Audit 353697

Finding 2024-002 Material Weakness in Internal Control Over Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Cash Management, Period of Performance and Reporting Assistance Listing Numbers 93.958 Block Grants for Community Mental Health Services 93.959 Block Grants for Prevention and Treatment Substance Abuse 93.696 Certified Community Behavioral Health Clinic (CCBHC) – Planning, Development, and Implementation Grants Federal Agency U.S. Department of Health and Human Services Passthrough Agency Illinois Department of Human Services Award Number/Year 2024 Criteria The Organization is responsible for keeping an accurate accounting of all federal expenditures and maintaining all of the required documentation and reports in accordance with applicable federal regulations. Condition For AL No. 93.958, Block Grants for Community Mental Health Services Program, a sample of twenty-nine (29) payroll expense and fringe benefits transactions were tested for Activities Allowed or Unallowed, Allowable Costs/Cost Principles and Period of Performance. For AL No. 93.959, Block Grants for Prevention and Treatment of Substance Abuse Program, a sample of thirty (30) payroll expense and fringe benefits transactions were tested for Activities Allowed or Unallowed, Allowable Costs/Cost Principles and Period of Performance. For AL No. 93.696, Certified Community Behavioral Health Clinic (CCBHC) – Planning, Development, and Implementation Grants Program, a sample of forty-four (44) payroll expense and fringe benefits transactions were tested for Activities Allowed or Unallowed, Allowable Costs/Cost Principles and Period of Performance. The Organization was not able to provide sufficient evidence of review and approval of employee salaries and wages charged to these grants. We did note that the payroll and fringe benefit expense transactions tested matched the appropriate vouchers for reimbursement and related supporting documentation of payroll expense and fringe benefits. It was also noted that one person prepared, reviewed and submitted all vouchers and reports which is an indication of improper segregation of duties. Cause The Organization did not follow its established policies and procedures regarding documentation of the time sheets or time studies supporting the allocation of salaries and fringe benefits for each employee charged to grants. Additionally, there was no support in each employee file regarding a merit increase provided in December 2023 for all employees. Effect The Organization is not in compliance with the Activities Allowed or Unallowed, Allowable Costs/Cost Principles, and Period of Performance requirements of its grant agreements within its federally funded programs as prescribed by Uniform Guidance. Questioned Costs None noted. Repeat Finding Yes Recommendation We recommend that the Organization implement the following corrective actions: • Enforce its current specific internal control procedures to ensure compliance with applicable federal regulations. • Require that all personnel files have authorization and approval of current pay rates along with correspondence regarding to which grant an employee’s salary and fringe benefits should be expensed including any allocations if the employee worked on several grants. • Require that all vouchers and reports be prepared by one individual and independently reviewed and approved by a second individual prior to submission. There should be documentation of the review such as a sign-off or initials. • Require that all vouchers and reports be filed timely in accordance with the various grant agreements. • Require that correspondence be received from those agencies indicating that required reports per the written grant agreements are not necessary when applicable. • Ensure that the data collection form is filed the earlier of thirty (30) days after the report date or no later than nine (9) months after the fiscal year-end. Views of Responsible Officials and Planned Corrective Actions See corrective action plan.

Finding 2024-002 Material Weakness in Internal Control Over Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Cash Management, Period of Performance and Reporting Assistance Listing Numbers 93.958 Block Grants for Community Mental Health Services 93.959 Block Grants for Prevention and Treatment Substance Abuse 93.696 Certified Community Behavioral Health Clinic (CCBHC) – Planning, Development, and Implementation Grants Federal Agency U.S. Department of Health and Human Services Passthrough Agency Illinois Department of Human Services Award Number/Year 2024 Criteria The Organization is responsible for keeping an accurate accounting of all federal expenditures and maintaining all of the required documentation and reports in accordance with applicable federal regulations. Condition For AL No. 93.958, Block Grants for Community Mental Health Services Program, a sample of twenty-nine (29) payroll expense and fringe benefits transactions were tested for Activities Allowed or Unallowed, Allowable Costs/Cost Principles and Period of Performance. For AL No. 93.959, Block Grants for Prevention and Treatment of Substance Abuse Program, a sample of thirty (30) payroll expense and fringe benefits transactions were tested for Activities Allowed or Unallowed, Allowable Costs/Cost Principles and Period of Performance. For AL No. 93.696, Certified Community Behavioral Health Clinic (CCBHC) – Planning, Development, and Implementation Grants Program, a sample of forty-four (44) payroll expense and fringe benefits transactions were tested for Activities Allowed or Unallowed, Allowable Costs/Cost Principles and Period of Performance. The Organization was not able to provide sufficient evidence of review and approval of employee salaries and wages charged to these grants. We did note that the payroll and fringe benefit expense transactions tested matched the appropriate vouchers for reimbursement and related supporting documentation of payroll expense and fringe benefits. It was also noted that one person prepared, reviewed and submitted all vouchers and reports which is an indication of improper segregation of duties. Cause The Organization did not follow its established policies and procedures regarding documentation of the time sheets or time studies supporting the allocation of salaries and fringe benefits for each employee charged to grants. Additionally, there was no support in each employee file regarding a merit increase provided in December 2023 for all employees. Effect The Organization is not in compliance with the Activities Allowed or Unallowed, Allowable Costs/Cost Principles, and Period of Performance requirements of its grant agreements within its federally funded programs as prescribed by Uniform Guidance. Questioned Costs None noted. Repeat Finding Yes Recommendation We recommend that the Organization implement the following corrective actions: • Enforce its current specific internal control procedures to ensure compliance with applicable federal regulations. • Require that all personnel files have authorization and approval of current pay rates along with correspondence regarding to which grant an employee’s salary and fringe benefits should be expensed including any allocations if the employee worked on several grants. • Require that all vouchers and reports be prepared by one individual and independently reviewed and approved by a second individual prior to submission. There should be documentation of the review such as a sign-off or initials. • Require that all vouchers and reports be filed timely in accordance with the various grant agreements. • Require that correspondence be received from those agencies indicating that required reports per the written grant agreements are not necessary when applicable. • Ensure that the data collection form is filed the earlier of thirty (30) days after the report date or no later than nine (9) months after the fiscal year-end. Views of Responsible Officials and Planned Corrective Actions See corrective action plan.

