to discuss processes and procedures and program expectations. During this meeting, supervisors will be shown how to complete the timesheet and given details on how to submit them for processing. Individual and group meetings will be held with program participants to explain the process to them and remind them that payments will not be made until timesheets are accurate and complete. Timesheets are due on Friday prior to pay dates. The ES will review submitted timesheets for accuracy and completeness and will forward them to the PM for review and final approval before they are submitted to Payroll for processing. The PM will review the form, sign, and date it after confirming that all information is accurate and complete. If there are inaccuracies and/or missing information, the form will be returned to the ES who will follow up with the host site to obtain the missing information or correct the inaccuracy. Steps 1 and 2 will be repeated. The QI department will conduct quarterly file reviews to determine if processes are being followed. •Anticipated Completion Date: Implemented in September 2023, but the process will be ongoing while the program is funded.

Type of Finding: Material Weakness in Internal Control over Compliance of Major Programs and Noncompliance within the Major Programs •Criteria: Caritas Family Solutions is responsible for maintaining and capturing supporting documentation such as timesheets to support the hours worked and paid to participants under the grant, ensuring compliance with activities allowed and unallowed and allowable costs. •Condition: During the audit, it was discovered that for four individuals, timesheets supporting the hours paid under the grant were unavailable. This deficiency in record-keeping and documentation hindered the verification of hours worked and compliance with allowable costs and activities allowed and unallowed. Cause: The absence of timesheets may be due to inadequate record-keeping practices, lack of a clear documentation procedure, or oversight in maintaining required records. •Effect: Failing to provide timesheets for these individuals raises concerns about the accuracy of hours reported and the potential for non-compliance with allowable costs and activities allowed and unallowed. This jeopardizes the integrity of grant management and could result in the misallocation or misuse of grant funds. •Recommendation: The Organization must establish and enforce clear procedures for the maintenance and retention of timesheets, ensuring that they are consistently documented and readily available for verification. •Responsible Party: Gary Huelsmann, Chief Executive Officer •Management Response and Corrective Action Plan: This deficiency was also discovered during our internal investigation, and Caritas Family Solutions has implemented a new process to ensure that internal controls are in place. After the PM has verified that timesheets are accurate and complete, they will be scanned and sent to Payroll for processing. Payroll will maintain a copy of the email providing the documents and will comply with federal guidelines of storing records for a period after the close of the grant. The PM will file a hard copy of the timesheets in the SCSEP office. The files will be kept in the office until completion of quarterly reviews for the fiscal year by the QI department, and then they will be transferred to the agency’s long-term storage facility for files. •Anticipated Completion Date: Implemented in September 2023, but the process will be ongoing while the program is funded.

Type of Finding: Significant Deficiency in Internal Controls of Major Programs •Criteria: Caritas Family Solutions is responsible for implementing and documenting controls over compliance with earmarking requirements. •Condition: The audit revealed that there was no defined internal control process in place to monitor and ensure compliance with the earmarking compliance requirements. Cause: The absence of an internal control process for earmarking compliance may result from a lack of clear procedures, oversight, or the failure to establish and implement necessary controls. •Effect: The lack of an internal control process to oversee earmarking compliance requirements raises concerns about the grant's adherence to its intended use, potentially jeopardizing the grant's integrity and purpose. •Recommendation: The Organization should establish and document an internal control process that ensures compliance with earmarking requirements. This process should include clear procedures, monitoring, and reporting mechanisms. •Responsible Party: Gary Huelsmann, Chief Executive Officer •Management Response: Caritas Family Solutions acknowledge the finding and are committed to establishing and enforcing internal control procedures for earmarking compliance requirements. We will work to improve our oversight and compliance in this regard. A compliance team from the QI Department will be appointed to ensure that the program adheres to all compliance requirements. The compliance team will work closely with the PM to coordinate and delegate tasks to determine how and what data will be collected. The compliance team will work closely with the PM to determine who has responsibility for data entry, compilation, and processing. The compliance team will assist the program in creating a process for maintaining, storing, and securing data for the required period. The compliance team will review compliance throughout the life of the grant and adjust, as necessary. •Anticipated Completion Date: The process will be implemented on January 3, 2024, and will be continually updated to align with best practices.

