Audit 359454

Criteria: In accordance with the Uniform Guidance, the Single Audit report must be submitted to the designated Federal Audit Clearinghouse (FAC) within 30 days of receipt or 9 months after the end of the audit period, whichever is earlier. Condition: The Single Audit report was not completed within 9 months after the end of the audit period. Cause: Personnel turnover within the Organization in addition to a delay in the prior year’s audit being completed. Effect: Failing to file a Single Audit report on time can result in several consequences, including federal funding restrictions, penalties, and potential legal actions. These consequences can impact an Organization's ability to receive and utilize federal funds. Repeat Finding: Yes – The Single Audit report for the year ended September 30, 2021 was not completed within 9 months after the end of the audit period. Recommendation: The Organization should close out the year end on a timely basis so that there is adequate time to complete the Single Audit and corresponding report within the required timeframe. Response: To address this finding, the Finance Department will be implementing the following procedures: • Continuing to recruit for key positions such as the Controller position and another Accountant position. • A month-end and year-end closing process will be implemented. This process will be consistently applied to ensure compliance by the finance staff. • Account reconciliations will be performed monthly as part of the month end closing process. • Analytics will be performed to determine consistency, completeness and accuracy of data in comparison to prior period. Significant variances will be investigated to determine completeness and accuracy of financial information. • The year-end close will be completed within sixty days but no more than 90 days after the end of the fiscal year. The annual audit will be scheduled during this timeline and shall commence after year-end closing is completed.

Criteria: In accordance with the Uniform Guidance, the Single Audit report must be submitted to the designated Federal Audit Clearinghouse (FAC) within 30 days of receipt or 9 months after the end of the audit period, whichever is earlier. Condition: The Single Audit report was not completed within 9 months after the end of the audit period. Cause: Personnel turnover within the Organization in addition to a delay in the prior year’s audit being completed. Effect: Failing to file a Single Audit report on time can result in several consequences, including federal funding restrictions, penalties, and potential legal actions. These consequences can impact an Organization's ability to receive and utilize federal funds. Repeat Finding: Yes – The Single Audit report for the year ended September 30, 2021 was not completed within 9 months after the end of the audit period. Recommendation: The Organization should close out the year end on a timely basis so that there is adequate time to complete the Single Audit and corresponding report within the required timeframe. Response: To address this finding, the Finance Department will be implementing the following procedures: • Continuing to recruit for key positions such as the Controller position and another Accountant position. • A month-end and year-end closing process will be implemented. This process will be consistently applied to ensure compliance by the finance staff. • Account reconciliations will be performed monthly as part of the month end closing process. • Analytics will be performed to determine consistency, completeness and accuracy of data in comparison to prior period. Significant variances will be investigated to determine completeness and accuracy of financial information. • The year-end close will be completed within sixty days but no more than 90 days after the end of the fiscal year. The annual audit will be scheduled during this timeline and shall commence after year-end closing is completed.

Criteria: In accordance with the Uniform Guidance, the Single Audit report must be submitted to the designated Federal Audit Clearinghouse (FAC) within 30 days of receipt or 9 months after the end of the audit period, whichever is earlier. Condition: The Single Audit report was not completed within 9 months after the end of the audit period. Cause: Personnel turnover within the Organization in addition to a delay in the prior year’s audit being completed. Effect: Failing to file a Single Audit report on time can result in several consequences, including federal funding restrictions, penalties, and potential legal actions. These consequences can impact an Organization's ability to receive and utilize federal funds. Repeat Finding: Yes – The Single Audit report for the year ended September 30, 2021 was not completed within 9 months after the end of the audit period. Recommendation: The Organization should close out the year end on a timely basis so that there is adequate time to complete the Single Audit and corresponding report within the required timeframe. Response: To address this finding, the Finance Department will be implementing the following procedures: • Continuing to recruit for key positions such as the Controller position and another Accountant position. • A month-end and year-end closing process will be implemented. This process will be consistently applied to ensure compliance by the finance staff. • Account reconciliations will be performed monthly as part of the month end closing process. • Analytics will be performed to determine consistency, completeness and accuracy of data in comparison to prior period. Significant variances will be investigated to determine completeness and accuracy of financial information. • The year-end close will be completed within sixty days but no more than 90 days after the end of the fiscal year. The annual audit will be scheduled during this timeline and shall commence after year-end closing is completed.

Criteria: In accordance with the Uniform Guidance, the Single Audit report must be submitted to the designated Federal Audit Clearinghouse (FAC) within 30 days of receipt or 9 months after the end of the audit period, whichever is earlier. Condition: The Single Audit report was not completed within 9 months after the end of the audit period. Cause: Personnel turnover within the Organization in addition to a delay in the prior year’s audit being completed. Effect: Failing to file a Single Audit report on time can result in several consequences, including federal funding restrictions, penalties, and potential legal actions. These consequences can impact an Organization's ability to receive and utilize federal funds. Repeat Finding: Yes – The Single Audit report for the year ended September 30, 2021 was not completed within 9 months after the end of the audit period. Recommendation: The Organization should close out the year end on a timely basis so that there is adequate time to complete the Single Audit and corresponding report within the required timeframe. Response: To address this finding, the Finance Department will be implementing the following procedures: • Continuing to recruit for key positions such as the Controller position and another Accountant position. • A month-end and year-end closing process will be implemented. This process will be consistently applied to ensure compliance by the finance staff. • Account reconciliations will be performed monthly as part of the month end closing process. • Analytics will be performed to determine consistency, completeness and accuracy of data in comparison to prior period. Significant variances will be investigated to determine completeness and accuracy of financial information. • The year-end close will be completed within sixty days but no more than 90 days after the end of the fiscal year. The annual audit will be scheduled during this timeline and shall commence after year-end closing is completed.

Criteria: In accordance with the Uniform Guidance, the Single Audit report must be submitted to the designated Federal Audit Clearinghouse (FAC) within 30 days of receipt or 9 months after the end of the audit period, whichever is earlier. Condition: The Single Audit report was not completed within 9 months after the end of the audit period. Cause: Personnel turnover within the Organization in addition to a delay in the prior year’s audit being completed. Effect: Failing to file a Single Audit report on time can result in several consequences, including federal funding restrictions, penalties, and potential legal actions. These consequences can impact an Organization's ability to receive and utilize federal funds. Repeat Finding: Yes – The Single Audit report for the year ended September 30, 2021 was not completed within 9 months after the end of the audit period. Recommendation: The Organization should close out the year end on a timely basis so that there is adequate time to complete the Single Audit and corresponding report within the required timeframe. Response: To address this finding, the Finance Department will be implementing the following procedures: • Continuing to recruit for key positions such as the Controller position and another Accountant position. • A month-end and year-end closing process will be implemented. This process will be consistently applied to ensure compliance by the finance staff. • Account reconciliations will be performed monthly as part of the month end closing process. • Analytics will be performed to determine consistency, completeness and accuracy of data in comparison to prior period. Significant variances will be investigated to determine completeness and accuracy of financial information. • The year-end close will be completed within sixty days but no more than 90 days after the end of the fiscal year. The annual audit will be scheduled during this timeline and shall commence after year-end closing is completed.

Criteria: In accordance with the Uniform Guidance, the Single Audit report must be submitted to the designated Federal Audit Clearinghouse (FAC) within 30 days of receipt or 9 months after the end of the audit period, whichever is earlier. Condition: The Single Audit report was not completed within 9 months after the end of the audit period. Cause: Personnel turnover within the Organization in addition to a delay in the prior year’s audit being completed. Effect: Failing to file a Single Audit report on time can result in several consequences, including federal funding restrictions, penalties, and potential legal actions. These consequences can impact an Organization's ability to receive and utilize federal funds. Repeat Finding: Yes – The Single Audit report for the year ended September 30, 2021 was not completed within 9 months after the end of the audit period. Recommendation: The Organization should close out the year end on a timely basis so that there is adequate time to complete the Single Audit and corresponding report within the required timeframe. Response: To address this finding, the Finance Department will be implementing the following procedures: • Continuing to recruit for key positions such as the Controller position and another Accountant position. • A month-end and year-end closing process will be implemented. This process will be consistently applied to ensure compliance by the finance staff. • Account reconciliations will be performed monthly as part of the month end closing process. • Analytics will be performed to determine consistency, completeness and accuracy of data in comparison to prior period. Significant variances will be investigated to determine completeness and accuracy of financial information. • The year-end close will be completed within sixty days but no more than 90 days after the end of the fiscal year. The annual audit will be scheduled during this timeline and shall commence after year-end closing is completed.