Finding 2024-002 Material Weakness in Internal Control Over Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Cash Management, Period of Performance and Reporting Assistance Listing Numbers 93.958 Block Grants for Community Mental Health Services 93.959 Block Grants for Prevention and Treatment Substance Abuse 93.696 Certified Community Behavioral Health Clinic (CCBHC) – Planning, Development, and Implementation Grants Federal Agency U.S. Department of Health and Human Services Passthrough Agency Illinois Department of Human Services Award Number/Year 2024 Criteria The Organization is responsible for keeping an accurate accounting of all federal expenditures and maintaining all of the required documentation and reports in accordance with applicable federal regulations. Condition For AL No. 93.958, Block Grants for Community Mental Health Services Program, a sample of twenty-nine (29) payroll expense and fringe benefits transactions were tested for Activities Allowed or Unallowed, Allowable Costs/Cost Principles and Period of Performance. For AL No. 93.959, Block Grants for Prevention and Treatment of Substance Abuse Program, a sample of thirty (30) payroll expense and fringe benefits transactions were tested for Activities Allowed or Unallowed, Allowable Costs/Cost Principles and Period of Performance. For AL No. 93.696, Certified Community Behavioral Health Clinic (CCBHC) – Planning, Development, and Implementation Grants Program, a sample of forty-four (44) payroll expense and fringe benefits transactions were tested for Activities Allowed or Unallowed, Allowable Costs/Cost Principles and Period of Performance. The Organization was not able to provide sufficient evidence of review and approval of employee salaries and wages charged to these grants. We did note that the payroll and fringe benefit expense transactions tested matched the appropriate vouchers for reimbursement and related supporting documentation of payroll expense and fringe benefits. It was also noted that one person prepared, reviewed and submitted all vouchers and reports which is an indication of improper segregation of duties. Cause The Organization did not follow its established policies and procedures regarding documentation of the time sheets or time studies supporting the allocation of salaries and fringe benefits for each employee charged to grants. Additionally, there was no support in each employee file regarding a merit increase provided in December 2023 for all employees. Effect The Organization is not in compliance with the Activities Allowed or Unallowed, Allowable Costs/Cost Principles, and Period of Performance requirements of its grant agreements within its federally funded programs as prescribed by Uniform Guidance. Questioned Costs None noted. Repeat Finding Yes Recommendation We recommend that the Organization implement the following corrective actions: • Enforce its current specific internal control procedures to ensure compliance with applicable federal regulations. • Require that all personnel files have authorization and approval of current pay rates along with correspondence regarding to which grant an employee’s salary and fringe benefits should be expensed including any allocations if the employee worked on several grants. • Require that all vouchers and reports be prepared by one individual and independently reviewed and approved by a second individual prior to submission. There should be documentation of the review such as a sign-off or initials. • Require that all vouchers and reports be filed timely in accordance with the various grant agreements. • Require that correspondence be received from those agencies indicating that required reports per the written grant agreements are not necessary when applicable. • Ensure that the data collection form is filed the earlier of thirty (30) days after the report date or no later than nine (9) months after the fiscal year-end. Views of Responsible Officials and Planned Corrective Actions See corrective action plan.

Finding 2024-002 Material Weakness in Internal Control Over Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Cash Management, Period of Performance and Reporting Assistance Listing Numbers 93.958 Block Grants for Community Mental Health Services 93.959 Block Grants for Prevention and Treatment Substance Abuse 93.696 Certified Community Behavioral Health Clinic (CCBHC) – Planning, Development, and Implementation Grants Federal Agency U.S. Department of Health and Human Services Passthrough Agency Illinois Department of Human Services Award Number/Year 2024 Criteria The Organization is responsible for keeping an accurate accounting of all federal expenditures and maintaining all of the required documentation and reports in accordance with applicable federal regulations. Condition For AL No. 93.958, Block Grants for Community Mental Health Services Program, a sample of twenty-nine (29) payroll expense and fringe benefits transactions were tested for Activities Allowed or Unallowed, Allowable Costs/Cost Principles and Period of Performance. For AL No. 93.959, Block Grants for Prevention and Treatment of Substance Abuse Program, a sample of thirty (30) payroll expense and fringe benefits transactions were tested for Activities Allowed or Unallowed, Allowable Costs/Cost Principles and Period of Performance. For AL No. 93.696, Certified Community Behavioral Health Clinic (CCBHC) – Planning, Development, and Implementation Grants Program, a sample of forty-four (44) payroll expense and fringe benefits transactions were tested for Activities Allowed or Unallowed, Allowable Costs/Cost Principles and Period of Performance. The Organization was not able to provide sufficient evidence of review and approval of employee salaries and wages charged to these grants. We did note that the payroll and fringe benefit expense transactions tested matched the appropriate vouchers for reimbursement and related supporting documentation of payroll expense and fringe benefits. It was also noted that one person prepared, reviewed and submitted all vouchers and reports which is an indication of improper segregation of duties. Cause The Organization did not follow its established policies and procedures regarding documentation of the time sheets or time studies supporting the allocation of salaries and fringe benefits for each employee charged to grants. Additionally, there was no support in each employee file regarding a merit increase provided in December 2023 for all employees. Effect The Organization is not in compliance with the Activities Allowed or Unallowed, Allowable Costs/Cost Principles, and Period of Performance requirements of its grant agreements within its federally funded programs as prescribed by Uniform Guidance. Questioned Costs None noted. Repeat Finding Yes Recommendation We recommend that the Organization implement the following corrective actions: • Enforce its current specific internal control procedures to ensure compliance with applicable federal regulations. • Require that all personnel files have authorization and approval of current pay rates along with correspondence regarding to which grant an employee’s salary and fringe benefits should be expensed including any allocations if the employee worked on several grants. • Require that all vouchers and reports be prepared by one individual and independently reviewed and approved by a second individual prior to submission. There should be documentation of the review such as a sign-off or initials. • Require that all vouchers and reports be filed timely in accordance with the various grant agreements. • Require that correspondence be received from those agencies indicating that required reports per the written grant agreements are not necessary when applicable. • Ensure that the data collection form is filed the earlier of thirty (30) days after the report date or no later than nine (9) months after the fiscal year-end. Views of Responsible Officials and Planned Corrective Actions See corrective action plan.