Type of Finding: Material Weakness in Internal Control over Compliance of Major Programs and Noncompliance within the Major Programs •Criteria: Caritas Family Solutions is responsible for implementing and maintaining an internal control system around eligibility of participants in the program and ensuring that documentation is maintained and readily accessible to prove participant eligibility. Condition: The audit identified that there was no documentation available in the file provided for four participants to indicate their eligibility under the major program and that an internal control system was in place. •Cause: The absence of eligibility documentation may result from a failure to establish proper recordkeeping procedures, oversight, or a lack of documentation requirements. •Effect: Failing to maintain eligibility documentation for participants raises concerns about the Organization’s compliance with the eligibility requirement and may jeopardize the integrity of grant management. •Recommendation: The Organization should promptly establish and enforce procedures and oversight to ensure that eligibility documentation for participants is consistently maintained, documented, and readily accessible. •Responsible Party: Gary Huelsmann, Chief Executive Officer •Management Response and Corrective Action Plan: This deficiency was also discovered during our internal investigation, and Caritas Family Solutions has implemented a new process to ensure that internal controls are in place. A SCSEP Employment Specialist will meet with participants to complete the recertification application and gather the necessary documentation. The recertification application and documentation will be forwarded to the PM for review and approval. The PM will review the form, sign, and date it after confirming that all information is accurate and complete. If there are inaccuracies and/or missing information, the form will be returned to the ES who will follow up with the host site to obtain the missing information or correct the inaccuracy. Steps 1 and 2 will be repeated. The QI department verify eligibility and recertification documents are within the file during their quarterly reviews to determine if processes are being followed. •Anticipated Completion Date: Implemented in September 2023, but the process will be ongoing while the program is funded.

Type of Finding: Material Weakness in Internal Control over Compliance of Major Programs and Noncompliance within the Major Programs •Criteria: Caritas Family Solutions is responsible to implement an internal control system and process for re-certifications be performed as part of the required annual process to ensure that participants remain eligible for the grant. •Condition: During the audit, it was observed that re-certification was not performed for two participants as part of the required annual process to verify their ongoing eligibility. •Cause: The failure to perform re-certification may be attributed to a lack of established procedures, oversight, or a misunderstanding of the re-certification requirements. This could result in individuals who are not eligible to receive funds under the major program. •Effect: The absence of re-certification for eligible participants may lead to non-compliance with federal eligibility regulations, raising concerns about the proper allocation of grant resources. •Recommendation: The Organization should promptly establish and enforce clear procedures and oversight for conducting re-certification as part of the required annual process to ensure ongoing eligibility for all participants. •Responsible Party: Gary Huelsmann, Chief Executive Officer •Management Response and Corrective Action Plan: This deficiency was also discovered during our internal investigation, and Caritas Family Solutions has implemented a new process to ensure that internal controls are in place. A SCSEP Employment Specialist will meet with participants to complete the recertification application and gather the necessary documentation. The recertification application and documentation will be forwarded to the PM for review and approval. The PM will review the form, sign, and date it after confirming that all information is accurate and complete. If there are inaccuracies and/or missing information, the form will be returned to the ES who will follow up with the host site to obtain the missing information or correct the inaccuracy. Steps 1 and 2 will be repeated. The QI department will conduct quarterly file reviews to determine if processes are being followed. Re-certification was modified during the pandemic out of an abundance of caution for the participants in the program. Those who had access to the internet were asked to email their documentation, and those who didn’t were asked to mail theirs. A drive through recertification process was implemented when COVID restrictions eased, and participants were asked to remain in their vehicles while SCSEP employment specialists obtained their recertification documentation. Many participants do not have transportation and were not able to participate in the drive through. The most recent, pre-pandemic certification information for participants was used for those who were not able to attend the drive through or virtual recertification processes. CWI did not end COVID protocols until Q4 of PY2022 (April 1, 2023). Alternative recertification methods were used to comply with the protocols. With the end of the COVID protocols and restrictions, we have reinstituted the in-person/face-to-face recertification process required by the funder. •Anticipated Completion Date: Implemented in September 2023, but the process will be ongoing while the program is funded.

