Corrective Action Plans

COMMONWEALTH OF PUERTO RICO CORRECTIVE ACTION PLAN MUNICIPALITY OF NARANJITO FOR THE FISCAL YEAR ENDED JUNE 30, 2023 Audit Report: Reports on Compliance and Internal Control in Accordance with Government Auditing Standards and 2 CFR 200 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards Audit Period: July 1, 2022 – June 30, 2023 Fiscal Year: 2022-2023 Principal Executive: Hon. Orlando Ortíz Chevres - Mayor Contact Person: Mrs. Belinda Álvarez, Finance Director Phone: (787) 869 – 2200 Original Finding Number: 2023-005 Statement of Concurrence or Nonconcurrence: We concur with the finding. Corrective Action : Quarterly Progress Reports for large projects will be prospectively adjusted to reflect expenditures incurred over the reporting period. Implementation Date: March 31, 2025 Responsible Person: Mrs. Belinda Álvarez - Finance Department Director

We understand how crucial it is to have strong policies and procedures in place. Here’s how we plan to move forward: 1. Review of Existing Policies and Procedures: We’re currently taking a close look at our existing policies and procedures to ensure they align with the Uniform Guidance. This will help us identify any gaps and make necessary updates so that we’re fully compliant. 2. Development of New Policies: Alongside this review, we will create clear and comprehensive written policies in key areas, such as: • Cash Management: Setting up procedures that comply with 2 CFR 200.305 to ensure timely payments. eCFR :: 2 CFR 200.305 -- Federal payment. • Allowability of Costs: Crafting guidelines that follow Subpart E—Cost Principles, so we can confidently determine which expenses are allowable. https://www.ecfr.gov/current/title-48/chapter-7/subchapter-E/part-731/subpart-731.7/section-731.770. • Conflict of Interest: Establishing standards of conduct that address potential conflicts and promote transparency. • Equipment and Real Property Management: Developing policies for managing equipment acquired under federal awards in line with 2 CFR 200.313(b). eCFR :: 2 CFR 200.313 -- Equipment. • Procurement Procedures: Creating clear procurement guidelines that align with 2 CFR 200.318 through 200.326 to ensure fairness and oversight. eCFR :: 2 CFR 200.318 -- General procurement standards. 3. Training and Communication: The Finance Department will be responsible for training all staff involved in managing federal awards. Training sessions will ensure that everyone understands the requirements and their roles in maintaining compliance. This training will be completed by December 31, 2024. Personnel responsible: Eduardo Cedeno, Director of Finance Anticipated completion date: December 31, 2024

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

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

Management agrees with the finding and is in process of developing and implementing the appropriate policies and procedures.

Finding Number: 2023-003 Condition: The Organization does not have written procedures to implement the requirements of CFR 200.305. The advance payment of the Federal award was not maintained in an interest-bearing account and no interest was remitted back to the Federal government. Planned Corrective Action: Management is in the process of updating written procedures for Federal award compliance. Management will calculate and remit interest for 2023 to the Department of Health and Human Services Payment Management System (PMS). Contact person responsible for corrective action: Manas Mehandru, COO Anticipated Completion Date: October 15, 2024

Condition: The Township's March 31, 2024 report overstated expenses incurred for the reporting period by approximately $600,000. Planned Corrective Action: Molly Phillips and Katelyn Massey are working together to ensure that the expenses will be reported within the year they are incurring, and allocated into the correct funds as approved by the Township Board. Contact person responsible for corrective action: Molly Phillips and Katelyn Massey Anticipated Completion Date: 12/31/2024

The Finance Director was responsible for ensuring that bank accounts are reconciled accurately and on a monthly basis. Due to performance, the finance director has been terminated and the agency has contracted with a CPA firm to review and make any corrections to account reconciliations.

FINDING 2023-003 Finding Subject: COVID-19 Coronavirus State and Local Fiscal Recovery Funds- Activities Allowed and Unallowed. Summary of Finding: Material Weakness, Modified Opinion Contact Person Responsible for Corrective Action: Mary Fletcher Contact Phone Number and Email Address: (765) 998-7439, mfletcher@uplandindiana.com Views of Responsible Officials: We concur with the finding Description of Corrective Action Plan: Although the funds were transferred to utilities and not paid directly from ARPA Funds, the funds were used to make necessary investments in utility infrastructure during 2023. We have been fully informed of the guidelines for the use of the ARPA funds since this transfer occurred and will use the remaining funds according to the ARPA guidelines. The Clerk-Treasurer has contacted the Department of the Treasury to get guidance on what can be done to rectify our misuse of the funds. Anticipated Completion Date: Unknown- When a resolution is reached with the Federal Government.