Criteria: In accordance with the Uniform Guidance, the Single Audit report must be submitted to the designated Federal Audit Clearinghouse (FAC) within 30 days of receipt or 9 months after the end of the audit period, whichever is earlier. Condition: The Single Audit report was not completed within 9 months after the end of the audit period. Cause: Personnel turnover within the Organization in addition to a delay in the prior year’s audit being completed. Effect: Failing to file a Single Audit report on time can result in several consequences, including federal funding restrictions, penalties, and potential legal actions. These consequences can impact an Organization's ability to receive and utilize federal funds. Repeat Finding: Yes – The Single Audit report for the year ended September 30, 2021 was not completed within 9 months after the end of the audit period. Recommendation: The Organization should close out the year end on a timely basis so that there is adequate time to complete the Single Audit and corresponding report within the required timeframe. Response: To address this finding, the Finance Department will be implementing the following procedures: • Continuing to recruit for key positions such as the Controller position and another Accountant position. • A month-end and year-end closing process will be implemented. This process will be consistently applied to ensure compliance by the finance staff. • Account reconciliations will be performed monthly as part of the month end closing process. • Analytics will be performed to determine consistency, completeness and accuracy of data in comparison to prior period. Significant variances will be investigated to determine completeness and accuracy of financial information. • The year-end close will be completed within sixty days but no more than 90 days after the end of the fiscal year. The annual audit will be scheduled during this timeline and shall commence after year-end closing is completed.

Criteria: In accordance with the Uniform Guidance, the Single Audit report must be submitted to the designated Federal Audit Clearinghouse (FAC) within 30 days of receipt or 9 months after the end of the audit period, whichever is earlier. Condition: The Single Audit report was not completed within 9 months after the end of the audit period. Cause: Personnel turnover within the Organization in addition to a delay in the prior year’s audit being completed. Effect: Failing to file a Single Audit report on time can result in several consequences, including federal funding restrictions, penalties, and potential legal actions. These consequences can impact an Organization's ability to receive and utilize federal funds. Repeat Finding: Yes – The Single Audit report for the year ended September 30, 2021 was not completed within 9 months after the end of the audit period. Recommendation: The Organization should close out the year end on a timely basis so that there is adequate time to complete the Single Audit and corresponding report within the required timeframe. Response: To address this finding, the Finance Department will be implementing the following procedures: • Continuing to recruit for key positions such as the Controller position and another Accountant position. • A month-end and year-end closing process will be implemented. This process will be consistently applied to ensure compliance by the finance staff. • Account reconciliations will be performed monthly as part of the month end closing process. • Analytics will be performed to determine consistency, completeness and accuracy of data in comparison to prior period. Significant variances will be investigated to determine completeness and accuracy of financial information. • The year-end close will be completed within sixty days but no more than 90 days after the end of the fiscal year. The annual audit will be scheduled during this timeline and shall commence after year-end closing is completed.

Criteria: In accordance with the Uniform Guidance, the Single Audit report must be submitted to the designated Federal Audit Clearinghouse (FAC) within 30 days of receipt or 9 months after the end of the audit period, whichever is earlier. Condition: The Single Audit report was not completed within 9 months after the end of the audit period. Cause: Personnel turnover within the Organization in addition to a delay in the prior year’s audit being completed. Effect: Failing to file a Single Audit report on time can result in several consequences, including federal funding restrictions, penalties, and potential legal actions. These consequences can impact an Organization's ability to receive and utilize federal funds. Repeat Finding: Yes – The Single Audit report for the year ended September 30, 2021 was not completed within 9 months after the end of the audit period. Recommendation: The Organization should close out the year end on a timely basis so that there is adequate time to complete the Single Audit and corresponding report within the required timeframe. Response: To address this finding, the Finance Department will be implementing the following procedures: • Continuing to recruit for key positions such as the Controller position and another Accountant position. • A month-end and year-end closing process will be implemented. This process will be consistently applied to ensure compliance by the finance staff. • Account reconciliations will be performed monthly as part of the month end closing process. • Analytics will be performed to determine consistency, completeness and accuracy of data in comparison to prior period. Significant variances will be investigated to determine completeness and accuracy of financial information. • The year-end close will be completed within sixty days but no more than 90 days after the end of the fiscal year. The annual audit will be scheduled during this timeline and shall commence after year-end closing is completed.

Criteria: In accordance with the Uniform Guidance, the Single Audit report must be submitted to the designated Federal Audit Clearinghouse (FAC) within 30 days of receipt or 9 months after the end of the audit period, whichever is earlier. Condition: The Single Audit report was not completed within 9 months after the end of the audit period. Cause: Personnel turnover within the Organization in addition to a delay in the prior year’s audit being completed. Effect: Failing to file a Single Audit report on time can result in several consequences, including federal funding restrictions, penalties, and potential legal actions. These consequences can impact an Organization's ability to receive and utilize federal funds. Repeat Finding: Yes – The Single Audit report for the year ended September 30, 2021 was not completed within 9 months after the end of the audit period. Recommendation: The Organization should close out the year end on a timely basis so that there is adequate time to complete the Single Audit and corresponding report within the required timeframe. Response: To address this finding, the Finance Department will be implementing the following procedures: • Continuing to recruit for key positions such as the Controller position and another Accountant position. • A month-end and year-end closing process will be implemented. This process will be consistently applied to ensure compliance by the finance staff. • Account reconciliations will be performed monthly as part of the month end closing process. • Analytics will be performed to determine consistency, completeness and accuracy of data in comparison to prior period. Significant variances will be investigated to determine completeness and accuracy of financial information. • The year-end close will be completed within sixty days but no more than 90 days after the end of the fiscal year. The annual audit will be scheduled during this timeline and shall commence after year-end closing is completed.

Criteria: In accordance with the Uniform Guidance, the Single Audit report must be submitted to the designated Federal Audit Clearinghouse (FAC) within 30 days of receipt or 9 months after the end of the audit period, whichever is earlier. Condition: The Single Audit report was not completed within 9 months after the end of the audit period. Cause: Personnel turnover within the Organization in addition to a delay in the prior year’s audit being completed. Effect: Failing to file a Single Audit report on time can result in several consequences, including federal funding restrictions, penalties, and potential legal actions. These consequences can impact an Organization's ability to receive and utilize federal funds. Repeat Finding: Yes – The Single Audit report for the year ended September 30, 2021 was not completed within 9 months after the end of the audit period. Recommendation: The Organization should close out the year end on a timely basis so that there is adequate time to complete the Single Audit and corresponding report within the required timeframe. Response: To address this finding, the Finance Department will be implementing the following procedures: • Continuing to recruit for key positions such as the Controller position and another Accountant position. • A month-end and year-end closing process will be implemented. This process will be consistently applied to ensure compliance by the finance staff. • Account reconciliations will be performed monthly as part of the month end closing process. • Analytics will be performed to determine consistency, completeness and accuracy of data in comparison to prior period. Significant variances will be investigated to determine completeness and accuracy of financial information. • The year-end close will be completed within sixty days but no more than 90 days after the end of the fiscal year. The annual audit will be scheduled during this timeline and shall commence after year-end closing is completed.

Criteria: In accordance with the Uniform Guidance, the Single Audit report must be submitted to the designated Federal Audit Clearinghouse (FAC) within 30 days of receipt or 9 months after the end of the audit period, whichever is earlier. Condition: The Single Audit report was not completed within 9 months after the end of the audit period. Cause: Personnel turnover within the Organization in addition to a delay in the prior year’s audit being completed. Effect: Failing to file a Single Audit report on time can result in several consequences, including federal funding restrictions, penalties, and potential legal actions. These consequences can impact an Organization's ability to receive and utilize federal funds. Repeat Finding: Yes – The Single Audit report for the year ended September 30, 2021 was not completed within 9 months after the end of the audit period. Recommendation: The Organization should close out the year end on a timely basis so that there is adequate time to complete the Single Audit and corresponding report within the required timeframe. Response: To address this finding, the Finance Department will be implementing the following procedures: • Continuing to recruit for key positions such as the Controller position and another Accountant position. • A month-end and year-end closing process will be implemented. This process will be consistently applied to ensure compliance by the finance staff. • Account reconciliations will be performed monthly as part of the month end closing process. • Analytics will be performed to determine consistency, completeness and accuracy of data in comparison to prior period. Significant variances will be investigated to determine completeness and accuracy of financial information. • The year-end close will be completed within sixty days but no more than 90 days after the end of the fiscal year. The annual audit will be scheduled during this timeline and shall commence after year-end closing is completed.

Criteria: In accordance with the Uniform Guidance, the Single Audit report must be submitted to the designated Federal Audit Clearinghouse (FAC) within 30 days of receipt or 9 months after the end of the audit period, whichever is earlier. Condition: The Single Audit report was not completed within 9 months after the end of the audit period. Cause: Personnel turnover within the Organization in addition to a delay in the prior year’s audit being completed. Effect: Failing to file a Single Audit report on time can result in several consequences, including federal funding restrictions, penalties, and potential legal actions. These consequences can impact an Organization's ability to receive and utilize federal funds. Repeat Finding: Yes – The Single Audit report for the year ended September 30, 2021 was not completed within 9 months after the end of the audit period. Recommendation: The Organization should close out the year end on a timely basis so that there is adequate time to complete the Single Audit and corresponding report within the required timeframe. Response: To address this finding, the Finance Department will be implementing the following procedures: • Continuing to recruit for key positions such as the Controller position and another Accountant position. • A month-end and year-end closing process will be implemented. This process will be consistently applied to ensure compliance by the finance staff. • Account reconciliations will be performed monthly as part of the month end closing process. • Analytics will be performed to determine consistency, completeness and accuracy of data in comparison to prior period. Significant variances will be investigated to determine completeness and accuracy of financial information. • The year-end close will be completed within sixty days but no more than 90 days after the end of the fiscal year. The annual audit will be scheduled during this timeline and shall commence after year-end closing is completed.