Type of Finding: Non-compliance within Major Programs •Criteria: Caritas Family Solutions is responsible to maintain documentation that participants demonstrate residency in the appropriate counties at the time of enrollment or re-certification. •Condition: During the audit, it was identified that there were three participants with expired driver's licenses in their files as part of the most recent re-certification process. This incomplete documentation prevented Armanino from verifying the participants' residency in the appropriate counties. •Cause: The inclusion of expired driver's licenses may result from inadequate record-keeping practices, a lack of clear procedures for residency verification, or an oversight in maintaining updated documentation. •Effect: The absence of valid residency documentation hinders compliance with the major program and raises concerns about whether participants meet the residency requirements, potentially impacting the proper allocation of grant resources. Recommendation: The Organization should establish and enforce procedures for collecting and maintaining valid and up-to-date documentation to verify participant residency during enrollment and re-certification. •Responsible Party: Gary Huelsmann, Chief Executive Officer •Management Response and Corrective Action Plan: This deficiency was also discovered during our internal investigation, and Caritas Family Solutions has implemented a new process to ensure that internal controls are in place. A SCSEP Employment Specialist will meet with participants to complete the recertification application and gather the necessary documentation. The recertification application and documentation will be forwarded to the PM for review and approval. The PM will review the form, sign, and date it after confirming that all information is accurate and complete. If there are inaccuracies and/or missing information, the form will be returned to the ES who will follow up with the host site to obtain the missing information or correct the inaccuracy. The QI department will conduct quarterly file reviews to determine if processes are being followed. The recertification process was modified during the pandemic, and the state of Illinois extended the expiration deadline for IDs and drivers’ licenses though December 2022. When driver’s license facilities reopened, many had limited hours or were by appointment only, and some participants had challenges renewing their IDs and licenses during the limited hours. The lifting of restrictions and return to normal business hours now makes it easier for participants to secure the documentation needed for recertification. Some participants were not aware that the COVID protocols and restrictions related to ID and driver’s license expiration had changed. With the end of the COVID protocols and restrictions, we have reinstituted the in-person/faceto- face recertification process required by the funder. We also have more face-to-face contact with participants and are able to better communicate information such when and where they can go to renew their IDs and drivers’ licenses. •Anticipated Completion Date: Implemented in September 2023, but the process will be ongoing while the program is funded.

Type of Finding: Non-compliance within Major Programs •Criteria: Caritas Family Solutions is responsible for submitting monthly reporting (i.e. SCSEP subgrantee reports) to monitor and ensure compliance with the major program and grant requirements. Condition: During the audit, it was observed that 4 months of the SCSEP sub-grantee reports were not available for review. This lack of documentation hindered the ability to verify whether these reports were properly submitted and reviewed. •Cause: The absence of monthly SCSEP sub-grantee reports may result from inadequate reporting procedures, a lack of established review mechanisms, or an oversight in documentation requirements. •Effect: The inability to obtain and review these reports raises concerns about compliance with major program requirements and the oversight of sub-grantee activities, potentially impacting the grant's integrity and transparency. •Recommendation: The Organization should promptly establish and enforce procedures for the submission and review of monthly reports to ensure compliance with major program requirements. •Responsible Party: Gary Huelsmann, Chief Executive Officer •Management Response and Corrective Action Plan: The monthly reports are submitted through the CWI portal and since the former Project Manager left the agency, no one else has been granted access to the portal. Several requests have been made to CWI and promises from CWI to grant access to the current Project Manager, but access remains elusive. Without access to the portal, - Caritas Family Solutions does not have the template for the report and do not know what data are reported. Moving forward, a hardcopy of the report will be kept on file in the SCSEP office for future reference and audit purposes. The reports are submitted via the funder’s portal and with the departure of the previous program manager, no one at Caritas has access to the portal. Several requests were made to the funder to grant the new program manager access, but those requests have not been honored. •Anticipated Completion Date: The process will be ongoing once management receives access to the portal.

