Audit 359166

Eligibility: Eligibility for Individuals Federal Program – Healthy Start Initiative Assistance Listing Number – 93.926 Material Weakness Criteria: The federal program specifies the criteria for determining the individuals or groups of individuals that can participate in the program. Condition/Context: Community Service Council of Greater Tulsa, Inc. (the Organization) did not have internal controls established for an independent review that the participants accepted into the program met the qualifying criteria. Eligibility may be determined by Organization employees or by certain health care facilities. Cause: The Organization did not perform an independent review of source data to verify participant eligibility. Effect: Lack of controls in place over acceptance of participants into the program increases the possibility that errors will be made when deciding who is eligible and the accuracy of data input into the system for tracking participants. Questioned Costs: Not applicable Identification as a repeat finding: Yes Recommendation: We recommend the Organization establish a control requiring participants to certify the accuracy of information. Additionally, the Organization should have an independent review of source data to verify participants are eligible and the accuracy of data entered into the system for tracking, and such review must be documented. Views of responsible officials and planned corrective actions: Management’s response is reported in “Corrective Action Plan” at the end of this report. The Healthy Start Program transitioned to another local non-profit October 31, 2023. The Council will no longer have direct control over their corrective action plan.

Participant Eligibility Federal Program – Supportive Housing for Veterans (Supportive Services for Veterans Families) (SSVF) Assistance Listing Number – 64.033 Significant Deficiency Criteria: The SSVF Program Guide (March 2021) Section V, Subsection C. Determining Income Eligibility, provides a summary of asset inclusions and exclusions for use in evaluating assets. Assets must be evaluated at entry to SSVF and at recertification. Condition/Context: The Office of Business Oversight (OBO) performed a review to assess the Organization’s compliance with SSVF program and other federal requirements and regulations. During this review, OBO found 45 case files missing evidence that the grantee evaluated assets (inclusions and exclusions) for certification of eligibility. Cause: Management misinterpreted the guidance and was not aware of the need to document asset evaluations if the veteran did not have any assets. Effect: The Organization’s failure to obtain and keep adequate income supporting documentation in the case files may result in the Organization providing services to an ineligible veteran or household. Questioned Costs: None Identification as a repeat finding: N/A Recommendation: We noted the Organization implemented the required use of the SSVF Asset Calculation Worksheet; updated the Organization’s policies and procedures to document the new processes; and provided training to individuals authorized to prepare eligibility documents and maintain case file documentation. We recommend management continue to monitor the use of these added procedures and to review program requirements on at least an annual basis. Views of responsible officials and planned corrective actions: Management’s response is reported in “Corrective Action Plan” at the end of this report.

Program Operations Federal Program – Supportive Housing for Veterans (Supportive Services for Veterans Families) (SSVF) Assistance Listing Number – 64.033 Significant Deficiency Criteria: The SSVF Program Guide (March 2021) Section VII, Subsection E. Notification to Participants, states: “To ensure that Veteran families receiving supportive services under the SSVF Program are receiving quality services, the grantee must give a VA-designated satisfaction survey to each participant within 30 days of the participant’s pending exit from the grantee’s program.” Condition/Context: The Office of Business Oversight (OBO) performed a review to assess the Organization’s compliance with SSVF program and other federal requirements and regulations. During this review, OBO found 15 case files where the Organization provided the VA-designated satisfaction survey late. Cause: As a result of staff turnover, the Organization failed to develop adequate internal controls to ensure management monitored case manager development and reviewed case files for adequate documentation. Effect: The Organization’s failure to provide the VA-designated satisfaction survey within 30 days may decrease feedback to the SSVF Program, which may result in veterans not receiving appropriate assistance and quality services. Questioned Costs: None Identification as a repeat finding: N/A Recommendation: We noted the Organization updated the Organization’s policies and procedures to reflect revised expectations and use of the VA-designated satisfaction survey; provided training to staff on new processes and maintains a list of personnel trained for auditor review; and as management reviews files for discharge, the VA Satisfaction Survey is reviewed for date of submission. We recommend management continue to monitor the use of these added procedures and to review program requirements on at least an annual basis. Views of responsible officials and planned corrective actions: Management’s response is reported in “Corrective Action Plan” at the end of this report.

Financial Management Federal Program – Supportive Housing for Veterans (Supportive Services for Veterans Families) (SSVF) Assistance Listing Number – 64.033 Significant Deficiency Criteria: The SSVF Program Guide Section VIII, Fiscal Administration, Subsection E. Documentation Required, states: “Grantees must use adequate financial management systems that follow generally accepted accounting principles (GAAP) and provide adequate fiscal control and account records including cost accounting records supported by documentation. Grantees must also maintain all back up documentation and invoices to support the costs paid with SSVF funds.” Condition/Context: During the OBO review, OBO found the Organization was unable to provide a general ledger detail that separated administrative costs from general costs. Cause: Because the Organization’s SSVF administrative costs are allocated payroll expenses, management was unaware they needed to segregate the administrative costs in the general ledger. Effect: The Organization’s failure to provide a general ledger that separates administrative and general expenses increases the risk of inaccurate financial results being provided at closeout or unauthorized and ineligible expenses being charged to the award, which may result in subsequent funding shortages for other qualified expenses. Questioned Costs: None Identification as a repeat finding: N/A Recommendation: We recommend the Organization update the coding in the financial system to include different classes under the administrative code. Views of responsible officials and planned corrective actions: Management’s response is reported in “Corrective Action Plan” at the end of this report.