Criteria: Where grants are used to pay for rent for all or a part of a structure, the rent paid must be reasonable in relation to rents being charged in the area for comparable space. As part of their internal control policies, the Organization requires that the following documents are included within the tenant file: signed sublease agreement between the Organization and member/tenant and signed master lease agreement between the tenant and landlord. Condition: We were unable to obtain both the signed sublease agreement and master lease agreement for 10 of the 21 tenant files selected for testing. Of those 10 files, there were 2 files where we were unable to obtain either the signed sublease agreement or master lease agreement. The Compliance Supplement does not specify that lease agreements must be examined to verify the rent paid is reasonable in relation to rents being charged in the area for comparable space. In addition, allowable costs/cost principles and activities allowed or unallowed is not applicable to the Continuum of Care Program. Therefore, no instances of noncompliance were identified. Cause: There was a change in personnel within the housing department. Also, the department relocated to a new building. Effect: While we were able to validate the rent paid was reasonable in relation to rents being charged in the area for a comparable space for the population tested, there is the potential that the amount being paid on behalf of the tenant is not in line with the agreed upon rate if lease agreements are not retained. Recommendation: The Organization should implement procedures to ensure that tenant files include all of the required documentation to support that the rent paid is reasonable in relation to rents being charged in the area for comparable space. Response: To ensure both subleases and master leases are obtained and properly uploaded to each tenant’s electronic file, a standardized checklist is now used at lease signing and annual recertification. Monthly ROI (Release of Information) reports are reviewed to identify upcoming expirations and prompt timely recertifications. Recertification documentation is first reviewed by the Housing Administrative Supervisor for accuracy and completeness, following by final review and approval from the Director of Housing.

Criteria: Where grants are used to pay for rent for all or a part of a structure, the rent paid must be reasonable in relation to rents being charged in the area for comparable space. As part of their internal control policies, the Organization requires that the following documents are included within the tenant file: signed sublease agreement between the Organization and member/tenant and signed master lease agreement between the tenant and landlord. Condition: We were unable to obtain both the signed sublease agreement and master lease agreement for 10 of the 21 tenant files selected for testing. Of those 10 files, there were 2 files where we were unable to obtain either the signed sublease agreement or master lease agreement. The Compliance Supplement does not specify that lease agreements must be examined to verify the rent paid is reasonable in relation to rents being charged in the area for comparable space. In addition, allowable costs/cost principles and activities allowed or unallowed is not applicable to the Continuum of Care Program. Therefore, no instances of noncompliance were identified. Cause: There was a change in personnel within the housing department. Also, the department relocated to a new building. Effect: While we were able to validate the rent paid was reasonable in relation to rents being charged in the area for a comparable space for the population tested, there is the potential that the amount being paid on behalf of the tenant is not in line with the agreed upon rate if lease agreements are not retained. Recommendation: The Organization should implement procedures to ensure that tenant files include all of the required documentation to support that the rent paid is reasonable in relation to rents being charged in the area for comparable space. Response: To ensure both subleases and master leases are obtained and properly uploaded to each tenant’s electronic file, a standardized checklist is now used at lease signing and annual recertification. Monthly ROI (Release of Information) reports are reviewed to identify upcoming expirations and prompt timely recertifications. Recertification documentation is first reviewed by the Housing Administrative Supervisor for accuracy and completeness, following by final review and approval from the Director of Housing.

Criteria: Where grants are used to pay for rent for all or a part of a structure, the rent paid must be reasonable in relation to rents being charged in the area for comparable space. As part of their internal control policies, the Organization requires that the following documents are included within the tenant file: signed sublease agreement between the Organization and member/tenant and signed master lease agreement between the tenant and landlord. Condition: We were unable to obtain both the signed sublease agreement and master lease agreement for 10 of the 21 tenant files selected for testing. Of those 10 files, there were 2 files where we were unable to obtain either the signed sublease agreement or master lease agreement. The Compliance Supplement does not specify that lease agreements must be examined to verify the rent paid is reasonable in relation to rents being charged in the area for comparable space. In addition, allowable costs/cost principles and activities allowed or unallowed is not applicable to the Continuum of Care Program. Therefore, no instances of noncompliance were identified. Cause: There was a change in personnel within the housing department. Also, the department relocated to a new building. Effect: While we were able to validate the rent paid was reasonable in relation to rents being charged in the area for a comparable space for the population tested, there is the potential that the amount being paid on behalf of the tenant is not in line with the agreed upon rate if lease agreements are not retained. Recommendation: The Organization should implement procedures to ensure that tenant files include all of the required documentation to support that the rent paid is reasonable in relation to rents being charged in the area for comparable space. Response: To ensure both subleases and master leases are obtained and properly uploaded to each tenant’s electronic file, a standardized checklist is now used at lease signing and annual recertification. Monthly ROI (Release of Information) reports are reviewed to identify upcoming expirations and prompt timely recertifications. Recertification documentation is first reviewed by the Housing Administrative Supervisor for accuracy and completeness, following by final review and approval from the Director of Housing.

Criteria: Where grants are used to pay for rent for all or a part of a structure, the rent paid must be reasonable in relation to rents being charged in the area for comparable space. As part of their internal control policies, the Organization requires that the following documents are included within the tenant file: signed sublease agreement between the Organization and member/tenant and signed master lease agreement between the tenant and landlord. Condition: We were unable to obtain both the signed sublease agreement and master lease agreement for 10 of the 21 tenant files selected for testing. Of those 10 files, there were 2 files where we were unable to obtain either the signed sublease agreement or master lease agreement. The Compliance Supplement does not specify that lease agreements must be examined to verify the rent paid is reasonable in relation to rents being charged in the area for comparable space. In addition, allowable costs/cost principles and activities allowed or unallowed is not applicable to the Continuum of Care Program. Therefore, no instances of noncompliance were identified. Cause: There was a change in personnel within the housing department. Also, the department relocated to a new building. Effect: While we were able to validate the rent paid was reasonable in relation to rents being charged in the area for a comparable space for the population tested, there is the potential that the amount being paid on behalf of the tenant is not in line with the agreed upon rate if lease agreements are not retained. Recommendation: The Organization should implement procedures to ensure that tenant files include all of the required documentation to support that the rent paid is reasonable in relation to rents being charged in the area for comparable space. Response: To ensure both subleases and master leases are obtained and properly uploaded to each tenant’s electronic file, a standardized checklist is now used at lease signing and annual recertification. Monthly ROI (Release of Information) reports are reviewed to identify upcoming expirations and prompt timely recertifications. Recertification documentation is first reviewed by the Housing Administrative Supervisor for accuracy and completeness, following by final review and approval from the Director of Housing.

Criteria: Where grants are used to pay for rent for all or a part of a structure, the rent paid must be reasonable in relation to rents being charged in the area for comparable space. As part of their internal control policies, the Organization requires that the following documents are included within the tenant file: signed sublease agreement between the Organization and member/tenant and signed master lease agreement between the tenant and landlord. Condition: We were unable to obtain both the signed sublease agreement and master lease agreement for 10 of the 21 tenant files selected for testing. Of those 10 files, there were 2 files where we were unable to obtain either the signed sublease agreement or master lease agreement. The Compliance Supplement does not specify that lease agreements must be examined to verify the rent paid is reasonable in relation to rents being charged in the area for comparable space. In addition, allowable costs/cost principles and activities allowed or unallowed is not applicable to the Continuum of Care Program. Therefore, no instances of noncompliance were identified. Cause: There was a change in personnel within the housing department. Also, the department relocated to a new building. Effect: While we were able to validate the rent paid was reasonable in relation to rents being charged in the area for a comparable space for the population tested, there is the potential that the amount being paid on behalf of the tenant is not in line with the agreed upon rate if lease agreements are not retained. Recommendation: The Organization should implement procedures to ensure that tenant files include all of the required documentation to support that the rent paid is reasonable in relation to rents being charged in the area for comparable space. Response: To ensure both subleases and master leases are obtained and properly uploaded to each tenant’s electronic file, a standardized checklist is now used at lease signing and annual recertification. Monthly ROI (Release of Information) reports are reviewed to identify upcoming expirations and prompt timely recertifications. Recertification documentation is first reviewed by the Housing Administrative Supervisor for accuracy and completeness, following by final review and approval from the Director of Housing.

Criteria: Where grants are used to pay for rent for all or a part of a structure, the rent paid must be reasonable in relation to rents being charged in the area for comparable space. As part of their internal control policies, the Organization requires that the following documents are included within the tenant file: signed sublease agreement between the Organization and member/tenant and signed master lease agreement between the tenant and landlord. Condition: We were unable to obtain both the signed sublease agreement and master lease agreement for 10 of the 21 tenant files selected for testing. Of those 10 files, there were 2 files where we were unable to obtain either the signed sublease agreement or master lease agreement. The Compliance Supplement does not specify that lease agreements must be examined to verify the rent paid is reasonable in relation to rents being charged in the area for comparable space. In addition, allowable costs/cost principles and activities allowed or unallowed is not applicable to the Continuum of Care Program. Therefore, no instances of noncompliance were identified. Cause: There was a change in personnel within the housing department. Also, the department relocated to a new building. Effect: While we were able to validate the rent paid was reasonable in relation to rents being charged in the area for a comparable space for the population tested, there is the potential that the amount being paid on behalf of the tenant is not in line with the agreed upon rate if lease agreements are not retained. Recommendation: The Organization should implement procedures to ensure that tenant files include all of the required documentation to support that the rent paid is reasonable in relation to rents being charged in the area for comparable space. Response: To ensure both subleases and master leases are obtained and properly uploaded to each tenant’s electronic file, a standardized checklist is now used at lease signing and annual recertification. Monthly ROI (Release of Information) reports are reviewed to identify upcoming expirations and prompt timely recertifications. Recertification documentation is first reviewed by the Housing Administrative Supervisor for accuracy and completeness, following by final review and approval from the Director of Housing.