Type of Finding: Significant Deficiency in Internal Control over Compliance of Major Programs •Criteria: Caritas Family Solutions is responsible for implementing and documenting internal controls over financial reporting to ensure accuracy and compliance with major program requirements. Condition: During the audit, it was observed that financial reports were submitted and subsequently reviewed by the Chief Financial and Administrative Officer (CFAO). We noted that two of the five months tested for the SA2 monthly financial report lacked the CFAO's review signature. •Cause: The absence of review signatures on the SA2 financial reports and subsequent review of the SA1 reports may result in inadequate reporting or a lack of established oversight of grant reporting requirements. •Effect: The lack of review indicates deficiencies in the financial reporting review process, potentially affecting the accuracy and compliance of financial reports submitted to the granting agency and the possible loss or return of funding. •Recommendation: The Organization should promptly establish and enforce clear procedures for reviewing financial reports, including requiring review by program or executive management before submission to the granting agency. •Responsible Party: Gary Huelsmann, Chief Executive Officer •Management Response and Corrective Action Plan: Caritas Family Solutions acknowledges the finding and agree to implement procedures for reviewing financial reports and ensuring that the CFAO signs off on the review before submission to the granting agency. We are committed to improving the accuracy and compliance of financial reports. •Anticipated Completion Date: In July 2023, management implemented formal review, performed by the CFAO, of all SA1 and SA2 reports.

Type of Finding: Material Weakness in Internal Control over Compliance of Major Programs •Criteria: Caritas Family Solutions is responsible for implementing and documenting internal controls over performance reporting to ensure accuracy and compliance with major program requirements. •Condition: During the audit, it was observed that there were no defined internal controls in place to oversee and ensure compliance with performance reporting requirements. •Cause: The absence of internal controls for performance reporting compliance may result from a lack of established procedures, oversight, or misunderstanding of reporting compliance requirements. Effect: The lack of internal controls hinders the Organization's ability to monitor and ensure compliance with performance reporting requirements, potentially affecting the accuracy and timeliness of performance reports. •Recommendation: The Organization should promptly establish and enforce clear procedures for reviewing performance reports, including requiring review by program or executive management before submission to the granting agency to improve the accuracy and timeliness of performance reports. •Responsible Party: Gary Huelsmann, Chief Executive Officer •Management Response and Corrective Action Plan: Caritas Family Solutions acknowledges the finding and is committed to establishing and enforcing internal control procedures for compliance with performance reporting requirements. We will work to improve our oversight and compliance in this regard. A compliance team will be appointed to ensure that the agency adheres to all compliance requirements. The compliance team will work closely with the PM to coordinate and delegate tasks to collect the data needed to complete the report. The compliance team will assist in creating a process for maintaining documentation to support what is reported. The compliance team will document the level of compliance in which internal controls are followed and report results to program and agency leadership along with recommendations for improvement. Internal audits will be conducted in preparation for external audits. •Anticipated Completion Date: The process will be implemented on January 3, 2024, and will continuously be reviewed and updated to align with best practices.

