Audit 310733

#2022-001 – Material Weakness – Segregation of Duties Criteria A good internal control structure consists of proper segregation of duties where no one person is involved in all aspects of a given transaction. This includes proper segregation of the following functions: authorization of transactions, custody of assets, and recordkeeping. Condition During the course of the audit, we noted improper segregation of duties over cash disbursements, payroll, and cash receipts: Cash Disbursements: During the year ended December 31, 2022, one individual had full signing authority on checks written from the Organization’s accounts, and also had full access to the check stock. Additionally, this individual was the one who authorized and regularly paid the expenses. This normally included making payments by cash. During the year ended December 31, 2022, the Organization did not have an accounting system in place nor were bank reconciliations performed. Payroll: During our audit, we noted that there is no documented approval of the hourly wages or salaries that are entered into the payroll spreadsheet used to generate payroll. We reviewed multiple timesheets that did not include a supervisor’s approval. We also noted that there was no review of the completed payroll registers. Cash Receipts: During our audit, we noted that the same individual opens the mail and regularly makes the deposits which could result in a misappropriation of funds, without a second level of review and reconciliation procedures between the cash received and the deposits made. We also noted that there are no procedures in place to reconcile the grant billing to the general ledger and the cash log to the bank records. Cause The Organization was unprepared for the sudden growth experienced when its grant funding increased, and did not properly implement internal controls to process its daily transactions. Effect Without proper segregation of duties over cash disbursements and receipts, funds could be misappropriated without detection by management or the Board. A lack of proper segregation over payroll controls could result in ghost employees on the Organization’s payroll or overpayment of hours and rates due to the lack of review and approval. Questioned Costs NonePerspective Information During the audit we gained an understanding of the Organization’s internal controls through inquiry and observation and by examining one item from each of the three cycles: cash receipts, cash disbursements, and payroll. Identification as a repeat finding A similar issue was noted in prior year finding #2021-001. Recommendation We recommend that the Organization implement policies and procedures which ensure that no one individual is involved in all aspects of the cash receipts, disbursements and payroll processes. The Organization should review these processes and segregate duties as much as considered practical.

#2022-002 – Material Weakness – Allowable Costs/Cost Principles Opioid STR Grant ALN 93.788 Block Grants for Prevention and Treatment of Substance Abuse 93.959 Criteria The Office of Management and Budget issuance of the Code of Federal Regulations (CFR) specifically states uniform administrative requirements, cost principles, and audit requirements for federal awards. CFR 200.430 states, “Charges to Federal Awards for salaries and wages must be based on records that accurately reflect the work performed. These records must be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated.” Condition During the course of the audit, we noted that the Organization used an allocation methodology to allocate salaries to the federal award based upon time spent on the program. However, for 54 employee time periods, there were no timesheets to support the amount of time allocated to the Organization’s grant programs. Cause The cause is a lack of proper internal controls which would require the Organization to maintain adequate support for time spent on grant programs and a formal allocation process to allocate payroll costs across the grant programs. Effect The potential effects of not having supporting documentation for the allocation of payroll expenses is the overbilling of expenses to the grant program. Questioned Costs $397,499 Perspective Information We reviewed a sample of monthly reports filed with the Pennsylvania Department of Military and Veterans Affairs and the Drug and Alcohol Program. We examined the payroll for each employee charged to the grant for a total of twenty-six employees. The finding is related to multiple individuals who did not complete timesheets or provide supporting documentation for the amount of time spent on the Organization’s grant programs. Identification as a repeat finding A similar issue was noted in prior year finding #2021-002. Recommendation We recommend that the Organization require timesheets for the hours allocated to the grant programs for all employees whether they are salary or hourly to ensure that the payroll charged to grants is accurate and properly supported.

#2022-003 – Material Weakness – Activities Allowed or Unallowed Opioid STR Grant ALN 93.788 Block Grants for Prevention and Treatment of Substance Abuse 93.959 Criteria The Office of Management and Budget issuance of the Code of Federal Regulations (CFR) specifically states uniform administrative requirements, cost principles, and audit requirements for federal awards. In accordance with CFR 200.430, payroll costs charged to the program are allowable when: the total compensation paid to individual employees is reasonable according to the work performed on the program and the compensation is in accordance with the established policies of the organization. Condition During the audit we noted the Organization does not have established policies and procedures over payroll. We noted that while the Organization has established hourly and salary pay rates, these rates are not formally established and approved by the Organization’s Board. Cause The cause is a lack of a proper control structure that requires Board approval of pay rates and salaries. The Organization also does not have a process in place to ensure that payroll reports are properly reviewed and approved by a second independent reviewer prior to submission to the payroll company for processing. Effect The potential effects of not having formally approved pay rates and not having payroll reports reviewed by a second level prior to payroll processing is the potential for errors and overcharging of grants. Questioned Costs None Perspective Information We reviewed a sample of reports filed with the Pennsylvania Department of Military and Veterans Affairs and the Drug and Alcohol Program. We examined the payroll for each employee charged to the grants for a total of 284 samples. The finding represents the unsupported costs noted from this review. Identification as a repeat finding A similar issue was noted in prior year finding #2021-003. Recommendation We recommend that the Organization begin to formally establish and approve employee pay rates and salaries at Official Board Meetings and that these rates are documented in the Board Minutes. The Organization should also implement procedures to include a second level review of the payroll report for accuracy and completeness prior to submission for payment.

#2022-004 – Material Weakness – Activities Allowed or Unallowed, Reporting, Cash Management, Period of Performance Opioid STR Grant ALN 93.788 Block Grants for Prevention and Treatment of Substance Abuse 93.959 Criteria The Office of Management and Budget issuance of the Code of Federal Regulations (CFR) specifically states uniform administrative requirements, cost principles, and audit requirements for federal awards. In accordance with 45 CFR § 75.403, “Except where otherwise authorized by statute, costs must meet the following general criteria in order to be allowable under Federal awards: (a) be necessary and reasonable for the performance (b) Conform to any limitations or exclusions set forth in these principles or in the Federal award as to types or amount of cost items. **** (g) Be adequately documented.” Condition During the audit we noted the Organization reported the following expenses that were not supported by the accounting records or supporting documentation: For the monthly reports tested, we were unable to examine supporting invoices or supporting documentation for $31,721.92 of the $90,546.79 charges reviewed. Additionally, for these items, because invoices or other support was not available, we were unable to verify the service period and whether the expense was charged to the correct grant period. Cause The cause is a lack of a proper control structure that includes retention of all supporting documentation for expenses and proper tracking of expenses charged to the grant programs. Effect The potential effects are overbilling the grant program and unsupported charges. Questioned Costs $149,061 Perspective Information We reviewed a sample of reports filed with the Pennsylvania Department of Military and Veterans Affairs and the Drug and Alcohol Program. We examined the payroll for each employee charged to the grant for a total of twenty-six employees. We also tested nonpayroll related expenses charged to the grant. The finding represents the unsupported costs noted from this review. Identification as a repeat finding A similar issue was noted in prior year finding #2021-004. **** - Citations not pertinent to this finding. Recommendation We recommend that the Organization develop a system to track all expenses charged to each grant contract by month and systematically file all supporting documentation in a manner that can easily be accessed. This information must be retained in accordance with the Federal and grant guidelines. The monthly reports filed for the grants should be supported by the Organization’s accounting records and invoices. We further recommend that the Organization perform a reconciliation between the monthly reports and the accounting records.