Criteria: Health centers must prepare and apply a sliding fee discount schedule so that amounts owed for health center services by eligible patients are adjusted (discounted) based on the patient’s ability to pay. Condition: While we were eventually able to obtain a complete and accurate population of the eligible patients that received the sliding fee discount for the year ended September 30, 2022, it took multiple attempts before the Organization was able to provide us with that population. Prior to receiving the accurate listing, we received multiple files that either included patients that received the sliding fee discount outside of the audit period or included ineligible patients. Cause: The sliding fee discount schedule is the responsibility of the Revenue Cycle Manager. There was turnover in this role and the current Revenue Cycle Manager was not employed during the audit period. Effect: There were delays in completing the testing. Recommendation: The Organization should implement procedures to ensure that a complete and accurate population of the eligible patients that received the sliding fee discount is maintained and readily available upon request. Response: The Organization has hired an Executive Director of Revenue Cycle to manage all aspects of revenue cycle (including the Sliding Fee Discount Program). The Director has created a Standard Operating Procedure (SOP) for each EHR system to ensure that all staff administering sliding fee discounts understand the sliding fee process. Additionally, the newly hired Director will implement a training program for all staff involved in the preparation and application of the sliding fee discount schedule.

Criteria: Health centers must prepare and apply a sliding fee discount schedule so that amounts owed for health center services by eligible patients are adjusted (discounted) based on the patient’s ability to pay. Condition: While we were eventually able to obtain a complete and accurate population of the eligible patients that received the sliding fee discount for the year ended September 30, 2022, it took multiple attempts before the Organization was able to provide us with that population. Prior to receiving the accurate listing, we received multiple files that either included patients that received the sliding fee discount outside of the audit period or included ineligible patients. Cause: The sliding fee discount schedule is the responsibility of the Revenue Cycle Manager. There was turnover in this role and the current Revenue Cycle Manager was not employed during the audit period. Effect: There were delays in completing the testing. Recommendation: The Organization should implement procedures to ensure that a complete and accurate population of the eligible patients that received the sliding fee discount is maintained and readily available upon request. Response: The Organization has hired an Executive Director of Revenue Cycle to manage all aspects of revenue cycle (including the Sliding Fee Discount Program). The Director has created a Standard Operating Procedure (SOP) for each EHR system to ensure that all staff administering sliding fee discounts understand the sliding fee process. Additionally, the newly hired Director will implement a training program for all staff involved in the preparation and application of the sliding fee discount schedule.

Criteria: Health centers must prepare and apply a sliding fee discount schedule so that amounts owed for health center services by eligible patients are adjusted (discounted) based on the patient’s ability to pay. Condition: While we were eventually able to obtain a complete and accurate population of the eligible patients that received the sliding fee discount for the year ended September 30, 2022, it took multiple attempts before the Organization was able to provide us with that population. Prior to receiving the accurate listing, we received multiple files that either included patients that received the sliding fee discount outside of the audit period or included ineligible patients. Cause: The sliding fee discount schedule is the responsibility of the Revenue Cycle Manager. There was turnover in this role and the current Revenue Cycle Manager was not employed during the audit period. Effect: There were delays in completing the testing. Recommendation: The Organization should implement procedures to ensure that a complete and accurate population of the eligible patients that received the sliding fee discount is maintained and readily available upon request. Response: The Organization has hired an Executive Director of Revenue Cycle to manage all aspects of revenue cycle (including the Sliding Fee Discount Program). The Director has created a Standard Operating Procedure (SOP) for each EHR system to ensure that all staff administering sliding fee discounts understand the sliding fee process. Additionally, the newly hired Director will implement a training program for all staff involved in the preparation and application of the sliding fee discount schedule.

Criteria: Health centers must prepare and apply a sliding fee discount schedule so that amounts owed for health center services by eligible patients are adjusted (discounted) based on the patient’s ability to pay. Condition: While we were eventually able to obtain a complete and accurate population of the eligible patients that received the sliding fee discount for the year ended September 30, 2022, it took multiple attempts before the Organization was able to provide us with that population. Prior to receiving the accurate listing, we received multiple files that either included patients that received the sliding fee discount outside of the audit period or included ineligible patients. Cause: The sliding fee discount schedule is the responsibility of the Revenue Cycle Manager. There was turnover in this role and the current Revenue Cycle Manager was not employed during the audit period. Effect: There were delays in completing the testing. Recommendation: The Organization should implement procedures to ensure that a complete and accurate population of the eligible patients that received the sliding fee discount is maintained and readily available upon request. Response: The Organization has hired an Executive Director of Revenue Cycle to manage all aspects of revenue cycle (including the Sliding Fee Discount Program). The Director has created a Standard Operating Procedure (SOP) for each EHR system to ensure that all staff administering sliding fee discounts understand the sliding fee process. Additionally, the newly hired Director will implement a training program for all staff involved in the preparation and application of the sliding fee discount schedule.

Criteria: Health centers must prepare and apply a sliding fee discount schedule so that amounts owed for health center services by eligible patients are adjusted (discounted) based on the patient’s ability to pay. Condition: While we were eventually able to obtain a complete and accurate population of the eligible patients that received the sliding fee discount for the year ended September 30, 2022, it took multiple attempts before the Organization was able to provide us with that population. Prior to receiving the accurate listing, we received multiple files that either included patients that received the sliding fee discount outside of the audit period or included ineligible patients. Cause: The sliding fee discount schedule is the responsibility of the Revenue Cycle Manager. There was turnover in this role and the current Revenue Cycle Manager was not employed during the audit period. Effect: There were delays in completing the testing. Recommendation: The Organization should implement procedures to ensure that a complete and accurate population of the eligible patients that received the sliding fee discount is maintained and readily available upon request. Response: The Organization has hired an Executive Director of Revenue Cycle to manage all aspects of revenue cycle (including the Sliding Fee Discount Program). The Director has created a Standard Operating Procedure (SOP) for each EHR system to ensure that all staff administering sliding fee discounts understand the sliding fee process. Additionally, the newly hired Director will implement a training program for all staff involved in the preparation and application of the sliding fee discount schedule.

Criteria: Health centers must prepare and apply a sliding fee discount schedule so that amounts owed for health center services by eligible patients are adjusted (discounted) based on the patient’s ability to pay. Condition: While we were eventually able to obtain a complete and accurate population of the eligible patients that received the sliding fee discount for the year ended September 30, 2022, it took multiple attempts before the Organization was able to provide us with that population. Prior to receiving the accurate listing, we received multiple files that either included patients that received the sliding fee discount outside of the audit period or included ineligible patients. Cause: The sliding fee discount schedule is the responsibility of the Revenue Cycle Manager. There was turnover in this role and the current Revenue Cycle Manager was not employed during the audit period. Effect: There were delays in completing the testing. Recommendation: The Organization should implement procedures to ensure that a complete and accurate population of the eligible patients that received the sliding fee discount is maintained and readily available upon request. Response: The Organization has hired an Executive Director of Revenue Cycle to manage all aspects of revenue cycle (including the Sliding Fee Discount Program). The Director has created a Standard Operating Procedure (SOP) for each EHR system to ensure that all staff administering sliding fee discounts understand the sliding fee process. Additionally, the newly hired Director will implement a training program for all staff involved in the preparation and application of the sliding fee discount schedule.

Criteria: Health centers must prepare and apply a sliding fee discount schedule so that amounts owed for health center services by eligible patients are adjusted (discounted) based on the patient’s ability to pay. Condition: While we were eventually able to obtain a complete and accurate population of the eligible patients that received the sliding fee discount for the year ended September 30, 2022, it took multiple attempts before the Organization was able to provide us with that population. Prior to receiving the accurate listing, we received multiple files that either included patients that received the sliding fee discount outside of the audit period or included ineligible patients. Cause: The sliding fee discount schedule is the responsibility of the Revenue Cycle Manager. There was turnover in this role and the current Revenue Cycle Manager was not employed during the audit period. Effect: There were delays in completing the testing. Recommendation: The Organization should implement procedures to ensure that a complete and accurate population of the eligible patients that received the sliding fee discount is maintained and readily available upon request. Response: The Organization has hired an Executive Director of Revenue Cycle to manage all aspects of revenue cycle (including the Sliding Fee Discount Program). The Director has created a Standard Operating Procedure (SOP) for each EHR system to ensure that all staff administering sliding fee discounts understand the sliding fee process. Additionally, the newly hired Director will implement a training program for all staff involved in the preparation and application of the sliding fee discount schedule.