2023-001: Lack of Internal Control Review for Allowable Costs Compliance Requirement: Activities Allowed/Unallowed & Allowable Costs Questioned Costs: None Type of Finding: Material Weakness in Internal Control over Compliance of Major Programs •Criteria: Caritas Family Solutions is responsible for implementing and maintaining a proper internal control system over allowable costs and activities allowed under the major program. •Condition: Lack of documentation of an internal control indicating formal review of timesheets of each individual funded under the grant. During the audit, it was observed that for three individuals, the timesheets for a selected payroll period lacked the necessary approval from the Host Site supervisor. •Cause: The Organization did not consistently implement a control to review the allowable costs and activities allowed allocated to the grant. The absence of Host Site supervisor approval on these timesheets may be attributed to oversight, miscommunication, or a lack of established procedures for timely approvals. •Effect: Failing to obtain Host Site supervisor approvals on timesheets raises concerns about the accuracy of reported hours worked and compliance with the major program requirements. This could result in the misallocation or misuse of grant funds. •Recommendation: The Organization should establish and communicate clear procedures for the timely approval of timesheets by Host Site supervisors and ensure that these procedures are consistentlyfollowed. •Responsible Party: Gary Huelsmann, Chief Executive Officer Management Response and Corrective Action Plan: This deficiency was also discovered during our internal investigation, and Caritas Family Solutions has implemented a new process to ensure that internal controls are in place. Program participants will only be paid for verified hours of service. An annual meeting (either oneon- one or in a group) will be held with site supervisors to discuss processes and procedures and program expectations. During this meeting, supervisors will be shown how to complete the timesheet and given details on how to submit them for processing. Individual and group meetings will be held with program participants to explain the process to them and remind them that payments will not be made until timesheets are accurate and complete. Timesheets are due on Friday prior to pay dates. The ES will review submitted timesheets for accuracy and completeness and will forward them to the PM for review and final approval before they are submitted to Payroll for processing. The PM will review the form, sign, and date it after confirming that all information is accurate and complete. If there are inaccuracies and/or missing information, the form will be returned to the ES who will follow up with the host site to obtain the missing information or correct the inaccuracy. Steps 1 and 2 will be repeated. The QI department will conduct quarterly file reviews to determine if processes are being followed. •Anticipated Completion Date: Implemented in September 2023, but the process will be ongoing while the program is funded.

Type of Finding: Material Weakness in Internal Control over Compliance of Major Programs and Noncompliance within the Major Programs •Criteria: Caritas Family Solutions is responsible for maintaining and capturing supporting documentation such as timesheets to support the hours worked and paid to participants under the grant, ensuring compliance with activities allowed and unallowed and allowable costs. •Condition: During the audit, it was discovered that for four individuals, timesheets supporting the hours paid under the grant were unavailable. This deficiency in record-keeping and documentation hindered the verification of hours worked and compliance with allowable costs and activities allowed and unallowed. Cause: The absence of timesheets may be due to inadequate record-keeping practices, lack of a clear documentation procedure, or oversight in maintaining required records. •Effect: Failing to provide timesheets for these individuals raises concerns about the accuracy of hours reported and the potential for non-compliance with allowable costs and activities allowed and unallowed. This jeopardizes the integrity of grant management and could result in the misallocation or misuse of grant funds. •Recommendation: The Organization must establish and enforce clear procedures for the maintenance and retention of timesheets, ensuring that they are consistently documented and readily available for verification. •Responsible Party: Gary Huelsmann, Chief Executive Officer •Management Response and Corrective Action Plan: This deficiency was also discovered during our internal investigation, and Caritas Family Solutions has implemented a new process to ensure that internal controls are in place. After the PM has verified that timesheets are accurate and complete, they will be scanned and sent to Payroll for processing. Payroll will maintain a copy of the email providing the documents and will comply with federal guidelines of storing records for a period after the close of the grant. The PM will file a hard copy of the timesheets in the SCSEP office. The files will be kept in the office until completion of quarterly reviews for the fiscal year by the QI department, and then they will be transferred to the agency’s long-term storage facility for files. •Anticipated Completion Date: Implemented in September 2023, but the process will be ongoing while the program is funded.