#2022-005 – Material Weakness – Reporting Opioid STR Grant ALN 93.788 Block Grants for Prevention and Treatment of Substance Abuse 93.959 Criteria The Organization’s agreements with the Department of Military and Veterans Affairs (DMVA) requires the Organization to submit monthly progress reports no later than 13 business days after the end of each month. Per the agreements with the Drug and Alcohol Programs, "Unless otherwise specified elsewhere in this Grant Agreement, the following shall apply. Grantee shall submit monthly invoices within 30 days from the last day of the month within which the work is performed. The final invoice shall be submitted within 45 days of the Grant Agreement’s termination date. The Department will neither honor nor be liable for invoices not submitted in compliance with the time requirements in this paragraph unless the Department agrees to an extension of these requirements in writing. The Grantee shall be reimbursed only for services acceptable to the Department." Condition During the audit we were not able to obtain the monthly reports filed with the DMVA properly approved by management and there was no date to indicate that the reports were filed within the appropriate period required by the grant agreements. During our audit, we noted that the Organization reallocated expenses across budget line items without a formal budget modification or tracking of the reallocation. The reallocations were not properly documented and resulted in unsupported expenditures charged to the grant programs. Cause The Organization does not have proper internal controls which include the review and approval of monthly reports filed with granting agencies for accuracy and completeness. These policies and procedures should also ensure that all reports are filed within the timeframe in accordance with the grant contract. The Organization also lacks a formal process for budget modifications and tracking of related expense adjustments. Effect The potential effect of not having proper review and approval of monthly reports is the potential for errors in the reports that would be caught by an independent review and improper reporting to the granting agencies. Reports not submitted within the required timeframe may not be approved for reimbursement. Questioned Costs None Perspective Information We reviewed a sample of reports filed with the Drug and Alcohol Program. The finding represents errors noted in all reports reviewed. Identification as a repeat finding A similar issue was noted in prior year finding #2021-005. Recommendation We recommend that the Organization implement policies and procedures to include a second independent review of the monthly reports filed with the granting agencies for accuracy and completeness. Monthly reports should be properly signed and dated to indicate this review and timely filing of the reports. Additionally, the reports should be filed on the correct basis of accounting and only include expenses of the period for which they are filed.

#2022-006 – Material Weakness – Reporting – Schedule of Expenditures of Federal Awards Opioid STR Grant ALN 93.788 Block Grants for Prevention and Treatment of Substance Abuse 93.959 Criteria The Office of Management and Budget issuance of the Code of Federal Regulations (CFR) specifically states uniform administrative requirements, cost principles, and audit requirements for federal awards. In accordance with 45 CFR 75.302(b) “The financial management system of each non-Federal entity must provide for the following: (1) Identification, in its accounts, of all Federal awards received and expended and the Federal programs under which they were received. Federal program and Federal award identification must include, as applicable, the ALN title and number, Federal award identification number and year, name of the HHS awarding agency, and name of the pass-through entity, if any. **** (3) Records that identify adequately the source and application of funds for federally-funded activities. These records must contain information pertaining to Federal awards, authorizations, obligations, unobligated balances, assets, expenditures, income and interest and be supported by source documentation.” Condition The Organization designated an individual responsible to oversee Hamilton and Musser, PC’s preparation of the SEFA. The Organization has assumed responsibility for evaluating the completeness and accuracy of the SEFA. The expenses reported on the Schedule of Expenditure of Federal Awards (SEFA) are not properly supported by the Organization’s accounting records and supporting source documentation. Additionally, the SEFA does not necessarily include all Federal awards and expenditures of the Organization for the year ended December 31, 2022. Cause The Organization was unable to provide supporting documentation for all grants received and expenses charged to grants for the year ended December 31, 2022. Effect The effect of not maintaining proper documentation and providing a complete and accurate SEFA is the potential for under or over-reported amounts to the granting agencies. Questioned Costs None **** - Citations not pertinent to this finding. Perspective Information Summaries of the expenditures reported on the reports filed with the granting agencies were compared to total expenses recorded in the Organizations accounting records and to the grant agreements. Identification as a repeat finding A similar issue was noted in prior year finding #2021-006. Recommendation We recommend that the Organization begin to track revenues and expenses in the accounting system by source. The Organization should also develop a record keeping system to properly maintain grant documentation (agreements, receipts, invoices, etc.). This will provide more accurate data for the preparation and reconciliation of the SEFA.

#2022-007 – Significant Deficiency – Special Tests Criteria Uniform Guidance (UG) requires non-Federal entities that receive grant funding to have written policies in the following areas: Internal Controls (2 CFR 200.303) Travel (2 CFR 200.474) Financial Management and Accounting which includes Cash Management and Allowability (2CFR 200.302) Personnel Compensation – Time and Effort Reporting (2CFR 200.430(i)) Conflict of Interest/Disclosures (2CFR 200.318) Procurement (2CFR 200.319) Condition During the audit we noted that the Organization does not have written policies in place over these areas in accordance with UG. Cause The Organization was not aware of the requirement to have these written policies in place. Effect The potential effect of not having these policies in place is that the Organization’s expenses are not in accordance with UG. Questioned Costs None Perspective Information No policies or procedures were noted that are in accordance with UG. As a response to the prior year finding, the Organization noted that they will add policies to the fiscal manual for future compliance. Identification as a repeat finding A similar issue was noted in prior year finding #2021-007. Recommendation We recommend that the Organization update the fiscal manual to include policies that are compliant with UG.

