Corrective Action Plans

Consolidated Health Centers Grant — Assistance Listing No. 93.224 & 93.527 Recommendation: Our auditors recommended the Organization to review internal controls in regards to the approval of federal fund drawdown requests. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization has reviewed all of our internal controls to ensure all approvals are documented. The procedure has been updated to include preparing the draw documentation, entering accounts receivable invoice into the accounting system, which now requires an approval for all accounts receivable invoices. Once the accounts receivable invoices are approved in the accounting system then a drawdown can be requested in the payment management system

Finding: The Uniform Guidance, 2 CFR Part 200, Appendix XI Compliance Supplement, dated May 2023, stipulates for a cost to be allowable under federal awards certain general criteria must be met, including costs that are adequately documented and necessary and reasonable for the performance of the federal award. The Alabama Department of Public Health (ADPH) passed through a portion of the Immunization Cooperative Agreement federal award to subrecipients. During our audit, the ADPH’s Office of Program Integrity (OPI) notified us that based on its investigation a subrecipient was not submitting adequate supporting documentation for reimbursement requests. A total of thirteen subrecipients requested and received reimbursement of program expenses during the fiscal year. Based upon procedures performed, we noted that of the 13 subrecipients who received federal award reimbursements, six did not provide adequate detailed documentation to support their requests for reimbursement. In addition, forty-eight of the sixty-three invoices submitted for reimbursement by the subrecipients did not have adequate documentation resulting in questioned costs of $8,478,032.39 and one of the invoices included an improper payment of $2,600.00 for a total question cost of $8,480,632.39. The ADPH did not have adequate policies and procedures in place to ensure that all requests for reimbursement were supported by adequate detailed documentation to ensure all coast are allowed under the federal award. This is a material weakness in internal controls. Recommendation: The Alabama Department of Public Health should take action to ensure that all reimbursements of expenses are adequately documented, based on true and accurate invoices, and to ensure costs are allowable under the federal award. Response/Views: We agree with the Examiners' finding; adequate documentation did not exist at the time of the audit to substantiate payments that resulted in questioned costs and improper payments. However, we do not concur with the total amount of the questioned costs cited in the report. ADPH's Office of Program Integrity initiated its own ongoing investigation. As this process continues, we are requesting additional documentation from the subrecipients, which will affect the questioned costs of this program. Corrective Action Planned: As noted, ADPH's Office of Program Integrity (OPI) has initiated its own internal on-going investigation. As part of that investigation, the Federal Grantor was notified of the situation and OPI is requesting supporting documentation from the sub grantees. ADPH is strengthening the internal control system for grants management. ADPH has and will continue to develop internal grant training for all employees who handle any phase of grant activities or have managerial responsibility for a grant. ADPH is working to make this training mandatory. In addition, the Centers for Disease Control has grant training available which will be utilized. The Bureau of Financial Services is establishing a Grants Management Office and has distributed grant tools such as a standard Risk Assessment Form for grant program use. Corrective action within the Immunization Division will include hiring additional staff to support the grant review and monitoring process. Immunization will implement the following procedures: • Grant guidance will be reviewed semi-annually, or when updated, with program grant monitoring staff to ensure compliance. • Invoices and supporting documentation for source documents will be reviewed against grant guidance as received by program staff and approved by Operations Manager or Division Director to ensure costs to the grant are reasonable, allowable, allocable, and consistently applied. • Grant monitoring staff will ensure that all reimbursements of expenses are adequately documented, based on true and accurate invoices, and costs are allowable under the federal award. • Invoices or vague requests requiring additional documentation will be held until the necessary information is provided. • Ensure all program grant staff have access to and attend all available Finance and Grant training courses. • Engage assigned Grant Accountant quarterly or as needed. • Conduct a Risk Assessment on all new subrecipients within 30 days of a signed grant agreement which will be forwarded to OPI for review. • Immunization staff will conduct a Risk Assessment on all current subrecipients within 60 days which will be forwarded to OPI for review. • Immunization staff, along with Finance and OPI, will develop a subrecipient monitoring plan based on the Risk Assessment of each subrecipient. The monitoring plan will be completed within 30 days of the receipt of the completed Risk Assessment. • Copies of all completed monitoring activities, as outlined in the monitoring plan, will be forwarded to OPI. Anticipated Completion Date: April 1, 2025 Contact Person(s): Immunization: Denise Strickland, Immunization Division Director; Daniels, Immunization Operations Manager; Harrison Wallace, Director, Bureau of Communicable Disease; Bureau of Financial Services: Shaundra B. Morris, Chief Accountant; Office of Program Integrity: Debra S. Thrash, Director