Criteria: In accordance with the Uniform Guidance, the Single Audit report must be submitted to the designated Federal Audit Clearinghouse (FAC) within 30 days of receipt or 9 months after the end of the audit period, whichever is earlier. Condition: The Single Audit report was not completed within 9 months after the end of the audit period. Cause: Personnel turnover within the Organization in addition to a delay in the prior year’s audit being completed. Effect: Failing to file a Single Audit report on time can result in several consequences, including federal funding restrictions, penalties, and potential legal actions. These consequences can impact an Organization's ability to receive and utilize federal funds. Repeat Finding: Yes – The Single Audit report for the year ended September 30, 2021 was not completed within 9 months after the end of the audit period. Recommendation: The Organization should close out the year end on a timely basis so that there is adequate time to complete the Single Audit and corresponding report within the required timeframe. Response: To address this finding, the Finance Department will be implementing the following procedures: • Continuing to recruit for key positions such as the Controller position and another Accountant position. • A month-end and year-end closing process will be implemented. This process will be consistently applied to ensure compliance by the finance staff. • Account reconciliations will be performed monthly as part of the month end closing process. • Analytics will be performed to determine consistency, completeness and accuracy of data in comparison to prior period. Significant variances will be investigated to determine completeness and accuracy of financial information. • The year-end close will be completed within sixty days but no more than 90 days after the end of the fiscal year. The annual audit will be scheduled during this timeline and shall commence after year-end closing is completed.

Criteria: In accordance with the Uniform Guidance, the Single Audit report must be submitted to the designated Federal Audit Clearinghouse (FAC) within 30 days of receipt or 9 months after the end of the audit period, whichever is earlier. Condition: The Single Audit report was not completed within 9 months after the end of the audit period. Cause: Personnel turnover within the Organization in addition to a delay in the prior year’s audit being completed. Effect: Failing to file a Single Audit report on time can result in several consequences, including federal funding restrictions, penalties, and potential legal actions. These consequences can impact an Organization's ability to receive and utilize federal funds. Repeat Finding: Yes – The Single Audit report for the year ended September 30, 2021 was not completed within 9 months after the end of the audit period. Recommendation: The Organization should close out the year end on a timely basis so that there is adequate time to complete the Single Audit and corresponding report within the required timeframe. Response: To address this finding, the Finance Department will be implementing the following procedures: • Continuing to recruit for key positions such as the Controller position and another Accountant position. • A month-end and year-end closing process will be implemented. This process will be consistently applied to ensure compliance by the finance staff. • Account reconciliations will be performed monthly as part of the month end closing process. • Analytics will be performed to determine consistency, completeness and accuracy of data in comparison to prior period. Significant variances will be investigated to determine completeness and accuracy of financial information. • The year-end close will be completed within sixty days but no more than 90 days after the end of the fiscal year. The annual audit will be scheduled during this timeline and shall commence after year-end closing is completed.

Criteria: In accordance with the Uniform Guidance, the Single Audit report must be submitted to the designated Federal Audit Clearinghouse (FAC) within 30 days of receipt or 9 months after the end of the audit period, whichever is earlier. Condition: The Single Audit report was not completed within 9 months after the end of the audit period. Cause: Personnel turnover within the Organization in addition to a delay in the prior year’s audit being completed. Effect: Failing to file a Single Audit report on time can result in several consequences, including federal funding restrictions, penalties, and potential legal actions. These consequences can impact an Organization's ability to receive and utilize federal funds. Repeat Finding: Yes – The Single Audit report for the year ended September 30, 2021 was not completed within 9 months after the end of the audit period. Recommendation: The Organization should close out the year end on a timely basis so that there is adequate time to complete the Single Audit and corresponding report within the required timeframe. Response: To address this finding, the Finance Department will be implementing the following procedures: • Continuing to recruit for key positions such as the Controller position and another Accountant position. • A month-end and year-end closing process will be implemented. This process will be consistently applied to ensure compliance by the finance staff. • Account reconciliations will be performed monthly as part of the month end closing process. • Analytics will be performed to determine consistency, completeness and accuracy of data in comparison to prior period. Significant variances will be investigated to determine completeness and accuracy of financial information. • The year-end close will be completed within sixty days but no more than 90 days after the end of the fiscal year. The annual audit will be scheduled during this timeline and shall commence after year-end closing is completed.

Criteria: In accordance with the Uniform Guidance, the Single Audit report must be submitted to the designated Federal Audit Clearinghouse (FAC) within 30 days of receipt or 9 months after the end of the audit period, whichever is earlier. Condition: The Single Audit report was not completed within 9 months after the end of the audit period. Cause: Personnel turnover within the Organization in addition to a delay in the prior year’s audit being completed. Effect: Failing to file a Single Audit report on time can result in several consequences, including federal funding restrictions, penalties, and potential legal actions. These consequences can impact an Organization's ability to receive and utilize federal funds. Repeat Finding: Yes – The Single Audit report for the year ended September 30, 2021 was not completed within 9 months after the end of the audit period. Recommendation: The Organization should close out the year end on a timely basis so that there is adequate time to complete the Single Audit and corresponding report within the required timeframe. Response: To address this finding, the Finance Department will be implementing the following procedures: • Continuing to recruit for key positions such as the Controller position and another Accountant position. • A month-end and year-end closing process will be implemented. This process will be consistently applied to ensure compliance by the finance staff. • Account reconciliations will be performed monthly as part of the month end closing process. • Analytics will be performed to determine consistency, completeness and accuracy of data in comparison to prior period. Significant variances will be investigated to determine completeness and accuracy of financial information. • The year-end close will be completed within sixty days but no more than 90 days after the end of the fiscal year. The annual audit will be scheduled during this timeline and shall commence after year-end closing is completed.

Criteria: In accordance with the Uniform Guidance, the Single Audit report must be submitted to the designated Federal Audit Clearinghouse (FAC) within 30 days of receipt or 9 months after the end of the audit period, whichever is earlier. Condition: The Single Audit report was not completed within 9 months after the end of the audit period. Cause: Personnel turnover within the Organization in addition to a delay in the prior year’s audit being completed. Effect: Failing to file a Single Audit report on time can result in several consequences, including federal funding restrictions, penalties, and potential legal actions. These consequences can impact an Organization's ability to receive and utilize federal funds. Repeat Finding: Yes – The Single Audit report for the year ended September 30, 2021 was not completed within 9 months after the end of the audit period. Recommendation: The Organization should close out the year end on a timely basis so that there is adequate time to complete the Single Audit and corresponding report within the required timeframe. Response: To address this finding, the Finance Department will be implementing the following procedures: • Continuing to recruit for key positions such as the Controller position and another Accountant position. • A month-end and year-end closing process will be implemented. This process will be consistently applied to ensure compliance by the finance staff. • Account reconciliations will be performed monthly as part of the month end closing process. • Analytics will be performed to determine consistency, completeness and accuracy of data in comparison to prior period. Significant variances will be investigated to determine completeness and accuracy of financial information. • The year-end close will be completed within sixty days but no more than 90 days after the end of the fiscal year. The annual audit will be scheduled during this timeline and shall commence after year-end closing is completed.

Criteria: In accordance with the Uniform Guidance, the Single Audit report must be submitted to the designated Federal Audit Clearinghouse (FAC) within 30 days of receipt or 9 months after the end of the audit period, whichever is earlier. Condition: The Single Audit report was not completed within 9 months after the end of the audit period. Cause: Personnel turnover within the Organization in addition to a delay in the prior year’s audit being completed. Effect: Failing to file a Single Audit report on time can result in several consequences, including federal funding restrictions, penalties, and potential legal actions. These consequences can impact an Organization's ability to receive and utilize federal funds. Repeat Finding: Yes – The Single Audit report for the year ended September 30, 2021 was not completed within 9 months after the end of the audit period. Recommendation: The Organization should close out the year end on a timely basis so that there is adequate time to complete the Single Audit and corresponding report within the required timeframe. Response: To address this finding, the Finance Department will be implementing the following procedures: • Continuing to recruit for key positions such as the Controller position and another Accountant position. • A month-end and year-end closing process will be implemented. This process will be consistently applied to ensure compliance by the finance staff. • Account reconciliations will be performed monthly as part of the month end closing process. • Analytics will be performed to determine consistency, completeness and accuracy of data in comparison to prior period. Significant variances will be investigated to determine completeness and accuracy of financial information. • The year-end close will be completed within sixty days but no more than 90 days after the end of the fiscal year. The annual audit will be scheduled during this timeline and shall commence after year-end closing is completed.