#2022-001 – Material Weakness – Segregation of Duties Criteria A good internal control structure consists of proper segregation of duties where no one person is involved in all aspects of a given transaction. This includes proper segregation of the following functions: authorization of transactions, custody of assets, and recordkeeping. Condition During the course of the audit, we noted improper segregation of duties over cash disbursements, payroll, and cash receipts: Cash Disbursements: During the year ended December 31, 2022, one individual had full signing authority on checks written from the Organization’s accounts, and also had full access to the check stock. Additionally, this individual was the one who authorized and regularly paid the expenses. This normally included making payments by cash. During the year ended December 31, 2022, the Organization did not have an accounting system in place nor were bank reconciliations performed. Payroll: During our audit, we noted that there is no documented approval of the hourly wages or salaries that are entered into the payroll spreadsheet used to generate payroll. We reviewed multiple timesheets that did not include a supervisor’s approval. We also noted that there was no review of the completed payroll registers. Cash Receipts: During our audit, we noted that the same individual opens the mail and regularly makes the deposits which could result in a misappropriation of funds, without a second level of review and reconciliation procedures between the cash received and the deposits made. We also noted that there are no procedures in place to reconcile the grant billing to the general ledger and the cash log to the bank records. Cause The Organization was unprepared for the sudden growth experienced when its grant funding increased, and did not properly implement internal controls to process its daily transactions. Effect Without proper segregation of duties over cash disbursements and receipts, funds could be misappropriated without detection by management or the Board. A lack of proper segregation over payroll controls could result in ghost employees on the Organization’s payroll or overpayment of hours and rates due to the lack of review and approval. Questioned Costs NonePerspective Information During the audit we gained an understanding of the Organization’s internal controls through inquiry and observation and by examining one item from each of the three cycles: cash receipts, cash disbursements, and payroll. Identification as a repeat finding A similar issue was noted in prior year finding #2021-001. Recommendation We recommend that the Organization implement policies and procedures which ensure that no one individual is involved in all aspects of the cash receipts, disbursements and payroll processes. The Organization should review these processes and segregate duties as much as considered practical.

#2022-002 – Material Weakness – Allowable Costs/Cost Principles Opioid STR Grant ALN 93.788 Block Grants for Prevention and Treatment of Substance Abuse 93.959 Criteria The Office of Management and Budget issuance of the Code of Federal Regulations (CFR) specifically states uniform administrative requirements, cost principles, and audit requirements for federal awards. CFR 200.430 states, “Charges to Federal Awards for salaries and wages must be based on records that accurately reflect the work performed. These records must be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated.” Condition During the course of the audit, we noted that the Organization used an allocation methodology to allocate salaries to the federal award based upon time spent on the program. However, for 54 employee time periods, there were no timesheets to support the amount of time allocated to the Organization’s grant programs. Cause The cause is a lack of proper internal controls which would require the Organization to maintain adequate support for time spent on grant programs and a formal allocation process to allocate payroll costs across the grant programs. Effect The potential effects of not having supporting documentation for the allocation of payroll expenses is the overbilling of expenses to the grant program. Questioned Costs $397,499 Perspective Information We reviewed a sample of monthly reports filed with the Pennsylvania Department of Military and Veterans Affairs and the Drug and Alcohol Program. We examined the payroll for each employee charged to the grant for a total of twenty-six employees. The finding is related to multiple individuals who did not complete timesheets or provide supporting documentation for the amount of time spent on the Organization’s grant programs. Identification as a repeat finding A similar issue was noted in prior year finding #2021-002. Recommendation We recommend that the Organization require timesheets for the hours allocated to the grant programs for all employees whether they are salary or hourly to ensure that the payroll charged to grants is accurate and properly supported.

#2022-003 – Material Weakness – Activities Allowed or Unallowed Opioid STR Grant ALN 93.788 Block Grants for Prevention and Treatment of Substance Abuse 93.959 Criteria The Office of Management and Budget issuance of the Code of Federal Regulations (CFR) specifically states uniform administrative requirements, cost principles, and audit requirements for federal awards. In accordance with CFR 200.430, payroll costs charged to the program are allowable when: the total compensation paid to individual employees is reasonable according to the work performed on the program and the compensation is in accordance with the established policies of the organization. Condition During the audit we noted the Organization does not have established policies and procedures over payroll. We noted that while the Organization has established hourly and salary pay rates, these rates are not formally established and approved by the Organization’s Board. Cause The cause is a lack of a proper control structure that requires Board approval of pay rates and salaries. The Organization also does not have a process in place to ensure that payroll reports are properly reviewed and approved by a second independent reviewer prior to submission to the payroll company for processing. Effect The potential effects of not having formally approved pay rates and not having payroll reports reviewed by a second level prior to payroll processing is the potential for errors and overcharging of grants. Questioned Costs None Perspective Information We reviewed a sample of reports filed with the Pennsylvania Department of Military and Veterans Affairs and the Drug and Alcohol Program. We examined the payroll for each employee charged to the grants for a total of 284 samples. The finding represents the unsupported costs noted from this review. Identification as a repeat finding A similar issue was noted in prior year finding #2021-003. Recommendation We recommend that the Organization begin to formally establish and approve employee pay rates and salaries at Official Board Meetings and that these rates are documented in the Board Minutes. The Organization should also implement procedures to include a second level review of the payroll report for accuracy and completeness prior to submission for payment.

#2022-004 – Material Weakness – Activities Allowed or Unallowed, Reporting, Cash Management, Period of Performance Opioid STR Grant ALN 93.788 Block Grants for Prevention and Treatment of Substance Abuse 93.959 Criteria The Office of Management and Budget issuance of the Code of Federal Regulations (CFR) specifically states uniform administrative requirements, cost principles, and audit requirements for federal awards. In accordance with 45 CFR § 75.403, “Except where otherwise authorized by statute, costs must meet the following general criteria in order to be allowable under Federal awards: (a) be necessary and reasonable for the performance (b) Conform to any limitations or exclusions set forth in these principles or in the Federal award as to types or amount of cost items. **** (g) Be adequately documented.” Condition During the audit we noted the Organization reported the following expenses that were not supported by the accounting records or supporting documentation: For the monthly reports tested, we were unable to examine supporting invoices or supporting documentation for $31,721.92 of the $90,546.79 charges reviewed. Additionally, for these items, because invoices or other support was not available, we were unable to verify the service period and whether the expense was charged to the correct grant period. Cause The cause is a lack of a proper control structure that includes retention of all supporting documentation for expenses and proper tracking of expenses charged to the grant programs. Effect The potential effects are overbilling the grant program and unsupported charges. Questioned Costs $149,061 Perspective Information We reviewed a sample of reports filed with the Pennsylvania Department of Military and Veterans Affairs and the Drug and Alcohol Program. We examined the payroll for each employee charged to the grant for a total of twenty-six employees. We also tested nonpayroll related expenses charged to the grant. The finding represents the unsupported costs noted from this review. Identification as a repeat finding A similar issue was noted in prior year finding #2021-004. **** - Citations not pertinent to this finding. Recommendation We recommend that the Organization develop a system to track all expenses charged to each grant contract by month and systematically file all supporting documentation in a manner that can easily be accessed. This information must be retained in accordance with the Federal and grant guidelines. The monthly reports filed for the grants should be supported by the Organization’s accounting records and invoices. We further recommend that the Organization perform a reconciliation between the monthly reports and the accounting records.