Finding 2024-002 Material Weakness in Internal Control Over Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Cash Management, Period of Performance and Reporting Assistance Listing Numbers 93.958 Block Grants for Community Mental Health Services 93.959 Block Grants for Prevention and Treatment Substance Abuse 93.696 Certified Community Behavioral Health Clinic (CCBHC) – Planning, Development, and Implementation Grants Federal Agency U.S. Department of Health and Human Services Passthrough Agency Illinois Department of Human Services Award Number/Year 2024 Criteria The Organization is responsible for keeping an accurate accounting of all federal expenditures and maintaining all of the required documentation and reports in accordance with applicable federal regulations. Condition For AL No. 93.958, Block Grants for Community Mental Health Services Program, a sample of twenty-nine (29) payroll expense and fringe benefits transactions were tested for Activities Allowed or Unallowed, Allowable Costs/Cost Principles and Period of Performance. For AL No. 93.959, Block Grants for Prevention and Treatment of Substance Abuse Program, a sample of thirty (30) payroll expense and fringe benefits transactions were tested for Activities Allowed or Unallowed, Allowable Costs/Cost Principles and Period of Performance. For AL No. 93.696, Certified Community Behavioral Health Clinic (CCBHC) – Planning, Development, and Implementation Grants Program, a sample of forty-four (44) payroll expense and fringe benefits transactions were tested for Activities Allowed or Unallowed, Allowable Costs/Cost Principles and Period of Performance. The Organization was not able to provide sufficient evidence of review and approval of employee salaries and wages charged to these grants. We did note that the payroll and fringe benefit expense transactions tested matched the appropriate vouchers for reimbursement and related supporting documentation of payroll expense and fringe benefits. It was also noted that one person prepared, reviewed and submitted all vouchers and reports which is an indication of improper segregation of duties. Cause The Organization did not follow its established policies and procedures regarding documentation of the time sheets or time studies supporting the allocation of salaries and fringe benefits for each employee charged to grants. Additionally, there was no support in each employee file regarding a merit increase provided in December 2023 for all employees. Effect The Organization is not in compliance with the Activities Allowed or Unallowed, Allowable Costs/Cost Principles, and Period of Performance requirements of its grant agreements within its federally funded programs as prescribed by Uniform Guidance. Questioned Costs None noted. Repeat Finding Yes Recommendation We recommend that the Organization implement the following corrective actions: • Enforce its current specific internal control procedures to ensure compliance with applicable federal regulations. • Require that all personnel files have authorization and approval of current pay rates along with correspondence regarding to which grant an employee’s salary and fringe benefits should be expensed including any allocations if the employee worked on several grants. • Require that all vouchers and reports be prepared by one individual and independently reviewed and approved by a second individual prior to submission. There should be documentation of the review such as a sign-off or initials. • Require that all vouchers and reports be filed timely in accordance with the various grant agreements. • Require that correspondence be received from those agencies indicating that required reports per the written grant agreements are not necessary when applicable. • Ensure that the data collection form is filed the earlier of thirty (30) days after the report date or no later than nine (9) months after the fiscal year-end. Views of Responsible Officials and Planned Corrective Actions See corrective action plan.

Finding 2024-002 Material Weakness in Internal Control Over Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Cash Management, Period of Performance and Reporting Assistance Listing Numbers 93.958 Block Grants for Community Mental Health Services 93.959 Block Grants for Prevention and Treatment Substance Abuse 93.696 Certified Community Behavioral Health Clinic (CCBHC) – Planning, Development, and Implementation Grants Federal Agency U.S. Department of Health and Human Services Passthrough Agency Illinois Department of Human Services Award Number/Year 2024 Criteria The Organization is responsible for keeping an accurate accounting of all federal expenditures and maintaining all of the required documentation and reports in accordance with applicable federal regulations. Condition For AL No. 93.958, Block Grants for Community Mental Health Services Program, a sample of twenty-nine (29) payroll expense and fringe benefits transactions were tested for Activities Allowed or Unallowed, Allowable Costs/Cost Principles and Period of Performance. For AL No. 93.959, Block Grants for Prevention and Treatment of Substance Abuse Program, a sample of thirty (30) payroll expense and fringe benefits transactions were tested for Activities Allowed or Unallowed, Allowable Costs/Cost Principles and Period of Performance. For AL No. 93.696, Certified Community Behavioral Health Clinic (CCBHC) – Planning, Development, and Implementation Grants Program, a sample of forty-four (44) payroll expense and fringe benefits transactions were tested for Activities Allowed or Unallowed, Allowable Costs/Cost Principles and Period of Performance. The Organization was not able to provide sufficient evidence of review and approval of employee salaries and wages charged to these grants. We did note that the payroll and fringe benefit expense transactions tested matched the appropriate vouchers for reimbursement and related supporting documentation of payroll expense and fringe benefits. It was also noted that one person prepared, reviewed and submitted all vouchers and reports which is an indication of improper segregation of duties. Cause The Organization did not follow its established policies and procedures regarding documentation of the time sheets or time studies supporting the allocation of salaries and fringe benefits for each employee charged to grants. Additionally, there was no support in each employee file regarding a merit increase provided in December 2023 for all employees. Effect The Organization is not in compliance with the Activities Allowed or Unallowed, Allowable Costs/Cost Principles, and Period of Performance requirements of its grant agreements within its federally funded programs as prescribed by Uniform Guidance. Questioned Costs None noted. Repeat Finding Yes Recommendation We recommend that the Organization implement the following corrective actions: • Enforce its current specific internal control procedures to ensure compliance with applicable federal regulations. • Require that all personnel files have authorization and approval of current pay rates along with correspondence regarding to which grant an employee’s salary and fringe benefits should be expensed including any allocations if the employee worked on several grants. • Require that all vouchers and reports be prepared by one individual and independently reviewed and approved by a second individual prior to submission. There should be documentation of the review such as a sign-off or initials. • Require that all vouchers and reports be filed timely in accordance with the various grant agreements. • Require that correspondence be received from those agencies indicating that required reports per the written grant agreements are not necessary when applicable. • Ensure that the data collection form is filed the earlier of thirty (30) days after the report date or no later than nine (9) months after the fiscal year-end. Views of Responsible Officials and Planned Corrective Actions See corrective action plan.

Finding 2024-002 Material Weakness in Internal Control Over Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Cash Management, Period of Performance and Reporting Assistance Listing Numbers 93.958 Block Grants for Community Mental Health Services 93.959 Block Grants for Prevention and Treatment Substance Abuse 93.696 Certified Community Behavioral Health Clinic (CCBHC) – Planning, Development, and Implementation Grants Federal Agency U.S. Department of Health and Human Services Passthrough Agency Illinois Department of Human Services Award Number/Year 2024 Criteria The Organization is responsible for keeping an accurate accounting of all federal expenditures and maintaining all of the required documentation and reports in accordance with applicable federal regulations. Condition For AL No. 93.958, Block Grants for Community Mental Health Services Program, a sample of twenty-nine (29) payroll expense and fringe benefits transactions were tested for Activities Allowed or Unallowed, Allowable Costs/Cost Principles and Period of Performance. For AL No. 93.959, Block Grants for Prevention and Treatment of Substance Abuse Program, a sample of thirty (30) payroll expense and fringe benefits transactions were tested for Activities Allowed or Unallowed, Allowable Costs/Cost Principles and Period of Performance. For AL No. 93.696, Certified Community Behavioral Health Clinic (CCBHC) – Planning, Development, and Implementation Grants Program, a sample of forty-four (44) payroll expense and fringe benefits transactions were tested for Activities Allowed or Unallowed, Allowable Costs/Cost Principles and Period of Performance. The Organization was not able to provide sufficient evidence of review and approval of employee salaries and wages charged to these grants. We did note that the payroll and fringe benefit expense transactions tested matched the appropriate vouchers for reimbursement and related supporting documentation of payroll expense and fringe benefits. It was also noted that one person prepared, reviewed and submitted all vouchers and reports which is an indication of improper segregation of duties. Cause The Organization did not follow its established policies and procedures regarding documentation of the time sheets or time studies supporting the allocation of salaries and fringe benefits for each employee charged to grants. Additionally, there was no support in each employee file regarding a merit increase provided in December 2023 for all employees. Effect The Organization is not in compliance with the Activities Allowed or Unallowed, Allowable Costs/Cost Principles, and Period of Performance requirements of its grant agreements within its federally funded programs as prescribed by Uniform Guidance. Questioned Costs None noted. Repeat Finding Yes Recommendation We recommend that the Organization implement the following corrective actions: • Enforce its current specific internal control procedures to ensure compliance with applicable federal regulations. • Require that all personnel files have authorization and approval of current pay rates along with correspondence regarding to which grant an employee’s salary and fringe benefits should be expensed including any allocations if the employee worked on several grants. • Require that all vouchers and reports be prepared by one individual and independently reviewed and approved by a second individual prior to submission. There should be documentation of the review such as a sign-off or initials. • Require that all vouchers and reports be filed timely in accordance with the various grant agreements. • Require that correspondence be received from those agencies indicating that required reports per the written grant agreements are not necessary when applicable. • Ensure that the data collection form is filed the earlier of thirty (30) days after the report date or no later than nine (9) months after the fiscal year-end. Views of Responsible Officials and Planned Corrective Actions See corrective action plan.