Finding: The Uniform Guidance, 2 CFR Part 200, Appendix XI Compliance Supplement, dated May 2023, stipulates for a cost to be allowable under federal awards certain general criteria must be met, including costs that are adequately documented and necessary and reasonable for the performance of the federal award. The Alabama Department of Transportation (the “Department”) passed through a portion of the Formula Grants for Rural Areas and Tribal Transit Program federal award to subrecipients. One of the subrecipients requested and received reimbursement of program expenses. Subsequent to the payments of the invoices, the Department received information alleging that falsified or altered documents related to expenditures submitted by a subrecipient. Upon receipt of these allegations, the Department initiated a review of the supporting documents which had been submitted by the subrecipient. The review consisted of obtaining documents from vendors and comparing those documents to the ones submitted by the subrecipient. The results of this comparison indicated that the amounts owed and the description of goods and services provided columns had been changed. Nine of ten supporting documents for meeting expenses submitted for reimbursement by the subrecipient during the audit period were altered and were not true and accurate. These altered supporting documents totaled $94,123.56. The Alabama Department of Transportation reimbursed the subrecipient based on the altered documents and, therefore, improperly expended Formula Grants for Rural Areas and Tribal Transit Program federal award funds. Recommendation: The Alabama Department of Transportation should take actions to ensure that all reimbursements of expenses are adequately documented, based on true and accurate supporting documentation, and to ensure costs are allowable under the federal award. Response/Views: We agree that there appears to have been falsified supporting documentation submitted by a subrecipient. Corrective Action Planned: Once we were made aware of the allegation, we began a thorough review of the subrecipient’s invoices. Based on the information discovered during our review, we notified the Federal Transit Administration, Alabama Attorney General’s Office, Alabama Ethics Commission, and the Alabama Department of Examiners of Public Accounts. The Office of Inspector General for the U.S. Department of Transportation is currently investigating the case. The subrecipient involved in this matter is no longer associated with our Transit Program. The duties that they performed were either moved to another subrecipient or in-house. We have modified our invoice review process, and the changes have been applied to all subrecipients for the Transit Program. Anticipated Completion Date: We have taken the steps outlined above as of August 28, 2024. Contact Person(s): Jeff Hornsby, Chief Financial Officer

Federal Agency: U.S. Department of Transportation Program/Cluster: Metropolitan Planning and Research Federal Assistance Listing Number: 20.505 Pass‐through: California Department of Transportation Award No. and Year: 74A0821, 2022/2023 Compliance Requirement: Reporting Type of Finding: Significant Deficiency over Compliance, Instance of Noncompliance Views of Responsible Officials and Corrective Action Plan: Management agrees with the finding. Delay in Caltrans approving the first quarter request for reimbursement and progress reports until January 24, 2023, as well as additional staff time needed to prepare the narrative information, resulted in the submittal of the second quarter reports nine days after the due date of January 30, 2023. Caltrans District 2 staff were notified early that there would be a delay in the reporting and indicated this was acceptable. This is an extraordinary occurrence, as it is SRTA’s common practice to submit all required reports before the deadline. Corrective Action Plan: The Agency will send a memorandum to all staff to ensure timely reporting of required quarterly reports in accordance with the agency’s established policies and procedures and compliance with the Master Fund Transfer Agreement that is active at the time of submittal. The Agency will also create reminders on the shared agency calendar that will be set to automatically alert the executive director, CFO, OWP manager, and relevant staff, of the deadline to submit the quarterly narratives to further eliminate the risk of late reporting. Responsible Individual(s): Sean Tiedgen, Executive Director and Jessica Carlson, Chief Fiscal Officer Anticipated Completion Date: June 30, 2024