#2022-005 – Material Weakness – Reporting Opioid STR Grant ALN 93.788 Block Grants for Prevention and Treatment of Substance Abuse 93.959 Criteria The Organization’s agreements with the Department of Military and Veterans Affairs (DMVA) requires the Organization to submit monthly progress reports no later than 13 business days after the end of each month. Per the agreements with the Drug and Alcohol Programs, "Unless otherwise specified elsewhere in this Grant Agreement, the following shall apply. Grantee shall submit monthly invoices within 30 days from the last day of the month within which the work is performed. The final invoice shall be submitted within 45 days of the Grant Agreement’s termination date. The Department will neither honor nor be liable for invoices not submitted in compliance with the time requirements in this paragraph unless the Department agrees to an extension of these requirements in writing. The Grantee shall be reimbursed only for services acceptable to the Department." Condition During the audit we were not able to obtain the monthly reports filed with the DMVA properly approved by management and there was no date to indicate that the reports were filed within the appropriate period required by the grant agreements. During our audit, we noted that the Organization reallocated expenses across budget line items without a formal budget modification or tracking of the reallocation. The reallocations were not properly documented and resulted in unsupported expenditures charged to the grant programs. Cause The Organization does not have proper internal controls which include the review and approval of monthly reports filed with granting agencies for accuracy and completeness. These policies and procedures should also ensure that all reports are filed within the timeframe in accordance with the grant contract. The Organization also lacks a formal process for budget modifications and tracking of related expense adjustments. Effect The potential effect of not having proper review and approval of monthly reports is the potential for errors in the reports that would be caught by an independent review and improper reporting to the granting agencies. Reports not submitted within the required timeframe may not be approved for reimbursement. Questioned Costs None Perspective Information We reviewed a sample of reports filed with the Drug and Alcohol Program. The finding represents errors noted in all reports reviewed. Identification as a repeat finding A similar issue was noted in prior year finding #2021-005. Recommendation We recommend that the Organization implement policies and procedures to include a second independent review of the monthly reports filed with the granting agencies for accuracy and completeness. Monthly reports should be properly signed and dated to indicate this review and timely filing of the reports. Additionally, the reports should be filed on the correct basis of accounting and only include expenses of the period for which they are filed.

#2022-006 – Material Weakness – Reporting – Schedule of Expenditures of Federal Awards Opioid STR Grant ALN 93.788 Block Grants for Prevention and Treatment of Substance Abuse 93.959 Criteria The Office of Management and Budget issuance of the Code of Federal Regulations (CFR) specifically states uniform administrative requirements, cost principles, and audit requirements for federal awards. In accordance with 45 CFR 75.302(b) “The financial management system of each non-Federal entity must provide for the following: (1) Identification, in its accounts, of all Federal awards received and expended and the Federal programs under which they were received. Federal program and Federal award identification must include, as applicable, the ALN title and number, Federal award identification number and year, name of the HHS awarding agency, and name of the pass-through entity, if any. **** (3) Records that identify adequately the source and application of funds for federally-funded activities. These records must contain information pertaining to Federal awards, authorizations, obligations, unobligated balances, assets, expenditures, income and interest and be supported by source documentation.” Condition The Organization designated an individual responsible to oversee Hamilton and Musser, PC’s preparation of the SEFA. The Organization has assumed responsibility for evaluating the completeness and accuracy of the SEFA. The expenses reported on the Schedule of Expenditure of Federal Awards (SEFA) are not properly supported by the Organization’s accounting records and supporting source documentation. Additionally, the SEFA does not necessarily include all Federal awards and expenditures of the Organization for the year ended December 31, 2022. Cause The Organization was unable to provide supporting documentation for all grants received and expenses charged to grants for the year ended December 31, 2022. Effect The effect of not maintaining proper documentation and providing a complete and accurate SEFA is the potential for under or over-reported amounts to the granting agencies. Questioned Costs None **** - Citations not pertinent to this finding. Perspective Information Summaries of the expenditures reported on the reports filed with the granting agencies were compared to total expenses recorded in the Organizations accounting records and to the grant agreements. Identification as a repeat finding A similar issue was noted in prior year finding #2021-006. Recommendation We recommend that the Organization begin to track revenues and expenses in the accounting system by source. The Organization should also develop a record keeping system to properly maintain grant documentation (agreements, receipts, invoices, etc.). This will provide more accurate data for the preparation and reconciliation of the SEFA.

#2022-007 – Significant Deficiency – Special Tests Criteria Uniform Guidance (UG) requires non-Federal entities that receive grant funding to have written policies in the following areas: Internal Controls (2 CFR 200.303) Travel (2 CFR 200.474) Financial Management and Accounting which includes Cash Management and Allowability (2CFR 200.302) Personnel Compensation – Time and Effort Reporting (2CFR 200.430(i)) Conflict of Interest/Disclosures (2CFR 200.318) Procurement (2CFR 200.319) Condition During the audit we noted that the Organization does not have written policies in place over these areas in accordance with UG. Cause The Organization was not aware of the requirement to have these written policies in place. Effect The potential effect of not having these policies in place is that the Organization’s expenses are not in accordance with UG. Questioned Costs None Perspective Information No policies or procedures were noted that are in accordance with UG. As a response to the prior year finding, the Organization noted that they will add policies to the fiscal manual for future compliance. Identification as a repeat finding A similar issue was noted in prior year finding #2021-007. Recommendation We recommend that the Organization update the fiscal manual to include policies that are compliant with UG.