CORRECTIVE ACTION PLAN The Spero Project, Inc. ( “Organization”), respectfully submits the following corrective action plan for the year ended December 31, 2023. Name and address of independent public accounting firm: HSPG & Associates, 5400 N. Grand Blvd., Suite 330, Oklahoma City, OK 73112. Audit period: As of and for the year ended December 31, 2023. The findings from the December 31, 2023, schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FEDERAL AWARDS FINDINGS – COMPLIANCE AND INTERNAL CONTROL Identifying Number: 2023-001; Lack of Written Policies and Procedures Recommendation: The Organization should develop and implement comprehensive written policies and procedures in accordance with the requirements of the Uniform Guidance. These should include, but not be limited to, the following areas: 1. Financial management, including procedures for payments and cash management. 2. Internal controls to ensure compliance with federal requirements. 3. Determination of allowable costs in accordance with federal regulations and the terms and conditions of the award. 4. Procurement standards and conflict of interest policies. 5. Time and effort reporting and compensation. The Organization should also ensure that staff are adequately trained in these policies and procedures to enhance compliance and operational efficiency. Action Taken: In response to the finding, management and will take action to develop and implement the necessary written policies and procedures by December 31, 2024. Comprehensive training will be provided to all relevant staff to ensure compliance with federal requirements. Anticipated completion date: December 31, 2024 Name of contact person and title: Ms. Kim Bandy, Executive Director

Finding 2023-006 – Coronavirus State and Local Fiscal Recovery Funds - Reporting (Significant Deficiency) Criteria: "The financial management system of each non-Federal entity must provide for the following: (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 Financial reporting . . . ." 34 CFR 76.722 states: "A State may require a subgrantee to submit reports in a manner and format that assists the State in complying with the requirements under 34 CFR 76.720 and in carrying out other responsibilities under the program." Context: There was no documented review by someone other than the preparer of the annual report to ensure the information submitted was complete and accurate. Per discussion with management, verbal review occurred but there is no documentation to support that review occurred. Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Management will ensure that review of the annual report is documented. Responsible Party and Timeline for Completion: The Clerk-Treasurer is the responsible party. The completion will go into effect in 2024.

FINDING 2023-003 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Allowable Costs/Cost Principles Summary of Finding: The County Council did not have an Allowable Cost policy in place during the audit period and supporting contracts for agreements with recipients of the grant funds could not be provided for the audit. Contact Person Responsible for Corrective Action: Amy Scarbrough Contact Phone Number and Email Address: 812-268-4491 ascarbrough@sullivancounty.in.gov Views of Responsible Officials: We concur with the finding Description of Corrective Action Plan: We concur with the finding. The County will adopt an allowable cost policy and the County Auditor will review all supporting documentation with claims to ensure that proper contracts or interlocal agreements are included with the claims for of the grant. Anticipated Completion Date: October, 2024