West Community Development Corporation (dba BuCu West Development Center) is revising its financial procedures to ensure all federal grant transactions are recorded on an accrual basis. We are working closely with our financial team and external consultants to realign our reporting practices by the next fiscal year. This includes enhanced staff training and system upgrades to support accrual-based tracking and reporting.

Individuals Responsible for Corrective Action Plan: Kristine Steinmann, Alliance Director Shelby Mahoney, State Alliances Accounting Manager Corrective Action: The Alliance will enhance its procedures and internal controls around cash management to ensure that time between receipt of federal funds and payment to its local clubs is minimized. The Alliance will also request notification of funding from the agency. Anticipated Completion Date: December 31, 2024

Individual Responsible for Corrective Action Plan: Lana Taylor, Alliance Director Shelby Mahoney, State Alliances Accounting Manager State Corrective Action: The Alliance will enhance its procedures and internal controls around cash management to ensure that time between receipt of federal funds and payment to its local clubs is minimized. The Alliance will also request notification of funding from the agency. Anticipated Completion Date: December 31, 2024

Views of Responsible Officials and Planned Corrective Action: Management acknowledges the terminations. The Board of Directors of the Neighbor Network of Northern Nevada determined not to seek an appeal of the Department’s decision. No corrective action was requested, required, or deemed necessary.

2023-005. Match Source Documentation United States Department of Housing and Urban Development Continuum of Care Program ALN: 14.267 Condition: Source documentation was not maintained to support costs applied to the match. Recommendation: The Organization should maintain an accounting for all funds expended attributed to meeting the match requirement, as well as the source documentation. Corrective Action: The Organization will implement procedures to ensure accounting for funds expended, as well as source documentation, is maintained for costs attributed to meeting the match requirement. Responsible Contact Person(s): Dolores Kordon, Executive Director, will be responsible for resolving this matter. Anticipated Completion Date: December 31, 2024.

2023-003. Written Intake Procedures United States Department of Housing and Urban Development Continuum of Care Program ALN: 14.267 Condition: The Organization was unable to provide written policies and procedures with respect to intake and the calculation of rent. Recommendation: The Organization should complete the written policies and procedures to comply with the written intake documentation and rent calculation. Corrective Action: The Organization will maintain the written intake policies and procedures, as well as rent calculations. Responsible Contact Person(s): Dolores Kordon, Executive Director, will be responsible for resolving this matter. Anticipated Completion Date: December 31, 2024.

Views of Responsible Officials and Action Taken: FCE implemented new internal controls in the fourth quarter of 2023 and has continued to document all draw down requests, review thereof, and approvals.

Contact Person Responsible for Corrective Acton Plan: Debbie Nelson County AuditorCondition During testing, we note 1 material charge-out transaction where the item taken out of inventory was not supported with a signed requisition slip. Corrective Action Plan We agree. We will review the internal control process to verify all requisition slips get signed. Anticipated Completion Date Fiscal Year 2024

Views of Responsible Officials and Planned Corrective Actions The Organization have experienced turnover of staff in the Organization as well as changes in leadership. In response to this finding the Organization has put together a corrective action plan that targets training of staff and puts into place a monthly audit for ensuring compliance to the sliding fee discount policy. Responsible persons: Nichole Henderson, Quality Improvement Quality Assurance Director and Demetria Johnson, Billing Manager will be in charge of implementing the corrective action. Expected Implementation Date: Started August 1, 2024.