Type of Finding: Significant Deficiency in Internal Controls of Major Programs •Criteria: Caritas Family Solutions is responsible for implementing and documenting controls over compliance with earmarking requirements. •Condition: The audit revealed that there was no defined internal control process in place to monitor and ensure compliance with the earmarking compliance requirements. Cause: The absence of an internal control process for earmarking compliance may result from a lack of clear procedures, oversight, or the failure to establish and implement necessary controls. •Effect: The lack of an internal control process to oversee earmarking compliance requirements raises concerns about the grant's adherence to its intended use, potentially jeopardizing the grant's integrity and purpose. •Recommendation: The Organization should establish and document an internal control process that ensures compliance with earmarking requirements. This process should include clear procedures, monitoring, and reporting mechanisms. •Responsible Party: Gary Huelsmann, Chief Executive Officer •Management Response: Caritas Family Solutions acknowledge the finding and are committed to establishing and enforcing internal control procedures for earmarking compliance requirements. We will work to improve our oversight and compliance in this regard. A compliance team from the QI Department will be appointed to ensure that the program adheres to all compliance requirements. The compliance team will work closely with the PM to coordinate and delegate tasks to determine how and what data will be collected. The compliance team will work closely with the PM to determine who has responsibility for data entry, compilation, and processing. The compliance team will assist the program in creating a process for maintaining, storing, and securing data for the required period. The compliance team will review compliance throughout the life of the grant and adjust, as necessary. •Anticipated Completion Date: The process will be implemented on January 3, 2024, and will be continually updated to align with best practices.

Type of Finding: Material Weakness in Internal Control over Compliance of Major Programs and Noncompliance within the Major Programs •Criteria: Caritas Family Solutions is responsible for implementing and maintaining an internal control system around eligibility of participants in the program and ensuring that documentation is maintained and readily accessible to prove participant eligibility. Condition: The audit identified that there was no documentation available in the file provided for four participants to indicate their eligibility under the major program and that an internal control system was in place. •Cause: The absence of eligibility documentation may result from a failure to establish proper recordkeeping procedures, oversight, or a lack of documentation requirements. •Effect: Failing to maintain eligibility documentation for participants raises concerns about the Organization’s compliance with the eligibility requirement and may jeopardize the integrity of grant management. •Recommendation: The Organization should promptly establish and enforce procedures and oversight to ensure that eligibility documentation for participants is consistently maintained, documented, and readily accessible. •Responsible Party: Gary Huelsmann, Chief Executive Officer •Management Response and Corrective Action Plan: This deficiency was also discovered during our internal investigation, and Caritas Family Solutions has implemented a new process to ensure that internal controls are in place. A SCSEP Employment Specialist will meet with participants to complete the recertification application and gather the necessary documentation. The recertification application and documentation will be forwarded to the PM for review and approval. The PM will review the form, sign, and date it after confirming that all information is accurate and complete. If there are inaccuracies and/or missing information, the form will be returned to the ES who will follow up with the host site to obtain the missing information or correct the inaccuracy. Steps 1 and 2 will be repeated. The QI department verify eligibility and recertification documents are within the file during their quarterly reviews to determine if processes are being followed. •Anticipated Completion Date: Implemented in September 2023, but the process will be ongoing while the program is funded.

Type of Finding: Material Weakness in Internal Control over Compliance of Major Programs and Noncompliance within the Major Programs •Criteria: Caritas Family Solutions is responsible to implement an internal control system and process for re-certifications be performed as part of the required annual process to ensure that participants remain eligible for the grant. •Condition: During the audit, it was observed that re-certification was not performed for two participants as part of the required annual process to verify their ongoing eligibility. •Cause: The failure to perform re-certification may be attributed to a lack of established procedures, oversight, or a misunderstanding of the re-certification requirements. This could result in individuals who are not eligible to receive funds under the major program. •Effect: The absence of re-certification for eligible participants may lead to non-compliance with federal eligibility regulations, raising concerns about the proper allocation of grant resources. •Recommendation: The Organization should promptly establish and enforce clear procedures and oversight for conducting re-certification as part of the required annual process to ensure ongoing eligibility for all participants. •Responsible Party: Gary Huelsmann, Chief Executive Officer •Management Response and Corrective Action Plan: This deficiency was also discovered during our internal investigation, and Caritas Family Solutions has implemented a new process to ensure that internal controls are in place. A SCSEP Employment Specialist will meet with participants to complete the recertification application and gather the necessary documentation. The recertification application and documentation will be forwarded to the PM for review and approval. The PM will review the form, sign, and date it after confirming that all information is accurate and complete. If there are inaccuracies and/or missing information, the form will be returned to the ES who will follow up with the host site to obtain the missing information or correct the inaccuracy. Steps 1 and 2 will be repeated. The QI department will conduct quarterly file reviews to determine if processes are being followed. Re-certification was modified during the pandemic out of an abundance of caution for the participants in the program. Those who had access to the internet were asked to email their documentation, and those who didn’t were asked to mail theirs. A drive through recertification process was implemented when COVID restrictions eased, and participants were asked to remain in their vehicles while SCSEP employment specialists obtained their recertification documentation. Many participants do not have transportation and were not able to participate in the drive through. The most recent, pre-pandemic certification information for participants was used for those who were not able to attend the drive through or virtual recertification processes. CWI did not end COVID protocols until Q4 of PY2022 (April 1, 2023). Alternative recertification methods were used to comply with the protocols. With the end of the COVID protocols and restrictions, we have reinstituted the in-person/face-to-face recertification process required by the funder. •Anticipated Completion Date: Implemented in September 2023, but the process will be ongoing while the program is funded.