FINDING 2023-001 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Period of Performance, and Procurement and Suspension and Debarment Summary of Finding: (copied from SBOA Findings document provided) The Allen County Department of Health (Department of Health), a department within Allen County, was awarded the Health Issues and Challenges grant through the Indiana Department of Health financed through the American Rescue Plan Act (ARPA) for the purpose of funding programs that focus on the improvement of chronic disease, specifically, elevated blood lead level reduction. The Health Issues and Challenges grant is a reimbursable grant, whereby the County received reimbursement on a percase basis at a stated rate for Case Management and Environmental Investigation activities performed. The Department of Health received federal receipts related to the grant in the amount of $130,479 during 2023. As part of sound management of the Federal award, the Department of Health was responsible for implementing a system of internal control that would ensure compliance with the applicable requirements. The Department of Health did not properly design or implement such a system. Receipts of the program were adequately identified through the use of an account number within the County Health Fund (285) in the Allen County's ledger (ledger) which was unique to the Health Issues and Challenges grant receipts. However, the ledger did not adequately identify the expenditures of the grant program within the County Health Fund. Through inquiry with the Department of Health employees and review of unitprepared support of grant expenditures, we determined expenditures were made with grant funds during the audit period, however, we were unable to distinguish between the expenditures of the Health Issues and Challenges grant and all other activities of the Department of Health in the County Health Fund. Due to the lack of separate identification of expenditures in the financial records, we were not able to establish a population from which to audit the Health Issues and Challenges grant for compliance with the following compliance requirements of the program: 􀁸 Activities Allowed or Unallowed 􀁸 Allowable Costs/Cost Principles 􀁸 Period of Performance 􀁸 Procurement and Suspension and Debarment As such, the full award amount of $130,479, as reported on the Schedule of Expenditures of Federal Awards, was determined to be questioned costs. The lack of internal controls and noncompliance were systemic issues throughout the audit period. Recommendation: We recommend that management of the Health Department establish a system of internal controls to ensure that grant award funds are adequately accounted for and tracked in such a manner as to determine the activity, receipts and disbursement, associated with the grant. ………………………… Contact Person Responsible for Corrective Action: JENNIFER MILLER (Finance Director) Contact Phone Number and Email Address: 260-449-7358 (Jennifer.miller@allencounty.us) Views of Responsible Officials: We concur with the finding Explanation and Reasons for Disagreement: N/A Description of Corrective Action Plan: When we were informed of the outcomes of the SBOA audit and the subsequent needs for a corrective action plan (CAP) relative to their findings, we moved quickly to begin the development of the CAP. We feel this finding/issue could be easily remedied by following our normal procedure for grants, whereby we develop a new fund, craft a Fund Ordinance for approval by the Allen County Commissioners to establish said new fund, and then subsequently track all expenditures and reimbursements in the separate fund vs. utilizing a line item for deposits in the main Health Fund as was done with this grant (which lacked the ability to denote exact salary expenditures and such next to each payment as it was all done within the larger fund for all staff and expenses. We were not aware of this need. THE PLAN (which will be added as a new “Grants” section in our existing Finance Internal Controls policies): For all grants (reimbursable or deliverables-based), once a contract is near completion or upon execution, a separate fund will be created through development and approval of a local fund ordinance. All expenditures allowed by said grant and all reimbursements received by the grant funder will be tracked solely and only within the separate grant fund that is tied to the signed contract from the funder. If there are staff payments for salaries or benefits being reimbursed by a grant, we will ensure that: (1) the hours/minutes per staff member per pay period for all work associated with these grant duties are tracked appropriately so as to ensure we are invoicing the grant funder for the exact and accurate work hours (regardless of whether or not the grant contract specifies this be tracked or reimbursed per minute/hour, as most do not require this); and (2) these amounts will be noted alongside the expenditures in the grant fund for clarity upon invoicing or auditing. Anticipated Completion Date: We will follow this practice for any new grants accepted by the Allen County Department of Health effective 9/17/2024. This is the standard practice for most grants we have accepted, and therefore, we will not vary from this practice in the future even if given permission to do so.

U.S. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT 2023-001 Coronavirus Local Fiscal Recovery– Assistance Listing No. 21.027 Recommendation: We recommend that the Authority implements a control to ensure that the preliminary SEFA is mostly accurate so that the correct programs are tested. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Finance Department has implemented several processes and procedures to ensure pass-through funds or sub-awards are reported timely and accurately in the SEFA. The new processes include (1) review of grant award letters to determine reporting requirements, (2) comparing the award letter against the Minutes of the City Council or County Commissioners meetings to ensure grants accepted during the year are disclosed as such on both ends, (3) confirmed with source Agency Single Audit requirements, (4) and the implementation of revenue source checklist that will identify the source of the funds, type of grant, program name and cluster title, name of federal funding agency, federal assisting listing number (formerly known as CFDA number), etc. Name(s) of the contact person(s) responsible for corrective action: Hector Ordonez, Vice President of Finance and Administration Planned completion date for corrective action plan: December 31, 2024 If the U.S. Department of Housing and Urban Development has questions regarding this plan, please contact Hector Ordonez, Vice President of Finance and Administration at (817) 333-3421 or hordonez@fwhs.org.