#2022-001 – Material Weakness – Segregation of Duties Criteria A good internal control structure consists of proper segregation of duties where no one person is involved in all aspects of a given transaction. This includes proper segregation of the following functions: authorization of transactions, custody of assets, and recordkeeping. Condition During the course of the audit, we noted improper segregation of duties over cash disbursements, payroll, and cash receipts: Cash Disbursements: During the year ended December 31, 2022, one individual had full signing authority on checks written from the Organization’s accounts, and also had full access to the check stock. Additionally, this individual was the one who authorized and regularly paid the expenses. This normally included making payments by cash. During the year ended December 31, 2022, the Organization did not have an accounting system in place nor were bank reconciliations performed. Payroll: During our audit, we noted that there is no documented approval of the hourly wages or salaries that are entered into the payroll spreadsheet used to generate payroll. We reviewed multiple timesheets that did not include a supervisor’s approval. We also noted that there was no review of the completed payroll registers. Cash Receipts: During our audit, we noted that the same individual opens the mail and regularly makes the deposits which could result in a misappropriation of funds, without a second level of review and reconciliation procedures between the cash received and the deposits made. We also noted that there are no procedures in place to reconcile the grant billing to the general ledger and the cash log to the bank records. Cause The Organization was unprepared for the sudden growth experienced when its grant funding increased, and did not properly implement internal controls to process its daily transactions. Effect Without proper segregation of duties over cash disbursements and receipts, funds could be misappropriated without detection by management or the Board. A lack of proper segregation over payroll controls could result in ghost employees on the Organization’s payroll or overpayment of hours and rates due to the lack of review and approval. Questioned Costs NonePerspective Information During the audit we gained an understanding of the Organization’s internal controls through inquiry and observation and by examining one item from each of the three cycles: cash receipts, cash disbursements, and payroll. Identification as a repeat finding A similar issue was noted in prior year finding #2021-001. Recommendation We recommend that the Organization implement policies and procedures which ensure that no one individual is involved in all aspects of the cash receipts, disbursements and payroll processes. The Organization should review these processes and segregate duties as much as considered practical.

#2022-002 – Material Weakness – Allowable Costs/Cost Principles Opioid STR Grant ALN 93.788 Block Grants for Prevention and Treatment of Substance Abuse 93.959 Criteria The Office of Management and Budget issuance of the Code of Federal Regulations (CFR) specifically states uniform administrative requirements, cost principles, and audit requirements for federal awards. CFR 200.430 states, “Charges to Federal Awards for salaries and wages must be based on records that accurately reflect the work performed. These records must be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated.” Condition During the course of the audit, we noted that the Organization used an allocation methodology to allocate salaries to the federal award based upon time spent on the program. However, for 54 employee time periods, there were no timesheets to support the amount of time allocated to the Organization’s grant programs. Cause The cause is a lack of proper internal controls which would require the Organization to maintain adequate support for time spent on grant programs and a formal allocation process to allocate payroll costs across the grant programs. Effect The potential effects of not having supporting documentation for the allocation of payroll expenses is the overbilling of expenses to the grant program. Questioned Costs $397,499 Perspective Information We reviewed a sample of monthly reports filed with the Pennsylvania Department of Military and Veterans Affairs and the Drug and Alcohol Program. We examined the payroll for each employee charged to the grant for a total of twenty-six employees. The finding is related to multiple individuals who did not complete timesheets or provide supporting documentation for the amount of time spent on the Organization’s grant programs. Identification as a repeat finding A similar issue was noted in prior year finding #2021-002. Recommendation We recommend that the Organization require timesheets for the hours allocated to the grant programs for all employees whether they are salary or hourly to ensure that the payroll charged to grants is accurate and properly supported.

#2022-003 – Material Weakness – Activities Allowed or Unallowed Opioid STR Grant ALN 93.788 Block Grants for Prevention and Treatment of Substance Abuse 93.959 Criteria The Office of Management and Budget issuance of the Code of Federal Regulations (CFR) specifically states uniform administrative requirements, cost principles, and audit requirements for federal awards. In accordance with CFR 200.430, payroll costs charged to the program are allowable when: the total compensation paid to individual employees is reasonable according to the work performed on the program and the compensation is in accordance with the established policies of the organization. Condition During the audit we noted the Organization does not have established policies and procedures over payroll. We noted that while the Organization has established hourly and salary pay rates, these rates are not formally established and approved by the Organization’s Board. Cause The cause is a lack of a proper control structure that requires Board approval of pay rates and salaries. The Organization also does not have a process in place to ensure that payroll reports are properly reviewed and approved by a second independent reviewer prior to submission to the payroll company for processing. Effect The potential effects of not having formally approved pay rates and not having payroll reports reviewed by a second level prior to payroll processing is the potential for errors and overcharging of grants. Questioned Costs None Perspective Information We reviewed a sample of reports filed with the Pennsylvania Department of Military and Veterans Affairs and the Drug and Alcohol Program. We examined the payroll for each employee charged to the grants for a total of 284 samples. The finding represents the unsupported costs noted from this review. Identification as a repeat finding A similar issue was noted in prior year finding #2021-003. Recommendation We recommend that the Organization begin to formally establish and approve employee pay rates and salaries at Official Board Meetings and that these rates are documented in the Board Minutes. The Organization should also implement procedures to include a second level review of the payroll report for accuracy and completeness prior to submission for payment.

#2022-004 – Material Weakness – Activities Allowed or Unallowed, Reporting, Cash Management, Period of Performance Opioid STR Grant ALN 93.788 Block Grants for Prevention and Treatment of Substance Abuse 93.959 Criteria The Office of Management and Budget issuance of the Code of Federal Regulations (CFR) specifically states uniform administrative requirements, cost principles, and audit requirements for federal awards. In accordance with 45 CFR § 75.403, “Except where otherwise authorized by statute, costs must meet the following general criteria in order to be allowable under Federal awards: (a) be necessary and reasonable for the performance (b) Conform to any limitations or exclusions set forth in these principles or in the Federal award as to types or amount of cost items. **** (g) Be adequately documented.” Condition During the audit we noted the Organization reported the following expenses that were not supported by the accounting records or supporting documentation: For the monthly reports tested, we were unable to examine supporting invoices or supporting documentation for $31,721.92 of the $90,546.79 charges reviewed. Additionally, for these items, because invoices or other support was not available, we were unable to verify the service period and whether the expense was charged to the correct grant period. Cause The cause is a lack of a proper control structure that includes retention of all supporting documentation for expenses and proper tracking of expenses charged to the grant programs. Effect The potential effects are overbilling the grant program and unsupported charges. Questioned Costs $149,061 Perspective Information We reviewed a sample of reports filed with the Pennsylvania Department of Military and Veterans Affairs and the Drug and Alcohol Program. We examined the payroll for each employee charged to the grant for a total of twenty-six employees. We also tested nonpayroll related expenses charged to the grant. The finding represents the unsupported costs noted from this review. Identification as a repeat finding A similar issue was noted in prior year finding #2021-004. **** - Citations not pertinent to this finding. Recommendation We recommend that the Organization develop a system to track all expenses charged to each grant contract by month and systematically file all supporting documentation in a manner that can easily be accessed. This information must be retained in accordance with the Federal and grant guidelines. The monthly reports filed for the grants should be supported by the Organization’s accounting records and invoices. We further recommend that the Organization perform a reconciliation between the monthly reports and the accounting records.