Criteria: In accordance with the Uniform Guidance, the Single Audit report must be submitted to the designated Federal Audit Clearinghouse (FAC) within 30 days of receipt or 9 months after the end of the audit period, whichever is earlier. Condition: The Single Audit report was not completed within 9 months after the end of the audit period. Cause: Personnel turnover within the Organization in addition to a delay in the prior year’s audit being completed. Effect: Failing to file a Single Audit report on time can result in several consequences, including federal funding restrictions, penalties, and potential legal actions. These consequences can impact an Organization's ability to receive and utilize federal funds. Repeat Finding: Yes – The Single Audit report for the year ended September 30, 2021 was not completed within 9 months after the end of the audit period. Recommendation: The Organization should close out the year end on a timely basis so that there is adequate time to complete the Single Audit and corresponding report within the required timeframe. Response: To address this finding, the Finance Department will be implementing the following procedures: • Continuing to recruit for key positions such as the Controller position and another Accountant position. • A month-end and year-end closing process will be implemented. This process will be consistently applied to ensure compliance by the finance staff. • Account reconciliations will be performed monthly as part of the month end closing process. • Analytics will be performed to determine consistency, completeness and accuracy of data in comparison to prior period. Significant variances will be investigated to determine completeness and accuracy of financial information. • The year-end close will be completed within sixty days but no more than 90 days after the end of the fiscal year. The annual audit will be scheduled during this timeline and shall commence after year-end closing is completed.

Criteria: In accordance with the Uniform Guidance, the Single Audit report must be submitted to the designated Federal Audit Clearinghouse (FAC) within 30 days of receipt or 9 months after the end of the audit period, whichever is earlier. Condition: The Single Audit report was not completed within 9 months after the end of the audit period. Cause: Personnel turnover within the Organization in addition to a delay in the prior year’s audit being completed. Effect: Failing to file a Single Audit report on time can result in several consequences, including federal funding restrictions, penalties, and potential legal actions. These consequences can impact an Organization's ability to receive and utilize federal funds. Repeat Finding: Yes – The Single Audit report for the year ended September 30, 2021 was not completed within 9 months after the end of the audit period. Recommendation: The Organization should close out the year end on a timely basis so that there is adequate time to complete the Single Audit and corresponding report within the required timeframe. Response: To address this finding, the Finance Department will be implementing the following procedures: • Continuing to recruit for key positions such as the Controller position and another Accountant position. • A month-end and year-end closing process will be implemented. This process will be consistently applied to ensure compliance by the finance staff. • Account reconciliations will be performed monthly as part of the month end closing process. • Analytics will be performed to determine consistency, completeness and accuracy of data in comparison to prior period. Significant variances will be investigated to determine completeness and accuracy of financial information. • The year-end close will be completed within sixty days but no more than 90 days after the end of the fiscal year. The annual audit will be scheduled during this timeline and shall commence after year-end closing is completed.

Criteria: In accordance with the Uniform Guidance, the Single Audit report must be submitted to the designated Federal Audit Clearinghouse (FAC) within 30 days of receipt or 9 months after the end of the audit period, whichever is earlier. Condition: The Single Audit report was not completed within 9 months after the end of the audit period. Cause: Personnel turnover within the Organization in addition to a delay in the prior year’s audit being completed. Effect: Failing to file a Single Audit report on time can result in several consequences, including federal funding restrictions, penalties, and potential legal actions. These consequences can impact an Organization's ability to receive and utilize federal funds. Repeat Finding: Yes – The Single Audit report for the year ended September 30, 2021 was not completed within 9 months after the end of the audit period. Recommendation: The Organization should close out the year end on a timely basis so that there is adequate time to complete the Single Audit and corresponding report within the required timeframe. Response: To address this finding, the Finance Department will be implementing the following procedures: • Continuing to recruit for key positions such as the Controller position and another Accountant position. • A month-end and year-end closing process will be implemented. This process will be consistently applied to ensure compliance by the finance staff. • Account reconciliations will be performed monthly as part of the month end closing process. • Analytics will be performed to determine consistency, completeness and accuracy of data in comparison to prior period. Significant variances will be investigated to determine completeness and accuracy of financial information. • The year-end close will be completed within sixty days but no more than 90 days after the end of the fiscal year. The annual audit will be scheduled during this timeline and shall commence after year-end closing is completed.

Criteria: In accordance with the Uniform Guidance, the Single Audit report must be submitted to the designated Federal Audit Clearinghouse (FAC) within 30 days of receipt or 9 months after the end of the audit period, whichever is earlier. Condition: The Single Audit report was not completed within 9 months after the end of the audit period. Cause: Personnel turnover within the Organization in addition to a delay in the prior year’s audit being completed. Effect: Failing to file a Single Audit report on time can result in several consequences, including federal funding restrictions, penalties, and potential legal actions. These consequences can impact an Organization's ability to receive and utilize federal funds. Repeat Finding: Yes – The Single Audit report for the year ended September 30, 2021 was not completed within 9 months after the end of the audit period. Recommendation: The Organization should close out the year end on a timely basis so that there is adequate time to complete the Single Audit and corresponding report within the required timeframe. Response: To address this finding, the Finance Department will be implementing the following procedures: • Continuing to recruit for key positions such as the Controller position and another Accountant position. • A month-end and year-end closing process will be implemented. This process will be consistently applied to ensure compliance by the finance staff. • Account reconciliations will be performed monthly as part of the month end closing process. • Analytics will be performed to determine consistency, completeness and accuracy of data in comparison to prior period. Significant variances will be investigated to determine completeness and accuracy of financial information. • The year-end close will be completed within sixty days but no more than 90 days after the end of the fiscal year. The annual audit will be scheduled during this timeline and shall commence after year-end closing is completed.

Criteria: In accordance with the Uniform Guidance, the Single Audit report must be submitted to the designated Federal Audit Clearinghouse (FAC) within 30 days of receipt or 9 months after the end of the audit period, whichever is earlier. Condition: The Single Audit report was not completed within 9 months after the end of the audit period. Cause: Personnel turnover within the Organization in addition to a delay in the prior year’s audit being completed. Effect: Failing to file a Single Audit report on time can result in several consequences, including federal funding restrictions, penalties, and potential legal actions. These consequences can impact an Organization's ability to receive and utilize federal funds. Repeat Finding: Yes – The Single Audit report for the year ended September 30, 2021 was not completed within 9 months after the end of the audit period. Recommendation: The Organization should close out the year end on a timely basis so that there is adequate time to complete the Single Audit and corresponding report within the required timeframe. Response: To address this finding, the Finance Department will be implementing the following procedures: • Continuing to recruit for key positions such as the Controller position and another Accountant position. • A month-end and year-end closing process will be implemented. This process will be consistently applied to ensure compliance by the finance staff. • Account reconciliations will be performed monthly as part of the month end closing process. • Analytics will be performed to determine consistency, completeness and accuracy of data in comparison to prior period. Significant variances will be investigated to determine completeness and accuracy of financial information. • The year-end close will be completed within sixty days but no more than 90 days after the end of the fiscal year. The annual audit will be scheduled during this timeline and shall commence after year-end closing is completed.

Criteria: In accordance with the Uniform Guidance, the Single Audit report must be submitted to the designated Federal Audit Clearinghouse (FAC) within 30 days of receipt or 9 months after the end of the audit period, whichever is earlier. Condition: The Single Audit report was not completed within 9 months after the end of the audit period. Cause: Personnel turnover within the Organization in addition to a delay in the prior year’s audit being completed. Effect: Failing to file a Single Audit report on time can result in several consequences, including federal funding restrictions, penalties, and potential legal actions. These consequences can impact an Organization's ability to receive and utilize federal funds. Repeat Finding: Yes – The Single Audit report for the year ended September 30, 2021 was not completed within 9 months after the end of the audit period. Recommendation: The Organization should close out the year end on a timely basis so that there is adequate time to complete the Single Audit and corresponding report within the required timeframe. Response: To address this finding, the Finance Department will be implementing the following procedures: • Continuing to recruit for key positions such as the Controller position and another Accountant position. • A month-end and year-end closing process will be implemented. This process will be consistently applied to ensure compliance by the finance staff. • Account reconciliations will be performed monthly as part of the month end closing process. • Analytics will be performed to determine consistency, completeness and accuracy of data in comparison to prior period. Significant variances will be investigated to determine completeness and accuracy of financial information. • The year-end close will be completed within sixty days but no more than 90 days after the end of the fiscal year. The annual audit will be scheduled during this timeline and shall commence after year-end closing is completed.

Criteria: In accordance with the Uniform Guidance, the Single Audit report must be submitted to the designated Federal Audit Clearinghouse (FAC) within 30 days of receipt or 9 months after the end of the audit period, whichever is earlier. Condition: The Single Audit report was not completed within 9 months after the end of the audit period. Cause: Personnel turnover within the Organization in addition to a delay in the prior year’s audit being completed. Effect: Failing to file a Single Audit report on time can result in several consequences, including federal funding restrictions, penalties, and potential legal actions. These consequences can impact an Organization's ability to receive and utilize federal funds. Repeat Finding: Yes – The Single Audit report for the year ended September 30, 2021 was not completed within 9 months after the end of the audit period. Recommendation: The Organization should close out the year end on a timely basis so that there is adequate time to complete the Single Audit and corresponding report within the required timeframe. Response: To address this finding, the Finance Department will be implementing the following procedures: • Continuing to recruit for key positions such as the Controller position and another Accountant position. • A month-end and year-end closing process will be implemented. This process will be consistently applied to ensure compliance by the finance staff. • Account reconciliations will be performed monthly as part of the month end closing process. • Analytics will be performed to determine consistency, completeness and accuracy of data in comparison to prior period. Significant variances will be investigated to determine completeness and accuracy of financial information. • The year-end close will be completed within sixty days but no more than 90 days after the end of the fiscal year. The annual audit will be scheduled during this timeline and shall commence after year-end closing is completed.