Type of Finding: Non-compliance within Major Programs •Criteria: Caritas Family Solutions is responsible to maintain documentation that participants demonstrate residency in the appropriate counties at the time of enrollment or re-certification. •Condition: During the audit, it was identified that there were three participants with expired driver's licenses in their files as part of the most recent re-certification process. This incomplete documentation prevented Armanino from verifying the participants' residency in the appropriate counties. •Cause: The inclusion of expired driver's licenses may result from inadequate record-keeping practices, a lack of clear procedures for residency verification, or an oversight in maintaining updated documentation. •Effect: The absence of valid residency documentation hinders compliance with the major program and raises concerns about whether participants meet the residency requirements, potentially impacting the proper allocation of grant resources. Recommendation: The Organization should establish and enforce procedures for collecting and maintaining valid and up-to-date documentation to verify participant residency during enrollment and re-certification. •Responsible Party: Gary Huelsmann, Chief Executive Officer •Management Response and Corrective Action Plan: This deficiency was also discovered during our internal investigation, and Caritas Family Solutions has implemented a new process to ensure that internal controls are in place. A SCSEP Employment Specialist will meet with participants to complete the recertification application and gather the necessary documentation. The recertification application and documentation will be forwarded to the PM for review and approval. The PM will review the form, sign, and date it after confirming that all information is accurate and complete. If there are inaccuracies and/or missing information, the form will be returned to the ES who will follow up with the host site to obtain the missing information or correct the inaccuracy. The QI department will conduct quarterly file reviews to determine if processes are being followed. The recertification process was modified during the pandemic, and the state of Illinois extended the expiration deadline for IDs and drivers’ licenses though December 2022. When driver’s license facilities reopened, many had limited hours or were by appointment only, and some participants had challenges renewing their IDs and licenses during the limited hours. The lifting of restrictions and return to normal business hours now makes it easier for participants to secure the documentation needed for recertification. Some participants were not aware that the COVID protocols and restrictions related to ID and driver’s license expiration had changed. With the end of the COVID protocols and restrictions, we have reinstituted the in-person/faceto- face recertification process required by the funder. We also have more face-to-face contact with participants and are able to better communicate information such when and where they can go to renew their IDs and drivers’ licenses. •Anticipated Completion Date: Implemented in September 2023, but the process will be ongoing while the program is funded.