#2022-005 – Material Weakness – Reporting Opioid STR Grant ALN 93.788 Block Grants for Prevention and Treatment of Substance Abuse 93.959 Criteria The Organization’s agreements with the Department of Military and Veterans Affairs (DMVA) requires the Organization to submit monthly progress reports no later than 13 business days after the end of each month. Per the agreements with the Drug and Alcohol Programs, "Unless otherwise specified elsewhere in this Grant Agreement, the following shall apply. Grantee shall submit monthly invoices within 30 days from the last day of the month within which the work is performed. The final invoice shall be submitted within 45 days of the Grant Agreement’s termination date. The Department will neither honor nor be liable for invoices not submitted in compliance with the time requirements in this paragraph unless the Department agrees to an extension of these requirements in writing. The Grantee shall be reimbursed only for services acceptable to the Department." Condition During the audit we were not able to obtain the monthly reports filed with the DMVA properly approved by management and there was no date to indicate that the reports were filed within the appropriate period required by the grant agreements. During our audit, we noted that the Organization reallocated expenses across budget line items without a formal budget modification or tracking of the reallocation. The reallocations were not properly documented and resulted in unsupported expenditures charged to the grant programs. Cause The Organization does not have proper internal controls which include the review and approval of monthly reports filed with granting agencies for accuracy and completeness. These policies and procedures should also ensure that all reports are filed within the timeframe in accordance with the grant contract. The Organization also lacks a formal process for budget modifications and tracking of related expense adjustments. Effect The potential effect of not having proper review and approval of monthly reports is the potential for errors in the reports that would be caught by an independent review and improper reporting to the granting agencies. Reports not submitted within the required timeframe may not be approved for reimbursement. Questioned Costs None Perspective Information We reviewed a sample of reports filed with the Drug and Alcohol Program. The finding represents errors noted in all reports reviewed. Identification as a repeat finding A similar issue was noted in prior year finding #2021-005. Recommendation We recommend that the Organization implement policies and procedures to include a second independent review of the monthly reports filed with the granting agencies for accuracy and completeness. Monthly reports should be properly signed and dated to indicate this review and timely filing of the reports. Additionally, the reports should be filed on the correct basis of accounting and only include expenses of the period for which they are filed.

#2022-006 – Material Weakness – Reporting – Schedule of Expenditures of Federal Awards Opioid STR Grant ALN 93.788 Block Grants for Prevention and Treatment of Substance Abuse 93.959 Criteria The Office of Management and Budget issuance of the Code of Federal Regulations (CFR) specifically states uniform administrative requirements, cost principles, and audit requirements for federal awards. In accordance with 45 CFR 75.302(b) “The financial management system of each non-Federal entity must provide for the following: (1) Identification, in its accounts, of all Federal awards received and expended and the Federal programs under which they were received. Federal program and Federal award identification must include, as applicable, the ALN title and number, Federal award identification number and year, name of the HHS awarding agency, and name of the pass-through entity, if any. **** (3) Records that identify adequately the source and application of funds for federally-funded activities. These records must contain information pertaining to Federal awards, authorizations, obligations, unobligated balances, assets, expenditures, income and interest and be supported by source documentation.” Condition The Organization designated an individual responsible to oversee Hamilton and Musser, PC’s preparation of the SEFA. The Organization has assumed responsibility for evaluating the completeness and accuracy of the SEFA. The expenses reported on the Schedule of Expenditure of Federal Awards (SEFA) are not properly supported by the Organization’s accounting records and supporting source documentation. Additionally, the SEFA does not necessarily include all Federal awards and expenditures of the Organization for the year ended December 31, 2022. Cause The Organization was unable to provide supporting documentation for all grants received and expenses charged to grants for the year ended December 31, 2022. Effect The effect of not maintaining proper documentation and providing a complete and accurate SEFA is the potential for under or over-reported amounts to the granting agencies. Questioned Costs None **** - Citations not pertinent to this finding. Perspective Information Summaries of the expenditures reported on the reports filed with the granting agencies were compared to total expenses recorded in the Organizations accounting records and to the grant agreements. Identification as a repeat finding A similar issue was noted in prior year finding #2021-006. Recommendation We recommend that the Organization begin to track revenues and expenses in the accounting system by source. The Organization should also develop a record keeping system to properly maintain grant documentation (agreements, receipts, invoices, etc.). This will provide more accurate data for the preparation and reconciliation of the SEFA.

#2022-007 – Significant Deficiency – Special Tests Criteria Uniform Guidance (UG) requires non-Federal entities that receive grant funding to have written policies in the following areas: Internal Controls (2 CFR 200.303) Travel (2 CFR 200.474) Financial Management and Accounting which includes Cash Management and Allowability (2CFR 200.302) Personnel Compensation – Time and Effort Reporting (2CFR 200.430(i)) Conflict of Interest/Disclosures (2CFR 200.318) Procurement (2CFR 200.319) Condition During the audit we noted that the Organization does not have written policies in place over these areas in accordance with UG. Cause The Organization was not aware of the requirement to have these written policies in place. Effect The potential effect of not having these policies in place is that the Organization’s expenses are not in accordance with UG. Questioned Costs None Perspective Information No policies or procedures were noted that are in accordance with UG. As a response to the prior year finding, the Organization noted that they will add policies to the fiscal manual for future compliance. Identification as a repeat finding A similar issue was noted in prior year finding #2021-007. Recommendation We recommend that the Organization update the fiscal manual to include policies that are compliant with UG.