REFERENCE # 2023-002 OTHER - BASIS OF ACCOUNTING – SIGNIFICANT DEFICIENCY Program WIOA CLUSTER: WIOA ADULT PROGRAM (Assistance Listing Number 17.258) WIOA YOUTH ACTIVITIES – (Assistance Listing Number 17.259) WIOA DISLOCATED WORKER FORMULA GRANTS – (Assistance Listing Number 17.278) Identification Number(s) VARIOUS AND AA-36336-21-55-A-36 Finding The Suffolk County Department of Labor (the “Department”) receives WIOA Adult; Youth and Dislocated Worker Formula Grants from New York State Department of Labor (the “Agency”). The Department reports to the Agency on an accrual basis, as required by the Agency. The County’s Schedule of Expenditures of Federal Awards (the “SEFA”) is presented on the accrual basis of accounting. The Department provides all supporting documents to the Agency for reimbursement. We noted that the Department included expenditures in the amount of $373,855, which were incurred and dated in the prior year. The Department recorded the expenditures and revenue in the 2023 financial statements. These expenditures were also added to the SEFA in calendar year ended December 31, 2023. Questioned Costs Cannot be determined. Recommendation We recommend the Department report expenditures on the SEFA on the accrual basis of accounting, which is the basis the County utilizes for other federal programs. Corrective Action Plan Throughout the year, the Department will regularly reconcile vouchers to ensure that expenditures and associated revenue are reported in the correct year on the SEFA. Two staff members in the department (one as the primary, the other as the alternate) will be assigned the responsibility of tracking the SEFA reconciliation process. When preparing the annual SEFA, the department will reconcile expenditure reports with the expenditures reported on the annual SEFA. During year-end processing, the Department, when entering vouchers into the financial system, will ensure items to be accrued will contain the letter “A” as a prefix to the voucher number. The Department will also check to ensure all items that should be accrued, are in fact accrued prior to year-end closing. In addition, the Department will confirm the date entered in the financial system, reflects the proper year in which the expenditure and associated revenue should be recorded. Action Date This process will commence on September 16, 2024. Final Implementation Date Implementation of this plan will be completed by 2/28/25. We recognize that since this is a continuous improvement process, we will review the success of our implemented procedures on an annual basis. Name And Phone No. Of Person Responsible For Implementation Paul Goerke (primary) 631.853.6606 Yvonne Spreckels (alternate) 631.853.6628

Finding Reference Number: 2023-001 Identification of the Federal Program: Grantor: United States Department of Agriculture Program Name: Special Supplemental Nutrition Program for Women, Infant, and Children Assistance Listing No.: 10.557 Name of responsible official: James Geraghty Vice President, Faculty Practice Group Phone: (718) 430-3255 Email: james.geraghty@einsteinmed.edu Projected completion date: September 12, 2024 Condition In accordance with Title 2 U.S. Code of Federal Regulations, Part 200.303, Internal controls, “Establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award.” Management was unable to provide evidence of a control being consistently performed to address the risk that the Health System may seek reimbursement for expenditures that are either out of contract period or are for non-permissible costs under the applicable contracts. Status Management concurred with the audit finding and has implemented a standardized review and approval process that will be performed prior to monthly vouchers being submitted for reimbursement, including verification of allowability of expenditures, and that all expenditures were incurred in the proper period. Evidence of the monthly review and approval will be retained.