Criteria: Where grants are used to pay for rent for all or a part of a structure, the rent paid must be reasonable in relation to rents being charged in the area for comparable space. As part of their internal control policies, the Organization requires that the following documents are included within the tenant file: signed sublease agreement between the Organization and member/tenant and signed master lease agreement between the tenant and landlord. Condition: We were unable to obtain both the signed sublease agreement and master lease agreement for 10 of the 21 tenant files selected for testing. Of those 10 files, there were 2 files where we were unable to obtain either the signed sublease agreement or master lease agreement. The Compliance Supplement does not specify that lease agreements must be examined to verify the rent paid is reasonable in relation to rents being charged in the area for comparable space. In addition, allowable costs/cost principles and activities allowed or unallowed is not applicable to the Continuum of Care Program. Therefore, no instances of noncompliance were identified. Cause: There was a change in personnel within the housing department. Also, the department relocated to a new building. Effect: While we were able to validate the rent paid was reasonable in relation to rents being charged in the area for a comparable space for the population tested, there is the potential that the amount being paid on behalf of the tenant is not in line with the agreed upon rate if lease agreements are not retained. Recommendation: The Organization should implement procedures to ensure that tenant files include all of the required documentation to support that the rent paid is reasonable in relation to rents being charged in the area for comparable space. Response: To ensure both subleases and master leases are obtained and properly uploaded to each tenant’s electronic file, a standardized checklist is now used at lease signing and annual recertification. Monthly ROI (Release of Information) reports are reviewed to identify upcoming expirations and prompt timely recertifications. Recertification documentation is first reviewed by the Housing Administrative Supervisor for accuracy and completeness, following by final review and approval from the Director of Housing.

Criteria: Where grants are used to pay for rent for all or a part of a structure, the rent paid must be reasonable in relation to rents being charged in the area for comparable space. As part of their internal control policies, the Organization requires that the following documents are included within the tenant file: signed sublease agreement between the Organization and member/tenant and signed master lease agreement between the tenant and landlord. Condition: We were unable to obtain both the signed sublease agreement and master lease agreement for 10 of the 21 tenant files selected for testing. Of those 10 files, there were 2 files where we were unable to obtain either the signed sublease agreement or master lease agreement. The Compliance Supplement does not specify that lease agreements must be examined to verify the rent paid is reasonable in relation to rents being charged in the area for comparable space. In addition, allowable costs/cost principles and activities allowed or unallowed is not applicable to the Continuum of Care Program. Therefore, no instances of noncompliance were identified. Cause: There was a change in personnel within the housing department. Also, the department relocated to a new building. Effect: While we were able to validate the rent paid was reasonable in relation to rents being charged in the area for a comparable space for the population tested, there is the potential that the amount being paid on behalf of the tenant is not in line with the agreed upon rate if lease agreements are not retained. Recommendation: The Organization should implement procedures to ensure that tenant files include all of the required documentation to support that the rent paid is reasonable in relation to rents being charged in the area for comparable space. Response: To ensure both subleases and master leases are obtained and properly uploaded to each tenant’s electronic file, a standardized checklist is now used at lease signing and annual recertification. Monthly ROI (Release of Information) reports are reviewed to identify upcoming expirations and prompt timely recertifications. Recertification documentation is first reviewed by the Housing Administrative Supervisor for accuracy and completeness, following by final review and approval from the Director of Housing.

Criteria: Where grants are used to pay for rent for all or a part of a structure, the rent paid must be reasonable in relation to rents being charged in the area for comparable space. As part of their internal control policies, the Organization requires that the following documents are included within the tenant file: signed sublease agreement between the Organization and member/tenant and signed master lease agreement between the tenant and landlord. Condition: We were unable to obtain both the signed sublease agreement and master lease agreement for 10 of the 21 tenant files selected for testing. Of those 10 files, there were 2 files where we were unable to obtain either the signed sublease agreement or master lease agreement. The Compliance Supplement does not specify that lease agreements must be examined to verify the rent paid is reasonable in relation to rents being charged in the area for comparable space. In addition, allowable costs/cost principles and activities allowed or unallowed is not applicable to the Continuum of Care Program. Therefore, no instances of noncompliance were identified. Cause: There was a change in personnel within the housing department. Also, the department relocated to a new building. Effect: While we were able to validate the rent paid was reasonable in relation to rents being charged in the area for a comparable space for the population tested, there is the potential that the amount being paid on behalf of the tenant is not in line with the agreed upon rate if lease agreements are not retained. Recommendation: The Organization should implement procedures to ensure that tenant files include all of the required documentation to support that the rent paid is reasonable in relation to rents being charged in the area for comparable space. Response: To ensure both subleases and master leases are obtained and properly uploaded to each tenant’s electronic file, a standardized checklist is now used at lease signing and annual recertification. Monthly ROI (Release of Information) reports are reviewed to identify upcoming expirations and prompt timely recertifications. Recertification documentation is first reviewed by the Housing Administrative Supervisor for accuracy and completeness, following by final review and approval from the Director of Housing.

Criteria: Where grants are used to pay for rent for all or a part of a structure, the rent paid must be reasonable in relation to rents being charged in the area for comparable space. As part of their internal control policies, the Organization requires that the following documents are included within the tenant file: signed sublease agreement between the Organization and member/tenant and signed master lease agreement between the tenant and landlord. Condition: We were unable to obtain both the signed sublease agreement and master lease agreement for 10 of the 21 tenant files selected for testing. Of those 10 files, there were 2 files where we were unable to obtain either the signed sublease agreement or master lease agreement. The Compliance Supplement does not specify that lease agreements must be examined to verify the rent paid is reasonable in relation to rents being charged in the area for comparable space. In addition, allowable costs/cost principles and activities allowed or unallowed is not applicable to the Continuum of Care Program. Therefore, no instances of noncompliance were identified. Cause: There was a change in personnel within the housing department. Also, the department relocated to a new building. Effect: While we were able to validate the rent paid was reasonable in relation to rents being charged in the area for a comparable space for the population tested, there is the potential that the amount being paid on behalf of the tenant is not in line with the agreed upon rate if lease agreements are not retained. Recommendation: The Organization should implement procedures to ensure that tenant files include all of the required documentation to support that the rent paid is reasonable in relation to rents being charged in the area for comparable space. Response: To ensure both subleases and master leases are obtained and properly uploaded to each tenant’s electronic file, a standardized checklist is now used at lease signing and annual recertification. Monthly ROI (Release of Information) reports are reviewed to identify upcoming expirations and prompt timely recertifications. Recertification documentation is first reviewed by the Housing Administrative Supervisor for accuracy and completeness, following by final review and approval from the Director of Housing.

Criteria: Where grants are used to pay for rent for all or a part of a structure, the rent paid must be reasonable in relation to rents being charged in the area for comparable space. As part of their internal control policies, the Organization requires that the following documents are included within the tenant file: signed sublease agreement between the Organization and member/tenant and signed master lease agreement between the tenant and landlord. Condition: We were unable to obtain both the signed sublease agreement and master lease agreement for 10 of the 21 tenant files selected for testing. Of those 10 files, there were 2 files where we were unable to obtain either the signed sublease agreement or master lease agreement. The Compliance Supplement does not specify that lease agreements must be examined to verify the rent paid is reasonable in relation to rents being charged in the area for comparable space. In addition, allowable costs/cost principles and activities allowed or unallowed is not applicable to the Continuum of Care Program. Therefore, no instances of noncompliance were identified. Cause: There was a change in personnel within the housing department. Also, the department relocated to a new building. Effect: While we were able to validate the rent paid was reasonable in relation to rents being charged in the area for a comparable space for the population tested, there is the potential that the amount being paid on behalf of the tenant is not in line with the agreed upon rate if lease agreements are not retained. Recommendation: The Organization should implement procedures to ensure that tenant files include all of the required documentation to support that the rent paid is reasonable in relation to rents being charged in the area for comparable space. Response: To ensure both subleases and master leases are obtained and properly uploaded to each tenant’s electronic file, a standardized checklist is now used at lease signing and annual recertification. Monthly ROI (Release of Information) reports are reviewed to identify upcoming expirations and prompt timely recertifications. Recertification documentation is first reviewed by the Housing Administrative Supervisor for accuracy and completeness, following by final review and approval from the Director of Housing.

Criteria: Where grants are used to pay for rent for all or a part of a structure, the rent paid must be reasonable in relation to rents being charged in the area for comparable space. As part of their internal control policies, the Organization requires that the following documents are included within the tenant file: signed sublease agreement between the Organization and member/tenant and signed master lease agreement between the tenant and landlord. Condition: We were unable to obtain both the signed sublease agreement and master lease agreement for 10 of the 21 tenant files selected for testing. Of those 10 files, there were 2 files where we were unable to obtain either the signed sublease agreement or master lease agreement. The Compliance Supplement does not specify that lease agreements must be examined to verify the rent paid is reasonable in relation to rents being charged in the area for comparable space. In addition, allowable costs/cost principles and activities allowed or unallowed is not applicable to the Continuum of Care Program. Therefore, no instances of noncompliance were identified. Cause: There was a change in personnel within the housing department. Also, the department relocated to a new building. Effect: While we were able to validate the rent paid was reasonable in relation to rents being charged in the area for a comparable space for the population tested, there is the potential that the amount being paid on behalf of the tenant is not in line with the agreed upon rate if lease agreements are not retained. Recommendation: The Organization should implement procedures to ensure that tenant files include all of the required documentation to support that the rent paid is reasonable in relation to rents being charged in the area for comparable space. Response: To ensure both subleases and master leases are obtained and properly uploaded to each tenant’s electronic file, a standardized checklist is now used at lease signing and annual recertification. Monthly ROI (Release of Information) reports are reviewed to identify upcoming expirations and prompt timely recertifications. Recertification documentation is first reviewed by the Housing Administrative Supervisor for accuracy and completeness, following by final review and approval from the Director of Housing.