#2022-001 – Material Weakness – Segregation of Duties Criteria A good internal control structure consists of proper segregation of duties where no one person is involved in all aspects of a given transaction. This includes proper segregation of the following functions: authorization of transactions, custody of assets, and recordkeeping. Condition During the course of the audit, we noted improper segregation of duties over cash disbursements, payroll, and cash receipts: Cash Disbursements: During the year ended December 31, 2022, one individual had full signing authority on checks written from the Organization’s accounts, and also had full access to the check stock. Additionally, this individual was the one who authorized and regularly paid the expenses. This normally included making payments by cash. During the year ended December 31, 2022, the Organization did not have an accounting system in place nor were bank reconciliations performed. Payroll: During our audit, we noted that there is no documented approval of the hourly wages or salaries that are entered into the payroll spreadsheet used to generate payroll. We reviewed multiple timesheets that did not include a supervisor’s approval. We also noted that there was no review of the completed payroll registers. Cash Receipts: During our audit, we noted that the same individual opens the mail and regularly makes the deposits which could result in a misappropriation of funds, without a second level of review and reconciliation procedures between the cash received and the deposits made. We also noted that there are no procedures in place to reconcile the grant billing to the general ledger and the cash log to the bank records. Cause The Organization was unprepared for the sudden growth experienced when its grant funding increased, and did not properly implement internal controls to process its daily transactions. Effect Without proper segregation of duties over cash disbursements and receipts, funds could be misappropriated without detection by management or the Board. A lack of proper segregation over payroll controls could result in ghost employees on the Organization’s payroll or overpayment of hours and rates due to the lack of review and approval. Questioned Costs NonePerspective Information During the audit we gained an understanding of the Organization’s internal controls through inquiry and observation and by examining one item from each of the three cycles: cash receipts, cash disbursements, and payroll. Identification as a repeat finding A similar issue was noted in prior year finding #2021-001. Recommendation We recommend that the Organization implement policies and procedures which ensure that no one individual is involved in all aspects of the cash receipts, disbursements and payroll processes. The Organization should review these processes and segregate duties as much as considered practical.

#2022-002 – Material Weakness – Allowable Costs/Cost Principles Opioid STR Grant ALN 93.788 Block Grants for Prevention and Treatment of Substance Abuse 93.959 Criteria The Office of Management and Budget issuance of the Code of Federal Regulations (CFR) specifically states uniform administrative requirements, cost principles, and audit requirements for federal awards. CFR 200.430 states, “Charges to Federal Awards for salaries and wages must be based on records that accurately reflect the work performed. These records must be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated.” Condition During the course of the audit, we noted that the Organization used an allocation methodology to allocate salaries to the federal award based upon time spent on the program. However, for 54 employee time periods, there were no timesheets to support the amount of time allocated to the Organization’s grant programs. Cause The cause is a lack of proper internal controls which would require the Organization to maintain adequate support for time spent on grant programs and a formal allocation process to allocate payroll costs across the grant programs. Effect The potential effects of not having supporting documentation for the allocation of payroll expenses is the overbilling of expenses to the grant program. Questioned Costs $397,499 Perspective Information We reviewed a sample of monthly reports filed with the Pennsylvania Department of Military and Veterans Affairs and the Drug and Alcohol Program. We examined the payroll for each employee charged to the grant for a total of twenty-six employees. The finding is related to multiple individuals who did not complete timesheets or provide supporting documentation for the amount of time spent on the Organization’s grant programs. Identification as a repeat finding A similar issue was noted in prior year finding #2021-002. Recommendation We recommend that the Organization require timesheets for the hours allocated to the grant programs for all employees whether they are salary or hourly to ensure that the payroll charged to grants is accurate and properly supported.

#2022-003 – Material Weakness – Activities Allowed or Unallowed Opioid STR Grant ALN 93.788 Block Grants for Prevention and Treatment of Substance Abuse 93.959 Criteria The Office of Management and Budget issuance of the Code of Federal Regulations (CFR) specifically states uniform administrative requirements, cost principles, and audit requirements for federal awards. In accordance with CFR 200.430, payroll costs charged to the program are allowable when: the total compensation paid to individual employees is reasonable according to the work performed on the program and the compensation is in accordance with the established policies of the organization. Condition During the audit we noted the Organization does not have established policies and procedures over payroll. We noted that while the Organization has established hourly and salary pay rates, these rates are not formally established and approved by the Organization’s Board. Cause The cause is a lack of a proper control structure that requires Board approval of pay rates and salaries. The Organization also does not have a process in place to ensure that payroll reports are properly reviewed and approved by a second independent reviewer prior to submission to the payroll company for processing. Effect The potential effects of not having formally approved pay rates and not having payroll reports reviewed by a second level prior to payroll processing is the potential for errors and overcharging of grants. Questioned Costs None Perspective Information We reviewed a sample of reports filed with the Pennsylvania Department of Military and Veterans Affairs and the Drug and Alcohol Program. We examined the payroll for each employee charged to the grants for a total of 284 samples. The finding represents the unsupported costs noted from this review. Identification as a repeat finding A similar issue was noted in prior year finding #2021-003. Recommendation We recommend that the Organization begin to formally establish and approve employee pay rates and salaries at Official Board Meetings and that these rates are documented in the Board Minutes. The Organization should also implement procedures to include a second level review of the payroll report for accuracy and completeness prior to submission for payment.

#2022-004 – Material Weakness – Activities Allowed or Unallowed, Reporting, Cash Management, Period of Performance Opioid STR Grant ALN 93.788 Block Grants for Prevention and Treatment of Substance Abuse 93.959 Criteria The Office of Management and Budget issuance of the Code of Federal Regulations (CFR) specifically states uniform administrative requirements, cost principles, and audit requirements for federal awards. In accordance with 45 CFR § 75.403, “Except where otherwise authorized by statute, costs must meet the following general criteria in order to be allowable under Federal awards: (a) be necessary and reasonable for the performance (b) Conform to any limitations or exclusions set forth in these principles or in the Federal award as to types or amount of cost items. **** (g) Be adequately documented.” Condition During the audit we noted the Organization reported the following expenses that were not supported by the accounting records or supporting documentation: For the monthly reports tested, we were unable to examine supporting invoices or supporting documentation for $31,721.92 of the $90,546.79 charges reviewed. Additionally, for these items, because invoices or other support was not available, we were unable to verify the service period and whether the expense was charged to the correct grant period. Cause The cause is a lack of a proper control structure that includes retention of all supporting documentation for expenses and proper tracking of expenses charged to the grant programs. Effect The potential effects are overbilling the grant program and unsupported charges. Questioned Costs $149,061 Perspective Information We reviewed a sample of reports filed with the Pennsylvania Department of Military and Veterans Affairs and the Drug and Alcohol Program. We examined the payroll for each employee charged to the grant for a total of twenty-six employees. We also tested nonpayroll related expenses charged to the grant. The finding represents the unsupported costs noted from this review. Identification as a repeat finding A similar issue was noted in prior year finding #2021-004. **** - Citations not pertinent to this finding. Recommendation We recommend that the Organization develop a system to track all expenses charged to each grant contract by month and systematically file all supporting documentation in a manner that can easily be accessed. This information must be retained in accordance with the Federal and grant guidelines. The monthly reports filed for the grants should be supported by the Organization’s accounting records and invoices. We further recommend that the Organization perform a reconciliation between the monthly reports and the accounting records.