FINDING 2023-002 Finding Subject: COVID- 19 – Education Stabilization Fund - Reporting Summary of Finding: The School Corporation completed and submitted three annual Data Collection reports (Reports) for the ESSER grants. For one of the three reports tested, the report was not supported by the unit’s records. The financial information provided did not agree with the data submitted in the Reports, therefore we could not determine their accuracy. Contact Person Responsible for Corrective Action: Matt Miles Contact Phone Number and Email Address: 317-423-8380 mattmiles@msdlt.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The School District will work to ensure the ESSER report amounts tie to the accounting records and will improve record keeping of supporting documentation. If the amounts do not match, District will document support for all claims. Anticipated Completion Date: Corrective action steps have been implemented and will be refreshed.

FINDING 2023-003 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Activities Allowed or Unallowed, Allowable Costs / Cost Principles, Period of Performance Summary of Finding: Material Weakness, Modified Opinion Contact Person Responsible for Corrective Action: Bri Lautzenheiser Contact Phone Number and Email Address: bri@blufftonindiana.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Any transfers that happen, will be reviewed, and will have better documentation of what claims made the transfer happen and make sure supporting documentation is attached to the claim to prove the use of the transferred funds. Anticipated Completion Date: Immediately

Significant Deficiency in Internal Control over Compliance, Other Matters 2023-002 Reporting Recommendation: We recommend the County review its processes and implement controls to formally review these quarterly reports and that they are compared and reconciled to the general ledger. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: The County is planning a more in-depth checklist of accounts to be reconciled and journal entries to be made along with regular check in and team meetings to meet the deadlines. Name(s) of the contact person(s) responsible for corrective action: Michelle Uitenbroek, Finance Director Planned completion date for corrective action plan: December 31, 2024 If the granting agencies have questions regarding this plan, please call Michelle Uitenbroek, Finance Director at 920-832-1674.

Internal Controls over Grant Management (Significant Deficiency and Noncompliance) Recommendation: We recommend the City develop a grants manual or additional written policies that comply with the requirements of 2 CFR 200 and ensure compliance. Response to 2023-005: Internal Controls over Grant Management Significant Deficiency and Non-Compliance In response to the Deficiency in the City of Tallassee’s corrective action plan, the City is in the process of establishing a written financial management system in accordance with 2 CFR 200.302 to include written procedures to implement requirements for payment methods and determine allowability of costs in accordance with subpart E. Due to the City of Tallassee being a small town, we did not have the staff available prior to receiving the grant monies to complete the task due in part to the lack of individuals looking for work in a rural sparsely populated area. Because of our lack of personnel the project was not completed. The City of Tallassee has financial management internal controls in place. All of the City’s grant activities (Federal and State) are tracked in funds under unique assigned general ledger numbers for each grant awarded to the City. All 2019-CWSRL-DL funds are deposited into a dedicated bank account and are not co-mingled with other funds of any kind. The City also contracts out grant management to certified and approved grant management commissions and engineering firms for required tracking and reporting to the appropriate state and federal agencies.

SECTION III – FEDERAL AWARD FINDINGS AND QUESTIONED COSTS 2023-002 Material Weakness Reporting Criteria and Condition: While the Organization has some written financial management procedures documentation, it does not meet all the recent specific requirements under 2 CFR 200.302 in the Uniform Grant Guidance. Context: The financial management requirements under 2 CFR 200.302 require each non-federal entity maintain effective control over, and accountability for all funds, property, and other assets, including having written procedures in place. Key changes which effect the Organization include: • Increased documentation • Time and effort reporting for payroll • Specific purchasing consideration Cause: The Borough did not implement adequate controls to ensure compliance with this reporting requirement. Potential Effect: Errors could occur in financial reporting. Recommendation: We recommend the Organization update its existing policies to comply with the requirements under 2 CFR 200.302. Views of Responsible Officials and Planned Corrective Actions: Management understands the importance of defining and following the necessary policies and procedures to remain in compliance with the requirements under 2 CFR 200.302. Borough of Yardley will implement these policies and procedures to ensure that the organization will comply going forward. Repeat: Repeat finding from 2017-002 Action Taken: The Borough will review guidance and create missing policies. Anticipated Completion: During 2024.