Criteria: Health centers must prepare and apply a sliding fee discount schedule so that amounts owed for health center services by eligible patients are adjusted (discounted) based on the patient’s ability to pay. Condition: While we were eventually able to obtain a complete and accurate population of the eligible patients that received the sliding fee discount for the year ended September 30, 2022, it took multiple attempts before the Organization was able to provide us with that population. Prior to receiving the accurate listing, we received multiple files that either included patients that received the sliding fee discount outside of the audit period or included ineligible patients. Cause: The sliding fee discount schedule is the responsibility of the Revenue Cycle Manager. There was turnover in this role and the current Revenue Cycle Manager was not employed during the audit period. Effect: There were delays in completing the testing. Recommendation: The Organization should implement procedures to ensure that a complete and accurate population of the eligible patients that received the sliding fee discount is maintained and readily available upon request. Response: The Organization has hired an Executive Director of Revenue Cycle to manage all aspects of revenue cycle (including the Sliding Fee Discount Program). The Director has created a Standard Operating Procedure (SOP) for each EHR system to ensure that all staff administering sliding fee discounts understand the sliding fee process. Additionally, the newly hired Director will implement a training program for all staff involved in the preparation and application of the sliding fee discount schedule.

Criteria: Health centers must prepare and apply a sliding fee discount schedule so that amounts owed for health center services by eligible patients are adjusted (discounted) based on the patient’s ability to pay. Condition: While we were eventually able to obtain a complete and accurate population of the eligible patients that received the sliding fee discount for the year ended September 30, 2022, it took multiple attempts before the Organization was able to provide us with that population. Prior to receiving the accurate listing, we received multiple files that either included patients that received the sliding fee discount outside of the audit period or included ineligible patients. Cause: The sliding fee discount schedule is the responsibility of the Revenue Cycle Manager. There was turnover in this role and the current Revenue Cycle Manager was not employed during the audit period. Effect: There were delays in completing the testing. Recommendation: The Organization should implement procedures to ensure that a complete and accurate population of the eligible patients that received the sliding fee discount is maintained and readily available upon request. Response: The Organization has hired an Executive Director of Revenue Cycle to manage all aspects of revenue cycle (including the Sliding Fee Discount Program). The Director has created a Standard Operating Procedure (SOP) for each EHR system to ensure that all staff administering sliding fee discounts understand the sliding fee process. Additionally, the newly hired Director will implement a training program for all staff involved in the preparation and application of the sliding fee discount schedule.

Criteria: Health centers must prepare and apply a sliding fee discount schedule so that amounts owed for health center services by eligible patients are adjusted (discounted) based on the patient’s ability to pay. Condition: While we were eventually able to obtain a complete and accurate population of the eligible patients that received the sliding fee discount for the year ended September 30, 2022, it took multiple attempts before the Organization was able to provide us with that population. Prior to receiving the accurate listing, we received multiple files that either included patients that received the sliding fee discount outside of the audit period or included ineligible patients. Cause: The sliding fee discount schedule is the responsibility of the Revenue Cycle Manager. There was turnover in this role and the current Revenue Cycle Manager was not employed during the audit period. Effect: There were delays in completing the testing. Recommendation: The Organization should implement procedures to ensure that a complete and accurate population of the eligible patients that received the sliding fee discount is maintained and readily available upon request. Response: The Organization has hired an Executive Director of Revenue Cycle to manage all aspects of revenue cycle (including the Sliding Fee Discount Program). The Director has created a Standard Operating Procedure (SOP) for each EHR system to ensure that all staff administering sliding fee discounts understand the sliding fee process. Additionally, the newly hired Director will implement a training program for all staff involved in the preparation and application of the sliding fee discount schedule.

Criteria: Health centers must prepare and apply a sliding fee discount schedule so that amounts owed for health center services by eligible patients are adjusted (discounted) based on the patient’s ability to pay. Condition: While we were eventually able to obtain a complete and accurate population of the eligible patients that received the sliding fee discount for the year ended September 30, 2022, it took multiple attempts before the Organization was able to provide us with that population. Prior to receiving the accurate listing, we received multiple files that either included patients that received the sliding fee discount outside of the audit period or included ineligible patients. Cause: The sliding fee discount schedule is the responsibility of the Revenue Cycle Manager. There was turnover in this role and the current Revenue Cycle Manager was not employed during the audit period. Effect: There were delays in completing the testing. Recommendation: The Organization should implement procedures to ensure that a complete and accurate population of the eligible patients that received the sliding fee discount is maintained and readily available upon request. Response: The Organization has hired an Executive Director of Revenue Cycle to manage all aspects of revenue cycle (including the Sliding Fee Discount Program). The Director has created a Standard Operating Procedure (SOP) for each EHR system to ensure that all staff administering sliding fee discounts understand the sliding fee process. Additionally, the newly hired Director will implement a training program for all staff involved in the preparation and application of the sliding fee discount schedule.

Criteria: Health centers must prepare and apply a sliding fee discount schedule so that amounts owed for health center services by eligible patients are adjusted (discounted) based on the patient’s ability to pay. Condition: While we were eventually able to obtain a complete and accurate population of the eligible patients that received the sliding fee discount for the year ended September 30, 2022, it took multiple attempts before the Organization was able to provide us with that population. Prior to receiving the accurate listing, we received multiple files that either included patients that received the sliding fee discount outside of the audit period or included ineligible patients. Cause: The sliding fee discount schedule is the responsibility of the Revenue Cycle Manager. There was turnover in this role and the current Revenue Cycle Manager was not employed during the audit period. Effect: There were delays in completing the testing. Recommendation: The Organization should implement procedures to ensure that a complete and accurate population of the eligible patients that received the sliding fee discount is maintained and readily available upon request. Response: The Organization has hired an Executive Director of Revenue Cycle to manage all aspects of revenue cycle (including the Sliding Fee Discount Program). The Director has created a Standard Operating Procedure (SOP) for each EHR system to ensure that all staff administering sliding fee discounts understand the sliding fee process. Additionally, the newly hired Director will implement a training program for all staff involved in the preparation and application of the sliding fee discount schedule.

Criteria: Health centers must prepare and apply a sliding fee discount schedule so that amounts owed for health center services by eligible patients are adjusted (discounted) based on the patient’s ability to pay. Condition: While we were eventually able to obtain a complete and accurate population of the eligible patients that received the sliding fee discount for the year ended September 30, 2022, it took multiple attempts before the Organization was able to provide us with that population. Prior to receiving the accurate listing, we received multiple files that either included patients that received the sliding fee discount outside of the audit period or included ineligible patients. Cause: The sliding fee discount schedule is the responsibility of the Revenue Cycle Manager. There was turnover in this role and the current Revenue Cycle Manager was not employed during the audit period. Effect: There were delays in completing the testing. Recommendation: The Organization should implement procedures to ensure that a complete and accurate population of the eligible patients that received the sliding fee discount is maintained and readily available upon request. Response: The Organization has hired an Executive Director of Revenue Cycle to manage all aspects of revenue cycle (including the Sliding Fee Discount Program). The Director has created a Standard Operating Procedure (SOP) for each EHR system to ensure that all staff administering sliding fee discounts understand the sliding fee process. Additionally, the newly hired Director will implement a training program for all staff involved in the preparation and application of the sliding fee discount schedule.

Criteria: Health centers must prepare and apply a sliding fee discount schedule so that amounts owed for health center services by eligible patients are adjusted (discounted) based on the patient’s ability to pay. Condition: While we were eventually able to obtain a complete and accurate population of the eligible patients that received the sliding fee discount for the year ended September 30, 2022, it took multiple attempts before the Organization was able to provide us with that population. Prior to receiving the accurate listing, we received multiple files that either included patients that received the sliding fee discount outside of the audit period or included ineligible patients. Cause: The sliding fee discount schedule is the responsibility of the Revenue Cycle Manager. There was turnover in this role and the current Revenue Cycle Manager was not employed during the audit period. Effect: There were delays in completing the testing. Recommendation: The Organization should implement procedures to ensure that a complete and accurate population of the eligible patients that received the sliding fee discount is maintained and readily available upon request. Response: The Organization has hired an Executive Director of Revenue Cycle to manage all aspects of revenue cycle (including the Sliding Fee Discount Program). The Director has created a Standard Operating Procedure (SOP) for each EHR system to ensure that all staff administering sliding fee discounts understand the sliding fee process. Additionally, the newly hired Director will implement a training program for all staff involved in the preparation and application of the sliding fee discount schedule.