#2022-005 – Material Weakness – Reporting Opioid STR Grant ALN 93.788 Block Grants for Prevention and Treatment of Substance Abuse 93.959 Criteria The Organization’s agreements with the Department of Military and Veterans Affairs (DMVA) requires the Organization to submit monthly progress reports no later than 13 business days after the end of each month. Per the agreements with the Drug and Alcohol Programs, "Unless otherwise specified elsewhere in this Grant Agreement, the following shall apply. Grantee shall submit monthly invoices within 30 days from the last day of the month within which the work is performed. The final invoice shall be submitted within 45 days of the Grant Agreement’s termination date. The Department will neither honor nor be liable for invoices not submitted in compliance with the time requirements in this paragraph unless the Department agrees to an extension of these requirements in writing. The Grantee shall be reimbursed only for services acceptable to the Department." Condition During the audit we were not able to obtain the monthly reports filed with the DMVA properly approved by management and there was no date to indicate that the reports were filed within the appropriate period required by the grant agreements. During our audit, we noted that the Organization reallocated expenses across budget line items without a formal budget modification or tracking of the reallocation. The reallocations were not properly documented and resulted in unsupported expenditures charged to the grant programs. Cause The Organization does not have proper internal controls which include the review and approval of monthly reports filed with granting agencies for accuracy and completeness. These policies and procedures should also ensure that all reports are filed within the timeframe in accordance with the grant contract. The Organization also lacks a formal process for budget modifications and tracking of related expense adjustments. Effect The potential effect of not having proper review and approval of monthly reports is the potential for errors in the reports that would be caught by an independent review and improper reporting to the granting agencies. Reports not submitted within the required timeframe may not be approved for reimbursement. Questioned Costs None Perspective Information We reviewed a sample of reports filed with the Drug and Alcohol Program. The finding represents errors noted in all reports reviewed. Identification as a repeat finding A similar issue was noted in prior year finding #2021-005. Recommendation We recommend that the Organization implement policies and procedures to include a second independent review of the monthly reports filed with the granting agencies for accuracy and completeness. Monthly reports should be properly signed and dated to indicate this review and timely filing of the reports. Additionally, the reports should be filed on the correct basis of accounting and only include expenses of the period for which they are filed.

#2022-006 – Material Weakness – Reporting – Schedule of Expenditures of Federal Awards Opioid STR Grant ALN 93.788 Block Grants for Prevention and Treatment of Substance Abuse 93.959 Criteria The Office of Management and Budget issuance of the Code of Federal Regulations (CFR) specifically states uniform administrative requirements, cost principles, and audit requirements for federal awards. In accordance with 45 CFR 75.302(b) “The financial management system of each non-Federal entity must provide for the following: (1) Identification, in its accounts, of all Federal awards received and expended and the Federal programs under which they were received. Federal program and Federal award identification must include, as applicable, the ALN title and number, Federal award identification number and year, name of the HHS awarding agency, and name of the pass-through entity, if any. **** (3) Records that identify adequately the source and application of funds for federally-funded activities. These records must contain information pertaining to Federal awards, authorizations, obligations, unobligated balances, assets, expenditures, income and interest and be supported by source documentation.” Condition The Organization designated an individual responsible to oversee Hamilton and Musser, PC’s preparation of the SEFA. The Organization has assumed responsibility for evaluating the completeness and accuracy of the SEFA. The expenses reported on the Schedule of Expenditure of Federal Awards (SEFA) are not properly supported by the Organization’s accounting records and supporting source documentation. Additionally, the SEFA does not necessarily include all Federal awards and expenditures of the Organization for the year ended December 31, 2022. Cause The Organization was unable to provide supporting documentation for all grants received and expenses charged to grants for the year ended December 31, 2022. Effect The effect of not maintaining proper documentation and providing a complete and accurate SEFA is the potential for under or over-reported amounts to the granting agencies. Questioned Costs None **** - Citations not pertinent to this finding. Perspective Information Summaries of the expenditures reported on the reports filed with the granting agencies were compared to total expenses recorded in the Organizations accounting records and to the grant agreements. Identification as a repeat finding A similar issue was noted in prior year finding #2021-006. Recommendation We recommend that the Organization begin to track revenues and expenses in the accounting system by source. The Organization should also develop a record keeping system to properly maintain grant documentation (agreements, receipts, invoices, etc.). This will provide more accurate data for the preparation and reconciliation of the SEFA.

#2022-007 – Significant Deficiency – Special Tests Criteria Uniform Guidance (UG) requires non-Federal entities that receive grant funding to have written policies in the following areas: Internal Controls (2 CFR 200.303) Travel (2 CFR 200.474) Financial Management and Accounting which includes Cash Management and Allowability (2CFR 200.302) Personnel Compensation – Time and Effort Reporting (2CFR 200.430(i)) Conflict of Interest/Disclosures (2CFR 200.318) Procurement (2CFR 200.319) Condition During the audit we noted that the Organization does not have written policies in place over these areas in accordance with UG. Cause The Organization was not aware of the requirement to have these written policies in place. Effect The potential effect of not having these policies in place is that the Organization’s expenses are not in accordance with UG. Questioned Costs None Perspective Information No policies or procedures were noted that are in accordance with UG. As a response to the prior year finding, the Organization noted that they will add policies to the fiscal manual for future compliance. Identification as a repeat finding A similar issue was noted in prior year finding #2021-007. Recommendation We recommend that the Organization update the fiscal manual to include policies that are compliant with UG.