Finding 2023-003 – Fiscal Management System (Material Weakness) Criteria: CFR Part 200.302.b Auditee Responsibilities includes the requirement that the financial management system of each non-Federal entity provide the following: Identification, in its accounts, of all Federal awards received and expended and the Federal programs under which they were received. Accurate, current, and complete disclosure of the financial results of each Federal award or program. Condition: The District prepared reimbursement calculations according to an internally developed spreadsheet tool, rather than using amounts directly obtained from the general ledger and supporting documentation. The reimbursement reports were to be reviewed by the District Manager prior to submission. Approval of the reimbursement requests and supporting reports by the District Manager were often delayed. Cause: General ledger data used to prepare spreadsheets, then used to complete reimbursement requests added unnecessary complexity and potential for errors in the reimbursement and request and grant reporting process. Internal control procedures assuring timely review of reports and filing of the reimbursement requests were not designed or implemented. Effect or Potential Effect: The lack of effective internal control activities over financial reporting could allow for inadvertent errors, such as calculation errors, payments for unauthorized purposes, and result in improper financial reporting. Lack of timely filing of reimbursement requests could result in overstating accounts receivable balances and critical revenues lost due to cutoff terms of the grant award. Questioned Cost: No Context: Delays in filing reimbursement claims and internal disputes regarding grant reimbursement request procedures were evident. The weak or nonexistent controls over the reimbursement request procedures resulted in lost revenues and delayed recognition of revenue, which required adjustments to correct the financial statements. Repeat of a Prior-Year Finding: Yes, Financial Statement Findings 2022-001 Recommendation: The District should establish a more simplified and effective process for the review and approval of GAAP basis reporting and grant reimbursement requests and grant reporting. As part of this process, supporting general ledger reports and supporting data should be subject to a qualified individual to review and approval on a timely basis. Monitoring of the control procedures related to the grant accounting and reimbursement request should be performed regularly to ensure reports are filed accurately and timely. Information and communication regarding identified weaknesses and opportunities to improve the policies and procedures should occur among management and the individual performing the monitoring of the procedures. District's Response: The District’s Finance Manager and District Manager are working towards using general ledger reporting exclusively for reimbursement request reporting. General ledger activity became more timely as improvements were implemented based on prior year findings. Management acknowledges delays in that process that continued as a result, to some extent, of the use of the self-developed spreadsheet reports then used for completing grant reimbursement requests. Corrective Action Plan: The District’s Finance Manager will continue to make improvements in general ledger recording and reporting systems so that those reports can then be used without intermediary report methods to prepare reimbursement request forms. Review of the reimbursement requests will take place within data reports generated directly from the general ledger. The district will engage an individual or firm to ensure that the timing and overall processes related to grant reimbursement and reporting does not result in reporting errors or omissions. Planned Implementation Date: September 30, 2024 Responsible Person: General Manager, Umpqua Public Transit District

Finding 2023-002 - Source Documentation (Significant Deficiency) CFDA Title and Number: 20.513 (5310) Enhanced Mobility of Seniors and Individuals with Disabilities. Name of Federal Agency: Transit Services Program Cluster Internal Control over Compliance: Cash Management CFDA Title and Number: 20.509 (5311) CARES 5311 Operating Assistance. Formula Grants for Rural. Name of Federal Agency: Transit Services Program Cluster Internal Control over Compliance: Cash Management Criteria: 2 CFR Part 200.302(b)(1) The financial management system of each non-federal entity must provide for the following: Identification, in its accounts, of all Federal awards received and expended and the Federal programs under which they were received. 200.302(b)(2) Accurate, current, and complete disclosure of the financial results of each Federal award or program in accordance with the reporting requirements set forth in 200.328 and 200.329. Condition: The District prepared reimbursement calculations according to an internally developed spreadsheet tool, rather than using amounts directly obtained from the general ledger and supporting documentation. Cause: General ledger data used to prepare spreadsheets, then used to complete reimbursement requests added unnecessary complexity and potential for errors in the reimbursement and request and grant reporting process. Internal control procedures assuring accurate and timely review of reports and filing of the reimbursement requests were not designed or implemented. Effect or Potential Effect: The lack of effective internal control activities over financial reporting could allow for inadvertent errors, such as calculation errors, payments for unauthorized purposes, and result in improper grant accounting, reporting, and reimbursement. Questioned Cost: No Context: Internal disputes regarding grant reimbursement request procedures were evident. The weak or nonexistent controls over the reimbursement request procedures created a potential for inaccurate, incomplete reporting. Repeat of a Prior-Year Finding: Yes, Findings and Questioned Costs 2022-003 Recommendation: The District should continue to improve grant accounting efforts, and establish a more simplified and effective process for the review and approval of grant accounting and reimbursement requests. Additional training of management should occur to ensure they fully understand all compliance regulations and have the skills to assist in designing and implementing effective controls. Monitoring of the control procedures related to the grant accounting and reimbursement request should be performed regularly to ensure reports are filed accurately and timely. Information and communication regarding identified weaknesses and opportunities to improve the policies and procedures should occur among management and the individual performing the monitoring of the procedures. District's Response: The District’s Finance Manager and District Manager are working towards using general ledger reporting exclusively for reimbursement request reporting. General ledger activity became more timely as improvements were implemented based on prior year findings. Management acknowledges delays in that process that continued as a result, to some extent, of the use of the self-developed spreadsheet reports then used for completing grant reimbursement requests. Corrective Action Plan: The District’s Finance Manager will continue to make improvements in general ledger recording and reporting systems so that those reports can then be used without intermediary report methods to prepare reimbursement request forms. Review of the reimbursement requests will take place within data reports generated directly from the general ledger. The district will engage an individual or firm to ensure that the timing and overall processes related to grant reimbursement and reporting does not result in reporting errors or omissions. . Planned Implementation Date: September 30, 2024 Responsible Person: General Manager, Umpqua Public Transit District