Finding 2024-002 Material Weakness in Internal Control Over Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Cash Management, Period of Performance and Reporting Assistance Listing Numbers 93.958 Block Grants for Community Mental Health Services 93.959 Block Grants for Prevention and Treatment Substance Abuse 93.696 Certified Community Behavioral Health Clinic (CCBHC) – Planning, Development, and Implementation Grants Federal Agency U.S. Department of Health and Human Services Passthrough Agency Illinois Department of Human Services Award Number/Year 2024 Criteria The Organization is responsible for keeping an accurate accounting of all federal expenditures and maintaining all of the required documentation and reports in accordance with applicable federal regulations. Condition For AL No. 93.958, Block Grants for Community Mental Health Services Program, a sample of twenty-nine (29) payroll expense and fringe benefits transactions were tested for Activities Allowed or Unallowed, Allowable Costs/Cost Principles and Period of Performance. For AL No. 93.959, Block Grants for Prevention and Treatment of Substance Abuse Program, a sample of thirty (30) payroll expense and fringe benefits transactions were tested for Activities Allowed or Unallowed, Allowable Costs/Cost Principles and Period of Performance. For AL No. 93.696, Certified Community Behavioral Health Clinic (CCBHC) – Planning, Development, and Implementation Grants Program, a sample of forty-four (44) payroll expense and fringe benefits transactions were tested for Activities Allowed or Unallowed, Allowable Costs/Cost Principles and Period of Performance. The Organization was not able to provide sufficient evidence of review and approval of employee salaries and wages charged to these grants. We did note that the payroll and fringe benefit expense transactions tested matched the appropriate vouchers for reimbursement and related supporting documentation of payroll expense and fringe benefits. It was also noted that one person prepared, reviewed and submitted all vouchers and reports which is an indication of improper segregation of duties. Cause The Organization did not follow its established policies and procedures regarding documentation of the time sheets or time studies supporting the allocation of salaries and fringe benefits for each employee charged to grants. Additionally, there was no support in each employee file regarding a merit increase provided in December 2023 for all employees. Effect The Organization is not in compliance with the Activities Allowed or Unallowed, Allowable Costs/Cost Principles, and Period of Performance requirements of its grant agreements within its federally funded programs as prescribed by Uniform Guidance. Questioned Costs None noted. Repeat Finding Yes Recommendation We recommend that the Organization implement the following corrective actions: • Enforce its current specific internal control procedures to ensure compliance with applicable federal regulations. • Require that all personnel files have authorization and approval of current pay rates along with correspondence regarding to which grant an employee’s salary and fringe benefits should be expensed including any allocations if the employee worked on several grants. • Require that all vouchers and reports be prepared by one individual and independently reviewed and approved by a second individual prior to submission. There should be documentation of the review such as a sign-off or initials. • Require that all vouchers and reports be filed timely in accordance with the various grant agreements. • Require that correspondence be received from those agencies indicating that required reports per the written grant agreements are not necessary when applicable. • Ensure that the data collection form is filed the earlier of thirty (30) days after the report date or no later than nine (9) months after the fiscal year-end. Views of Responsible Officials and Planned Corrective Actions See corrective action plan.

Finding 2024-002 Material Weakness in Internal Control Over Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Cash Management, Period of Performance and Reporting Assistance Listing Numbers 93.958 Block Grants for Community Mental Health Services 93.959 Block Grants for Prevention and Treatment Substance Abuse 93.696 Certified Community Behavioral Health Clinic (CCBHC) – Planning, Development, and Implementation Grants Federal Agency U.S. Department of Health and Human Services Passthrough Agency Illinois Department of Human Services Award Number/Year 2024 Criteria The Organization is responsible for keeping an accurate accounting of all federal expenditures and maintaining all of the required documentation and reports in accordance with applicable federal regulations. Condition For AL No. 93.958, Block Grants for Community Mental Health Services Program, a sample of twenty-nine (29) payroll expense and fringe benefits transactions were tested for Activities Allowed or Unallowed, Allowable Costs/Cost Principles and Period of Performance. For AL No. 93.959, Block Grants for Prevention and Treatment of Substance Abuse Program, a sample of thirty (30) payroll expense and fringe benefits transactions were tested for Activities Allowed or Unallowed, Allowable Costs/Cost Principles and Period of Performance. For AL No. 93.696, Certified Community Behavioral Health Clinic (CCBHC) – Planning, Development, and Implementation Grants Program, a sample of forty-four (44) payroll expense and fringe benefits transactions were tested for Activities Allowed or Unallowed, Allowable Costs/Cost Principles and Period of Performance. The Organization was not able to provide sufficient evidence of review and approval of employee salaries and wages charged to these grants. We did note that the payroll and fringe benefit expense transactions tested matched the appropriate vouchers for reimbursement and related supporting documentation of payroll expense and fringe benefits. It was also noted that one person prepared, reviewed and submitted all vouchers and reports which is an indication of improper segregation of duties. Cause The Organization did not follow its established policies and procedures regarding documentation of the time sheets or time studies supporting the allocation of salaries and fringe benefits for each employee charged to grants. Additionally, there was no support in each employee file regarding a merit increase provided in December 2023 for all employees. Effect The Organization is not in compliance with the Activities Allowed or Unallowed, Allowable Costs/Cost Principles, and Period of Performance requirements of its grant agreements within its federally funded programs as prescribed by Uniform Guidance. Questioned Costs None noted. Repeat Finding Yes Recommendation We recommend that the Organization implement the following corrective actions: • Enforce its current specific internal control procedures to ensure compliance with applicable federal regulations. • Require that all personnel files have authorization and approval of current pay rates along with correspondence regarding to which grant an employee’s salary and fringe benefits should be expensed including any allocations if the employee worked on several grants. • Require that all vouchers and reports be prepared by one individual and independently reviewed and approved by a second individual prior to submission. There should be documentation of the review such as a sign-off or initials. • Require that all vouchers and reports be filed timely in accordance with the various grant agreements. • Require that correspondence be received from those agencies indicating that required reports per the written grant agreements are not necessary when applicable. • Ensure that the data collection form is filed the earlier of thirty (30) days after the report date or no later than nine (9) months after the fiscal year-end. Views of Responsible Officials and Planned Corrective Actions See corrective action plan.