Eligibility: Eligibility for Individuals Federal Program – Healthy Start Initiative Assistance Listing Number – 93.926 Material Weakness Criteria: The federal program specifies the criteria for determining the individuals or groups of individuals that can participate in the program. Condition/Context: Community Service Council of Greater Tulsa, Inc. (the Organization) did not have internal controls established for an independent review that the participants accepted into the program met the qualifying criteria. Eligibility may be determined by Organization employees or by certain health care facilities. Cause: The Organization did not perform an independent review of source data to verify participant eligibility. Effect: Lack of controls in place over acceptance of participants into the program increases the possibility that errors will be made when deciding who is eligible and the accuracy of data input into the system for tracking participants. Questioned Costs: Not applicable Identification as a repeat finding: Yes Recommendation: We recommend the Organization establish a control requiring participants to certify the accuracy of information. Additionally, the Organization should have an independent review of source data to verify participants are eligible and the accuracy of data entered into the system for tracking, and such review must be documented. Views of responsible officials and planned corrective actions: Management’s response is reported in “Corrective Action Plan” at the end of this report. The Healthy Start Program transitioned to another local non-profit October 31, 2023. The Council will no longer have direct control over their corrective action plan.

Participant Eligibility Federal Program – Supportive Housing for Veterans (Supportive Services for Veterans Families) (SSVF) Assistance Listing Number – 64.033 Significant Deficiency Criteria: The SSVF Program Guide (March 2021) Section V, Subsection C. Determining Income Eligibility, provides a summary of asset inclusions and exclusions for use in evaluating assets. Assets must be evaluated at entry to SSVF and at recertification. Condition/Context: The Office of Business Oversight (OBO) performed a review to assess the Organization’s compliance with SSVF program and other federal requirements and regulations. During this review, OBO found 45 case files missing evidence that the grantee evaluated assets (inclusions and exclusions) for certification of eligibility. Cause: Management misinterpreted the guidance and was not aware of the need to document asset evaluations if the veteran did not have any assets. Effect: The Organization’s failure to obtain and keep adequate income supporting documentation in the case files may result in the Organization providing services to an ineligible veteran or household. Questioned Costs: None Identification as a repeat finding: N/A Recommendation: We noted the Organization implemented the required use of the SSVF Asset Calculation Worksheet; updated the Organization’s policies and procedures to document the new processes; and provided training to individuals authorized to prepare eligibility documents and maintain case file documentation. We recommend management continue to monitor the use of these added procedures and to review program requirements on at least an annual basis. Views of responsible officials and planned corrective actions: Management’s response is reported in “Corrective Action Plan” at the end of this report.

Program Operations Federal Program – Supportive Housing for Veterans (Supportive Services for Veterans Families) (SSVF) Assistance Listing Number – 64.033 Significant Deficiency Criteria: The SSVF Program Guide (March 2021) Section VII, Subsection E. Notification to Participants, states: “To ensure that Veteran families receiving supportive services under the SSVF Program are receiving quality services, the grantee must give a VA-designated satisfaction survey to each participant within 30 days of the participant’s pending exit from the grantee’s program.” Condition/Context: The Office of Business Oversight (OBO) performed a review to assess the Organization’s compliance with SSVF program and other federal requirements and regulations. During this review, OBO found 15 case files where the Organization provided the VA-designated satisfaction survey late. Cause: As a result of staff turnover, the Organization failed to develop adequate internal controls to ensure management monitored case manager development and reviewed case files for adequate documentation. Effect: The Organization’s failure to provide the VA-designated satisfaction survey within 30 days may decrease feedback to the SSVF Program, which may result in veterans not receiving appropriate assistance and quality services. Questioned Costs: None Identification as a repeat finding: N/A Recommendation: We noted the Organization updated the Organization’s policies and procedures to reflect revised expectations and use of the VA-designated satisfaction survey; provided training to staff on new processes and maintains a list of personnel trained for auditor review; and as management reviews files for discharge, the VA Satisfaction Survey is reviewed for date of submission. We recommend management continue to monitor the use of these added procedures and to review program requirements on at least an annual basis. Views of responsible officials and planned corrective actions: Management’s response is reported in “Corrective Action Plan” at the end of this report.

Financial Management Federal Program – Supportive Housing for Veterans (Supportive Services for Veterans Families) (SSVF) Assistance Listing Number – 64.033 Significant Deficiency Criteria: The SSVF Program Guide Section VIII, Fiscal Administration, Subsection E. Documentation Required, states: “Grantees must use adequate financial management systems that follow generally accepted accounting principles (GAAP) and provide adequate fiscal control and account records including cost accounting records supported by documentation. Grantees must also maintain all back up documentation and invoices to support the costs paid with SSVF funds.” Condition/Context: During the OBO review, OBO found the Organization was unable to provide a general ledger detail that separated administrative costs from general costs. Cause: Because the Organization’s SSVF administrative costs are allocated payroll expenses, management was unaware they needed to segregate the administrative costs in the general ledger. Effect: The Organization’s failure to provide a general ledger that separates administrative and general expenses increases the risk of inaccurate financial results being provided at closeout or unauthorized and ineligible expenses being charged to the award, which may result in subsequent funding shortages for other qualified expenses. Questioned Costs: None Identification as a repeat finding: N/A Recommendation: We recommend the Organization update the coding in the financial system to include different classes under the administrative code. Views of responsible officials and planned corrective actions: Management’s response is reported in “Corrective Action Plan” at the end of this report.