2023-008 - Significant Deficiency in Internal Control and Non-material Noncompliance - Schedule of Expenditures of Federal Award Awareness and Preparation WPHW understands this finding and has already taken steps to ensure this issue does not come back up for FY24. The follow process has been put in place to ensure compliance: 1) Director of Accounting and Grants Director will ensure they have appropriate training and work collaboratively to develop documentation process a. The Grant Director will update all grants as they are received, to ensure an accurate list of grants b. The Director of Accounting will update all of the financial data for each grant 2) The Director of Accounting will be responsible for the review and submitting document to the auditing firm For FY24, the Director of Accounting and Grant Director will jointly build the document and review to ensure completeness and accuracy. In FY25, the schedule of expenditures of federal award will be prepared as the year progresses.

Planned Corrective Action: Executive Director will be tracking their time spent on specific grants on a weekly basis. The Board of Directors will review and approve the time summary at least quarterly. Executive Director non‐payroll reimbursements will also be reviewed and approved by at least one board member. The Program Director will provide oversight of these two newly established processes. Name of Contact Person: Rhonda Conn, Program Director Anticipated Completion Date: October 1, 2024

2022-002 Internal Control over Compliance and Compliance with Cash Management Contact: Karishma Borgohain-Menta Title: Senior Manager, HQ Accounting Phone Number: (202) 777-2297 Estimated Completion Date: December 31, 2024 Corrective Action Plan: Majority of the projects with the US government where search is prime implementer, are on monthly drawdown based on field office projections. We typically spend these funds within a reasonable time. However, Projects where SFCG is not the prime recipient have quarterly advance arrangements with Prime recipients and therefore liquidation typically takes approximately the same time. Search have not kept that money in interest bearing account. Guidance identified by the auditors is well noted and we will convert our non-interest-bearing accounts into interest-bearing accounts. Any interest earned will be reported as program income in the respective award.

REPORTING Recommendation: The County should design procedures and controls to ensure all reports are formally reviewed, all deadlines are met, and supporting documentation is retained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: The County will review procedures and implement changes as needed to ensure reports are formally reviewed, submitted timely, and proper documentation is retained. Name of the contact person responsible for corrective action: Charlene Dale, Human Services Supervisor Planned completion date for corrective action plan: December 31, 2024

Management has reviewed the loan requirements and will ensure that excess cash will not be pulled from the Project except as allowed under the Section 232 guidelines and at annual or semi‐annual intervals. Additional training was provided to the cash director as of November 2023 and will ensure that excess cash will not be pulled from the Project.