Finding 2024-002 Material Weakness in Internal Control Over Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Cash Management, Period of Performance and Reporting Assistance Listing Numbers 93.958 Block Grants for Community Mental Health Services 93.959 Block Grants for Prevention and Treatment Substance Abuse 93.696 Certified Community Behavioral Health Clinic (CCBHC) – Planning, Development, and Implementation Grants Federal Agency U.S. Department of Health and Human Services Passthrough Agency Illinois Department of Human Services Award Number/Year 2024 Criteria The Organization is responsible for keeping an accurate accounting of all federal expenditures and maintaining all of the required documentation and reports in accordance with applicable federal regulations. Condition For AL No. 93.958, Block Grants for Community Mental Health Services Program, a sample of twenty-nine (29) payroll expense and fringe benefits transactions were tested for Activities Allowed or Unallowed, Allowable Costs/Cost Principles and Period of Performance. For AL No. 93.959, Block Grants for Prevention and Treatment of Substance Abuse Program, a sample of thirty (30) payroll expense and fringe benefits transactions were tested for Activities Allowed or Unallowed, Allowable Costs/Cost Principles and Period of Performance. For AL No. 93.696, Certified Community Behavioral Health Clinic (CCBHC) – Planning, Development, and Implementation Grants Program, a sample of forty-four (44) payroll expense and fringe benefits transactions were tested for Activities Allowed or Unallowed, Allowable Costs/Cost Principles and Period of Performance. The Organization was not able to provide sufficient evidence of review and approval of employee salaries and wages charged to these grants. We did note that the payroll and fringe benefit expense transactions tested matched the appropriate vouchers for reimbursement and related supporting documentation of payroll expense and fringe benefits. It was also noted that one person prepared, reviewed and submitted all vouchers and reports which is an indication of improper segregation of duties. Cause The Organization did not follow its established policies and procedures regarding documentation of the time sheets or time studies supporting the allocation of salaries and fringe benefits for each employee charged to grants. Additionally, there was no support in each employee file regarding a merit increase provided in December 2023 for all employees. Effect The Organization is not in compliance with the Activities Allowed or Unallowed, Allowable Costs/Cost Principles, and Period of Performance requirements of its grant agreements within its federally funded programs as prescribed by Uniform Guidance. Questioned Costs None noted. Repeat Finding Yes Recommendation We recommend that the Organization implement the following corrective actions: • Enforce its current specific internal control procedures to ensure compliance with applicable federal regulations. • Require that all personnel files have authorization and approval of current pay rates along with correspondence regarding to which grant an employee’s salary and fringe benefits should be expensed including any allocations if the employee worked on several grants. • Require that all vouchers and reports be prepared by one individual and independently reviewed and approved by a second individual prior to submission. There should be documentation of the review such as a sign-off or initials. • Require that all vouchers and reports be filed timely in accordance with the various grant agreements. • Require that correspondence be received from those agencies indicating that required reports per the written grant agreements are not necessary when applicable. • Ensure that the data collection form is filed the earlier of thirty (30) days after the report date or no later than nine (9) months after the fiscal year-end. Views of Responsible Officials and Planned Corrective Actions See corrective action plan.

Finding 2024-002 Material Weakness in Internal Control Over Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Cash Management, Period of Performance and Reporting Assistance Listing Numbers 93.958 Block Grants for Community Mental Health Services 93.959 Block Grants for Prevention and Treatment Substance Abuse 93.696 Certified Community Behavioral Health Clinic (CCBHC) – Planning, Development, and Implementation Grants Federal Agency U.S. Department of Health and Human Services Passthrough Agency Illinois Department of Human Services Award Number/Year 2024 Criteria The Organization is responsible for keeping an accurate accounting of all federal expenditures and maintaining all of the required documentation and reports in accordance with applicable federal regulations. Condition For AL No. 93.958, Block Grants for Community Mental Health Services Program, a sample of twenty-nine (29) payroll expense and fringe benefits transactions were tested for Activities Allowed or Unallowed, Allowable Costs/Cost Principles and Period of Performance. For AL No. 93.959, Block Grants for Prevention and Treatment of Substance Abuse Program, a sample of thirty (30) payroll expense and fringe benefits transactions were tested for Activities Allowed or Unallowed, Allowable Costs/Cost Principles and Period of Performance. For AL No. 93.696, Certified Community Behavioral Health Clinic (CCBHC) – Planning, Development, and Implementation Grants Program, a sample of forty-four (44) payroll expense and fringe benefits transactions were tested for Activities Allowed or Unallowed, Allowable Costs/Cost Principles and Period of Performance. The Organization was not able to provide sufficient evidence of review and approval of employee salaries and wages charged to these grants. We did note that the payroll and fringe benefit expense transactions tested matched the appropriate vouchers for reimbursement and related supporting documentation of payroll expense and fringe benefits. It was also noted that one person prepared, reviewed and submitted all vouchers and reports which is an indication of improper segregation of duties. Cause The Organization did not follow its established policies and procedures regarding documentation of the time sheets or time studies supporting the allocation of salaries and fringe benefits for each employee charged to grants. Additionally, there was no support in each employee file regarding a merit increase provided in December 2023 for all employees. Effect The Organization is not in compliance with the Activities Allowed or Unallowed, Allowable Costs/Cost Principles, and Period of Performance requirements of its grant agreements within its federally funded programs as prescribed by Uniform Guidance. Questioned Costs None noted. Repeat Finding Yes Recommendation We recommend that the Organization implement the following corrective actions: • Enforce its current specific internal control procedures to ensure compliance with applicable federal regulations. • Require that all personnel files have authorization and approval of current pay rates along with correspondence regarding to which grant an employee’s salary and fringe benefits should be expensed including any allocations if the employee worked on several grants. • Require that all vouchers and reports be prepared by one individual and independently reviewed and approved by a second individual prior to submission. There should be documentation of the review such as a sign-off or initials. • Require that all vouchers and reports be filed timely in accordance with the various grant agreements. • Require that correspondence be received from those agencies indicating that required reports per the written grant agreements are not necessary when applicable. • Ensure that the data collection form is filed the earlier of thirty (30) days after the report date or no later than nine (9) months after the fiscal year-end. Views of Responsible Officials and Planned Corrective Actions See corrective action plan.