Type of Finding: Non-compliance within Major Programs •Criteria: Caritas Family Solutions is responsible for submitting monthly reporting (i.e. SCSEP subgrantee reports) to monitor and ensure compliance with the major program and grant requirements. Condition: During the audit, it was observed that 4 months of the SCSEP sub-grantee reports were not available for review. This lack of documentation hindered the ability to verify whether these reports were properly submitted and reviewed. •Cause: The absence of monthly SCSEP sub-grantee reports may result from inadequate reporting procedures, a lack of established review mechanisms, or an oversight in documentation requirements. •Effect: The inability to obtain and review these reports raises concerns about compliance with major program requirements and the oversight of sub-grantee activities, potentially impacting the grant's integrity and transparency. •Recommendation: The Organization should promptly establish and enforce procedures for the submission and review of monthly reports to ensure compliance with major program requirements. •Responsible Party: Gary Huelsmann, Chief Executive Officer •Management Response and Corrective Action Plan: The monthly reports are submitted through the CWI portal and since the former Project Manager left the agency, no one else has been granted access to the portal. Several requests have been made to CWI and promises from CWI to grant access to the current Project Manager, but access remains elusive. Without access to the portal, - Caritas Family Solutions does not have the template for the report and do not know what data are reported. Moving forward, a hardcopy of the report will be kept on file in the SCSEP office for future reference and audit purposes. The reports are submitted via the funder’s portal and with the departure of the previous program manager, no one at Caritas has access to the portal. Several requests were made to the funder to grant the new program manager access, but those requests have not been honored. •Anticipated Completion Date: The process will be ongoing once management receives access to the portal.

Type of Finding: Significant Deficiency in Internal Control over Compliance of Major Programs •Criteria: Caritas Family Solutions is responsible for implementing and documenting internal controls over financial reporting to ensure accuracy and compliance with major program requirements. Condition: During the audit, it was observed that financial reports were submitted and subsequently reviewed by the Chief Financial and Administrative Officer (CFAO). We noted that two of the five months tested for the SA2 monthly financial report lacked the CFAO's review signature. •Cause: The absence of review signatures on the SA2 financial reports and subsequent review of the SA1 reports may result in inadequate reporting or a lack of established oversight of grant reporting requirements. •Effect: The lack of review indicates deficiencies in the financial reporting review process, potentially affecting the accuracy and compliance of financial reports submitted to the granting agency and the possible loss or return of funding. •Recommendation: The Organization should promptly establish and enforce clear procedures for reviewing financial reports, including requiring review by program or executive management before submission to the granting agency. •Responsible Party: Gary Huelsmann, Chief Executive Officer •Management Response and Corrective Action Plan: Caritas Family Solutions acknowledges the finding and agree to implement procedures for reviewing financial reports and ensuring that the CFAO signs off on the review before submission to the granting agency. We are committed to improving the accuracy and compliance of financial reports. •Anticipated Completion Date: In July 2023, management implemented formal review, performed by the CFAO, of all SA1 and SA2 reports.

Type of Finding: Material Weakness in Internal Control over Compliance of Major Programs •Criteria: Caritas Family Solutions is responsible for implementing and documenting internal controls over performance reporting to ensure accuracy and compliance with major program requirements. •Condition: During the audit, it was observed that there were no defined internal controls in place to oversee and ensure compliance with performance reporting requirements. •Cause: The absence of internal controls for performance reporting compliance may result from a lack of established procedures, oversight, or misunderstanding of reporting compliance requirements. Effect: The lack of internal controls hinders the Organization's ability to monitor and ensure compliance with performance reporting requirements, potentially affecting the accuracy and timeliness of performance reports. •Recommendation: The Organization should promptly establish and enforce clear procedures for reviewing performance reports, including requiring review by program or executive management before submission to the granting agency to improve the accuracy and timeliness of performance reports. •Responsible Party: Gary Huelsmann, Chief Executive Officer •Management Response and Corrective Action Plan: Caritas Family Solutions acknowledges the finding and is committed to establishing and enforcing internal control procedures for compliance with performance reporting requirements. We will work to improve our oversight and compliance in this regard. A compliance team will be appointed to ensure that the agency adheres to all compliance requirements. The compliance team will work closely with the PM to coordinate and delegate tasks to collect the data needed to complete the report. The compliance team will assist in creating a process for maintaining documentation to support what is reported. The compliance team will document the level of compliance in which internal controls are followed and report results to program and agency leadership along with recommendations for improvement. Internal audits will be conducted in preparation for external audits. •Anticipated Completion Date: The process will be implemented on January 3, 2024, and will continuously be reviewed and updated to align with best practices.