Recommendation: We recommend that the Organization implement policies and procedures to ensure subrecipients are paid within 30 days of when the billing is received. If the request is believed to be improper, support for the delay in payment should be maintained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: We will review and update our policies and procedures for managing accounts payable. Furthermore, we will provide additional orientation and training sessions focused on disbursements for subrecipients involved in federal grant programs. We will improve the enforcement of policies and procedures by setting up a system to track the receipt and payment of bills. Additionally, we will implement a weekly review by the compliance team to ensure that payments are made on time and that accurate documentation is retained to support any delays in payment requests that are found to be inappropriate. Name(s) of the contact person(s) responsible for corrective action: Jan Warren/Amber Henderson (Compliance), Haydee Hill (CFO) Planned completion date for corrective action plan: 12/30/2024

2023-003: Internal Controls over Cash Management Condition: An effective internal control system was not in place to ensure compliance with requirements related to the grant agreement and the Cash Management compliance requirements. Management’s Corrective Actions: Management is working to establish the policies and procedures for reviewing and approving reimbursement claims to ensure that the claims are properly prepared and submitted timely.

Type of Finding: Significant Deficiency in Compliance and Internal Control over Compliance Federal Agency: U.S. Department of Defense Federal Program Name: Conservation and Rehabilitation of Natural Resources on Military Installations Assistance Listing Number: 12.005 Federal Award Identification Number and Year: H79TI083313 - 2020 Award Period: September 28, 2020, through September 27, 2025 Criteria or specific requirement: 2 CFR 200.302(a) on Financial management states that "... the other non-Federal entity's financial management systems, including records documenting compliance with Federal statutes, regulations, and the terms and conditions of the Federal award, must be sufficient to permit the preparation of reports required by general and program-specific terms and conditions; and the tracing of funds to a level of expenditures adequate to establish that such funds have been used according to the Federal statutes, regulations, and the terms and conditions of the Federal award". Condition: During testing, 2 of the 5 samples selected did not include sufficient documentation to agree all amounts requested for reimbursement for the month in question to the expenditures listed in the general ledger detail by program. Questioned costs: Unknown. Context: A sample of 5 monthly reimbursement requests were taken from a population of 13. Of the 5 sampled, two were insufficiently supported to agree the amounts requested for reimbursement for the month in question to the expenditures listed in the general ledger detail by program. Cause: The Organization was using a cumulative profit and loss to file monthly reimbursement requests (beginning of the year through the reimbursement month). In addition, profit and loss reports were not consistently saved at the time the reports were prepared for reimbursement for January and February 2023. Effect: The Organization is currently in noncompliance with federal regulations with regard to adequate documentation. Without adequate documentation in place to ensure costs are evidenced and reconcile to the expenditures documented in the underlying accounting information that is used to prepare the SEFA, the Organization could incorrectly charge expenditures to the federal program, or not request appropriate reimbursement that the Organization is entitled to under the terms of the grant. Repeat Finding: The finding is a repeat of a finding in the immediately prior year. Prior year finding number was 2022-005. Recommendation: Starting in March 2023, the Organization has already implemented a new process for the preparation of monthly reimbursement requests, including documentation retention. Point-in-time reports (i.e., profit and losses) are saved at the time of report preparation. This has enhanced clarity of costs attributable to each monthly period and reduces the chance that costs will be missed when requesting for reimbursement. Views of responsible officials: There is no disagreement with the audit finding. Action taken in response to finding: Previous corrective actions were completed in April 2024 upon receipt of our FY 2022 Audit from CLA. As noted above, we believe these corrective actions would have captured most, if not all, of the findings if they were in place for the entire FY23 period. That said we continue to review and strengthen our internal controls and training for admin staff for preparing reimbursement requests. Name(s) of the contact person(s) responsible for corrective action: Gary Slater Planned completion date for corrective action plan: 10/1/2024