Finding 2024-002 Material Weakness in Internal Control Over Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Cash Management, Period of Performance and Reporting Assistance Listing Numbers 93.958 Block Grants for Community Mental Health Services 93.959 Block Grants for Prevention and Treatment Substance Abuse 93.696 Certified Community Behavioral Health Clinic (CCBHC) – Planning, Development, and Implementation Grants Federal Agency U.S. Department of Health and Human Services Passthrough Agency Illinois Department of Human Services Award Number/Year 2024 Criteria The Organization is responsible for keeping an accurate accounting of all federal expenditures and maintaining all of the required documentation and reports in accordance with applicable federal regulations. Condition For AL No. 93.958, Block Grants for Community Mental Health Services Program, a sample of twenty-nine (29) payroll expense and fringe benefits transactions were tested for Activities Allowed or Unallowed, Allowable Costs/Cost Principles and Period of Performance. For AL No. 93.959, Block Grants for Prevention and Treatment of Substance Abuse Program, a sample of thirty (30) payroll expense and fringe benefits transactions were tested for Activities Allowed or Unallowed, Allowable Costs/Cost Principles and Period of Performance. For AL No. 93.696, Certified Community Behavioral Health Clinic (CCBHC) – Planning, Development, and Implementation Grants Program, a sample of forty-four (44) payroll expense and fringe benefits transactions were tested for Activities Allowed or Unallowed, Allowable Costs/Cost Principles and Period of Performance. The Organization was not able to provide sufficient evidence of review and approval of employee salaries and wages charged to these grants. We did note that the payroll and fringe benefit expense transactions tested matched the appropriate vouchers for reimbursement and related supporting documentation of payroll expense and fringe benefits. It was also noted that one person prepared, reviewed and submitted all vouchers and reports which is an indication of improper segregation of duties. Cause The Organization did not follow its established policies and procedures regarding documentation of the time sheets or time studies supporting the allocation of salaries and fringe benefits for each employee charged to grants. Additionally, there was no support in each employee file regarding a merit increase provided in December 2023 for all employees. Effect The Organization is not in compliance with the Activities Allowed or Unallowed, Allowable Costs/Cost Principles, and Period of Performance requirements of its grant agreements within its federally funded programs as prescribed by Uniform Guidance. Questioned Costs None noted. Repeat Finding Yes Recommendation We recommend that the Organization implement the following corrective actions: • Enforce its current specific internal control procedures to ensure compliance with applicable federal regulations. • Require that all personnel files have authorization and approval of current pay rates along with correspondence regarding to which grant an employee’s salary and fringe benefits should be expensed including any allocations if the employee worked on several grants. • Require that all vouchers and reports be prepared by one individual and independently reviewed and approved by a second individual prior to submission. There should be documentation of the review such as a sign-off or initials. • Require that all vouchers and reports be filed timely in accordance with the various grant agreements. • Require that correspondence be received from those agencies indicating that required reports per the written grant agreements are not necessary when applicable. • Ensure that the data collection form is filed the earlier of thirty (30) days after the report date or no later than nine (9) months after the fiscal year-end. Views of Responsible Officials and Planned Corrective Actions See corrective action plan.

Finding 2024-002 Material Weakness in Internal Control Over Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Cash Management, Period of Performance and Reporting Assistance Listing Numbers 93.958 Block Grants for Community Mental Health Services 93.959 Block Grants for Prevention and Treatment Substance Abuse 93.696 Certified Community Behavioral Health Clinic (CCBHC) – Planning, Development, and Implementation Grants Federal Agency U.S. Department of Health and Human Services Passthrough Agency Illinois Department of Human Services Award Number/Year 2024 Criteria The Organization is responsible for keeping an accurate accounting of all federal expenditures and maintaining all of the required documentation and reports in accordance with applicable federal regulations. Condition For AL No. 93.958, Block Grants for Community Mental Health Services Program, a sample of twenty-nine (29) payroll expense and fringe benefits transactions were tested for Activities Allowed or Unallowed, Allowable Costs/Cost Principles and Period of Performance. For AL No. 93.959, Block Grants for Prevention and Treatment of Substance Abuse Program, a sample of thirty (30) payroll expense and fringe benefits transactions were tested for Activities Allowed or Unallowed, Allowable Costs/Cost Principles and Period of Performance. For AL No. 93.696, Certified Community Behavioral Health Clinic (CCBHC) – Planning, Development, and Implementation Grants Program, a sample of forty-four (44) payroll expense and fringe benefits transactions were tested for Activities Allowed or Unallowed, Allowable Costs/Cost Principles and Period of Performance. The Organization was not able to provide sufficient evidence of review and approval of employee salaries and wages charged to these grants. We did note that the payroll and fringe benefit expense transactions tested matched the appropriate vouchers for reimbursement and related supporting documentation of payroll expense and fringe benefits. It was also noted that one person prepared, reviewed and submitted all vouchers and reports which is an indication of improper segregation of duties. Cause The Organization did not follow its established policies and procedures regarding documentation of the time sheets or time studies supporting the allocation of salaries and fringe benefits for each employee charged to grants. Additionally, there was no support in each employee file regarding a merit increase provided in December 2023 for all employees. Effect The Organization is not in compliance with the Activities Allowed or Unallowed, Allowable Costs/Cost Principles, and Period of Performance requirements of its grant agreements within its federally funded programs as prescribed by Uniform Guidance. Questioned Costs None noted. Repeat Finding Yes Recommendation We recommend that the Organization implement the following corrective actions: • Enforce its current specific internal control procedures to ensure compliance with applicable federal regulations. • Require that all personnel files have authorization and approval of current pay rates along with correspondence regarding to which grant an employee’s salary and fringe benefits should be expensed including any allocations if the employee worked on several grants. • Require that all vouchers and reports be prepared by one individual and independently reviewed and approved by a second individual prior to submission. There should be documentation of the review such as a sign-off or initials. • Require that all vouchers and reports be filed timely in accordance with the various grant agreements. • Require that correspondence be received from those agencies indicating that required reports per the written grant agreements are not necessary when applicable. • Ensure that the data collection form is filed the earlier of thirty (30) days after the report date or no later than nine (9) months after the fiscal year-end. Views of Responsible Officials and Planned Corrective Actions See corrective action plan.