2023-002 U.S. Department of Environment Protection – Assistance Listing # 66.468 Capitalization Grants for Drinking Water State Revolving Fund (Drinking Water State Revolving Fund Cluster) Lack of Required Written Policies & Procedures – Compliance Condition & Criteria: The Authority does not currently have all the written policies and procedures in place as required by the Uniform Guidance as it relates to financial management and determining allowability of costs for the federal program (Title 2 U.S. Code of Federal Regulations (CFR) 200.302 & 200.305). In addition CFR sections 200.318, 200.319, and 200.320 require there to be written policies and procedures regarding procurement and conflicts of interest. Planned Corrective Action: The water systems improvements federally funded project is the Authority’s first time subject to the requirements of the Uniform Guidance as we have not had any significant grant funding since 2004. The Authority does have a set of informal policies and procedures that are followed as it relates to financial management, allowability of costs, procurement, and conflicts of interest, and have been very careful to carry out all federal program activities in accordance with established regulations; however, the Authority was simply not aware of the requirement that these polices and procedures be documented in writing. The Authority has been working over the past year to draft and develop these policies and procedures as they relate to federal programs, and to get them documented in writing. The Authority is currently working with their attorney to have the written polices established and plan to have this completed within the next fiscal year. Once the required policies are written, the Board of the Authority will review the policies, revise as appropriate, and adopt the policies for the Authority to comply with the federal funding requirements.

The finding arose due to conditions created as a result of turnover experienced by the Center within the finance department, expense reimbursement requests were inadvertently completed incorrectly using incorrect allocation percentages and information. Additional preventative internal control procedures will be implemented, including an additional level of review of the reimbursement request prior to submission.

Following the Auditor's recommendations and as a corrective action, the staff or department in charge locate and document all required reports that were filed according to the requirements of the grant agreement, including the reconciliation thereof with the official Municipality’s accounting subsidiaries. In addition, the Municipality will design, document, establish and provide the necessary and required training, including guidelines and procedures, to all personnel who work directly or indirectly with the management of these federal funds. The Finance Department personnel continue to carry out the process of locating the remaining reports and documents as submitted in order to be filed according to the requirements of the grant agreement.

Following the Auditor's recommendations and as a corrective action, the staff or department in charge locate and document all required reports that were filed according to the requirements of the grant agreement, including the reconciliation thereof with the official Municipality’s accounting subsidiaries. In addition, the Municipality will design, document, establish and provide the necessary and required training, including guidelines and procedures, to all personnel who work directly or indirectly with the management of these federal funds. The Finance Department personnel continue to carry out the process of locating the remaining reports and documents as submitted in order to be filed according to the requirements of the grant agreement.

September 9, 2024 Re: SAMHSA Notice of Award for 6H79SM083161-01M003 MTBH submitted our budget based on anticipated salary costs for new hires, which we believe stayed at or below our actual costs. We made available all necessary documentation requested from payroll, grant-related expenses, grant reports and timekeeping records to Wade Stables P.C for review. We did not have the grant in our financial software as we were beginning a migration to new software during the early stages of the grant; therefore, we tracked that grant on an excel spreadsheet that annually was provided to our auditors. Most of the staff assigned to the grant were full-time staff, so time allocation was easily tracked. For the few staff that were part-time we had designated codes in our Electronic Medical Record to identify work done on behalf of the grant. In response to Finding 2023-001- B Allowable Costs, we agree with the Statement of Cause citing the exponential growth of the organization regarding preparedness for a first-time grant award of this size being our largest challenge. Initially we were informed we had not received the grant then, due to additional COVID funding, we were invited to participate in the grant with a very short turnaround to finalize budgets and hire staff. Our salaries are consistent with the positions designated in the grant and in a few cases our staff salaries exceeded the allowable costs; therefore, those allowable costs were used to calculate the drawdown. MTBH did not have an established de minimis rate; therefore, we used the 10% designated rate associated with the grant. The interactive Budget Narrative Form template, required per SAMHSA guidelines, had 10% built into the template. If afforded future opportunities to secure a SAMSHA grant, we would be better positioned to execute the financial management in our SAGE software to segregate costs for the purpose of tracking the expenditures associated agency grant operations. Currently all agency expenditures have transferred into SAGE by our Vice President of Finance, Jenny Haught MBA, which would also be the Responsible Official to fiscally manage future grants. Respectfully, Angela Caraway, VP of Clinical Operations