Finding 2024-002 Material Weakness in Internal Control Over Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Cash Management, Period of Performance and Reporting Assistance Listing Numbers 93.958 Block Grants for Community Mental Health Services 93.959 Block Grants for Prevention and Treatment Substance Abuse 93.696 Certified Community Behavioral Health Clinic (CCBHC) – Planning, Development, and Implementation Grants Federal Agency U.S. Department of Health and Human Services Passthrough Agency Illinois Department of Human Services Award Number/Year 2024 Criteria The Organization is responsible for keeping an accurate accounting of all federal expenditures and maintaining all of the required documentation and reports in accordance with applicable federal regulations. Condition For AL No. 93.958, Block Grants for Community Mental Health Services Program, a sample of twenty-nine (29) payroll expense and fringe benefits transactions were tested for Activities Allowed or Unallowed, Allowable Costs/Cost Principles and Period of Performance. For AL No. 93.959, Block Grants for Prevention and Treatment of Substance Abuse Program, a sample of thirty (30) payroll expense and fringe benefits transactions were tested for Activities Allowed or Unallowed, Allowable Costs/Cost Principles and Period of Performance. For AL No. 93.696, Certified Community Behavioral Health Clinic (CCBHC) – Planning, Development, and Implementation Grants Program, a sample of forty-four (44) payroll expense and fringe benefits transactions were tested for Activities Allowed or Unallowed, Allowable Costs/Cost Principles and Period of Performance. The Organization was not able to provide sufficient evidence of review and approval of employee salaries and wages charged to these grants. We did note that the payroll and fringe benefit expense transactions tested matched the appropriate vouchers for reimbursement and related supporting documentation of payroll expense and fringe benefits. It was also noted that one person prepared, reviewed and submitted all vouchers and reports which is an indication of improper segregation of duties. Cause The Organization did not follow its established policies and procedures regarding documentation of the time sheets or time studies supporting the allocation of salaries and fringe benefits for each employee charged to grants. Additionally, there was no support in each employee file regarding a merit increase provided in December 2023 for all employees. Effect The Organization is not in compliance with the Activities Allowed or Unallowed, Allowable Costs/Cost Principles, and Period of Performance requirements of its grant agreements within its federally funded programs as prescribed by Uniform Guidance. Questioned Costs None noted. Repeat Finding Yes Recommendation We recommend that the Organization implement the following corrective actions: • Enforce its current specific internal control procedures to ensure compliance with applicable federal regulations. • Require that all personnel files have authorization and approval of current pay rates along with correspondence regarding to which grant an employee’s salary and fringe benefits should be expensed including any allocations if the employee worked on several grants. • Require that all vouchers and reports be prepared by one individual and independently reviewed and approved by a second individual prior to submission. There should be documentation of the review such as a sign-off or initials. • Require that all vouchers and reports be filed timely in accordance with the various grant agreements. • Require that correspondence be received from those agencies indicating that required reports per the written grant agreements are not necessary when applicable. • Ensure that the data collection form is filed the earlier of thirty (30) days after the report date or no later than nine (9) months after the fiscal year-end. Views of Responsible Officials and Planned Corrective Actions See corrective action plan.

Finding 2024-002 Material Weakness in Internal Control Over Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Cash Management, Period of Performance and Reporting Assistance Listing Numbers 93.958 Block Grants for Community Mental Health Services 93.959 Block Grants for Prevention and Treatment Substance Abuse 93.696 Certified Community Behavioral Health Clinic (CCBHC) – Planning, Development, and Implementation Grants Federal Agency U.S. Department of Health and Human Services Passthrough Agency Illinois Department of Human Services Award Number/Year 2024 Criteria The Organization is responsible for keeping an accurate accounting of all federal expenditures and maintaining all of the required documentation and reports in accordance with applicable federal regulations. Condition For AL No. 93.958, Block Grants for Community Mental Health Services Program, a sample of twenty-nine (29) payroll expense and fringe benefits transactions were tested for Activities Allowed or Unallowed, Allowable Costs/Cost Principles and Period of Performance. For AL No. 93.959, Block Grants for Prevention and Treatment of Substance Abuse Program, a sample of thirty (30) payroll expense and fringe benefits transactions were tested for Activities Allowed or Unallowed, Allowable Costs/Cost Principles and Period of Performance. For AL No. 93.696, Certified Community Behavioral Health Clinic (CCBHC) – Planning, Development, and Implementation Grants Program, a sample of forty-four (44) payroll expense and fringe benefits transactions were tested for Activities Allowed or Unallowed, Allowable Costs/Cost Principles and Period of Performance. The Organization was not able to provide sufficient evidence of review and approval of employee salaries and wages charged to these grants. We did note that the payroll and fringe benefit expense transactions tested matched the appropriate vouchers for reimbursement and related supporting documentation of payroll expense and fringe benefits. It was also noted that one person prepared, reviewed and submitted all vouchers and reports which is an indication of improper segregation of duties. Cause The Organization did not follow its established policies and procedures regarding documentation of the time sheets or time studies supporting the allocation of salaries and fringe benefits for each employee charged to grants. Additionally, there was no support in each employee file regarding a merit increase provided in December 2023 for all employees. Effect The Organization is not in compliance with the Activities Allowed or Unallowed, Allowable Costs/Cost Principles, and Period of Performance requirements of its grant agreements within its federally funded programs as prescribed by Uniform Guidance. Questioned Costs None noted. Repeat Finding Yes Recommendation We recommend that the Organization implement the following corrective actions: • Enforce its current specific internal control procedures to ensure compliance with applicable federal regulations. • Require that all personnel files have authorization and approval of current pay rates along with correspondence regarding to which grant an employee’s salary and fringe benefits should be expensed including any allocations if the employee worked on several grants. • Require that all vouchers and reports be prepared by one individual and independently reviewed and approved by a second individual prior to submission. There should be documentation of the review such as a sign-off or initials. • Require that all vouchers and reports be filed timely in accordance with the various grant agreements. • Require that correspondence be received from those agencies indicating that required reports per the written grant agreements are not necessary when applicable. • Ensure that the data collection form is filed the earlier of thirty (30) days after the report date or no later than nine (9) months after the fiscal year-end. Views of Responsible Officials and Planned Corrective Actions See corrective action plan.

Finding 2024-002 Material Weakness in Internal Control Over Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Cash Management, Period of Performance and Reporting Assistance Listing Numbers 93.958 Block Grants for Community Mental Health Services 93.959 Block Grants for Prevention and Treatment Substance Abuse 93.696 Certified Community Behavioral Health Clinic (CCBHC) – Planning, Development, and Implementation Grants Federal Agency U.S. Department of Health and Human Services Passthrough Agency Illinois Department of Human Services Award Number/Year 2024 Criteria The Organization is responsible for keeping an accurate accounting of all federal expenditures and maintaining all of the required documentation and reports in accordance with applicable federal regulations. Condition For AL No. 93.958, Block Grants for Community Mental Health Services Program, a sample of twenty-nine (29) payroll expense and fringe benefits transactions were tested for Activities Allowed or Unallowed, Allowable Costs/Cost Principles and Period of Performance. For AL No. 93.959, Block Grants for Prevention and Treatment of Substance Abuse Program, a sample of thirty (30) payroll expense and fringe benefits transactions were tested for Activities Allowed or Unallowed, Allowable Costs/Cost Principles and Period of Performance. For AL No. 93.696, Certified Community Behavioral Health Clinic (CCBHC) – Planning, Development, and Implementation Grants Program, a sample of forty-four (44) payroll expense and fringe benefits transactions were tested for Activities Allowed or Unallowed, Allowable Costs/Cost Principles and Period of Performance. The Organization was not able to provide sufficient evidence of review and approval of employee salaries and wages charged to these grants. We did note that the payroll and fringe benefit expense transactions tested matched the appropriate vouchers for reimbursement and related supporting documentation of payroll expense and fringe benefits. It was also noted that one person prepared, reviewed and submitted all vouchers and reports which is an indication of improper segregation of duties. Cause The Organization did not follow its established policies and procedures regarding documentation of the time sheets or time studies supporting the allocation of salaries and fringe benefits for each employee charged to grants. Additionally, there was no support in each employee file regarding a merit increase provided in December 2023 for all employees. Effect The Organization is not in compliance with the Activities Allowed or Unallowed, Allowable Costs/Cost Principles, and Period of Performance requirements of its grant agreements within its federally funded programs as prescribed by Uniform Guidance. Questioned Costs None noted. Repeat Finding Yes Recommendation We recommend that the Organization implement the following corrective actions: • Enforce its current specific internal control procedures to ensure compliance with applicable federal regulations. • Require that all personnel files have authorization and approval of current pay rates along with correspondence regarding to which grant an employee’s salary and fringe benefits should be expensed including any allocations if the employee worked on several grants. • Require that all vouchers and reports be prepared by one individual and independently reviewed and approved by a second individual prior to submission. There should be documentation of the review such as a sign-off or initials. • Require that all vouchers and reports be filed timely in accordance with the various grant agreements. • Require that correspondence be received from those agencies indicating that required reports per the written grant agreements are not necessary when applicable. • Ensure that the data collection form is filed the earlier of thirty (30) days after the report date or no later than nine (9) months after the fiscal year-end. Views of Responsible Officials and Planned Corrective Actions See corrective action plan.

Finding 2024-002 Material Weakness in Internal Control Over Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Cash Management, Period of Performance and Reporting Assistance Listing Numbers 93.958 Block Grants for Community Mental Health Services 93.959 Block Grants for Prevention and Treatment Substance Abuse 93.696 Certified Community Behavioral Health Clinic (CCBHC) – Planning, Development, and Implementation Grants Federal Agency U.S. Department of Health and Human Services Passthrough Agency Illinois Department of Human Services Award Number/Year 2024 Criteria The Organization is responsible for keeping an accurate accounting of all federal expenditures and maintaining all of the required documentation and reports in accordance with applicable federal regulations. Condition For AL No. 93.958, Block Grants for Community Mental Health Services Program, a sample of twenty-nine (29) payroll expense and fringe benefits transactions were tested for Activities Allowed or Unallowed, Allowable Costs/Cost Principles and Period of Performance. For AL No. 93.959, Block Grants for Prevention and Treatment of Substance Abuse Program, a sample of thirty (30) payroll expense and fringe benefits transactions were tested for Activities Allowed or Unallowed, Allowable Costs/Cost Principles and Period of Performance. For AL No. 93.696, Certified Community Behavioral Health Clinic (CCBHC) – Planning, Development, and Implementation Grants Program, a sample of forty-four (44) payroll expense and fringe benefits transactions were tested for Activities Allowed or Unallowed, Allowable Costs/Cost Principles and Period of Performance. The Organization was not able to provide sufficient evidence of review and approval of employee salaries and wages charged to these grants. We did note that the payroll and fringe benefit expense transactions tested matched the appropriate vouchers for reimbursement and related supporting documentation of payroll expense and fringe benefits. It was also noted that one person prepared, reviewed and submitted all vouchers and reports which is an indication of improper segregation of duties. Cause The Organization did not follow its established policies and procedures regarding documentation of the time sheets or time studies supporting the allocation of salaries and fringe benefits for each employee charged to grants. Additionally, there was no support in each employee file regarding a merit increase provided in December 2023 for all employees. Effect The Organization is not in compliance with the Activities Allowed or Unallowed, Allowable Costs/Cost Principles, and Period of Performance requirements of its grant agreements within its federally funded programs as prescribed by Uniform Guidance. Questioned Costs None noted. Repeat Finding Yes Recommendation We recommend that the Organization implement the following corrective actions: • Enforce its current specific internal control procedures to ensure compliance with applicable federal regulations. • Require that all personnel files have authorization and approval of current pay rates along with correspondence regarding to which grant an employee’s salary and fringe benefits should be expensed including any allocations if the employee worked on several grants. • Require that all vouchers and reports be prepared by one individual and independently reviewed and approved by a second individual prior to submission. There should be documentation of the review such as a sign-off or initials. • Require that all vouchers and reports be filed timely in accordance with the various grant agreements. • Require that correspondence be received from those agencies indicating that required reports per the written grant agreements are not necessary when applicable. • Ensure that the data collection form is filed the earlier of thirty (30) days after the report date or no later than nine (9) months after the fiscal year-end. Views of Responsible Officials and Planned Corrective Actions See corrective action plan.

Finding 2024-002 Material Weakness in Internal Control Over Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Cash Management, Period of Performance and Reporting Assistance Listing Numbers 93.958 Block Grants for Community Mental Health Services 93.959 Block Grants for Prevention and Treatment Substance Abuse 93.696 Certified Community Behavioral Health Clinic (CCBHC) – Planning, Development, and Implementation Grants Federal Agency U.S. Department of Health and Human Services Passthrough Agency Illinois Department of Human Services Award Number/Year 2024 Criteria The Organization is responsible for keeping an accurate accounting of all federal expenditures and maintaining all of the required documentation and reports in accordance with applicable federal regulations. Condition For AL No. 93.958, Block Grants for Community Mental Health Services Program, a sample of twenty-nine (29) payroll expense and fringe benefits transactions were tested for Activities Allowed or Unallowed, Allowable Costs/Cost Principles and Period of Performance. For AL No. 93.959, Block Grants for Prevention and Treatment of Substance Abuse Program, a sample of thirty (30) payroll expense and fringe benefits transactions were tested for Activities Allowed or Unallowed, Allowable Costs/Cost Principles and Period of Performance. For AL No. 93.696, Certified Community Behavioral Health Clinic (CCBHC) – Planning, Development, and Implementation Grants Program, a sample of forty-four (44) payroll expense and fringe benefits transactions were tested for Activities Allowed or Unallowed, Allowable Costs/Cost Principles and Period of Performance. The Organization was not able to provide sufficient evidence of review and approval of employee salaries and wages charged to these grants. We did note that the payroll and fringe benefit expense transactions tested matched the appropriate vouchers for reimbursement and related supporting documentation of payroll expense and fringe benefits. It was also noted that one person prepared, reviewed and submitted all vouchers and reports which is an indication of improper segregation of duties. Cause The Organization did not follow its established policies and procedures regarding documentation of the time sheets or time studies supporting the allocation of salaries and fringe benefits for each employee charged to grants. Additionally, there was no support in each employee file regarding a merit increase provided in December 2023 for all employees. Effect The Organization is not in compliance with the Activities Allowed or Unallowed, Allowable Costs/Cost Principles, and Period of Performance requirements of its grant agreements within its federally funded programs as prescribed by Uniform Guidance. Questioned Costs None noted. Repeat Finding Yes Recommendation We recommend that the Organization implement the following corrective actions: • Enforce its current specific internal control procedures to ensure compliance with applicable federal regulations. • Require that all personnel files have authorization and approval of current pay rates along with correspondence regarding to which grant an employee’s salary and fringe benefits should be expensed including any allocations if the employee worked on several grants. • Require that all vouchers and reports be prepared by one individual and independently reviewed and approved by a second individual prior to submission. There should be documentation of the review such as a sign-off or initials. • Require that all vouchers and reports be filed timely in accordance with the various grant agreements. • Require that correspondence be received from those agencies indicating that required reports per the written grant agreements are not necessary when applicable. • Ensure that the data collection form is filed the earlier of thirty (30) days after the report date or no later than nine (9) months after the fiscal year-end. Views of Responsible Officials and Planned Corrective Actions See corrective action plan.