Corrective Action Plans

Finding 663 (2022-007)

None 2022

IN

Allowable Costs / Cost Principles HUD Housing Programs Internal Control / Segregation of Duties § 200.403

Recommendation: We recommend the review and approval of timecards be completed by a direct supervisor, that payroll records be regularly reviewed against timecards, and all supporting documentation for program costs be retained internally. Planned Corrective Action: We agree with the recommendation...

Recommendation: We recommend the review and approval of timecards be completed by a direct supervisor, that payroll records be regularly reviewed against timecards, and all supporting documentation for program costs be retained internally. Planned Corrective Action: We agree with the recommendations and plan to have corrective actions fully implemented by the end of fiscal year 2023.

View Audit 1234

Finding 659 (2022-003)

Material Weakness 2022

Indianapolis Housing Agency

IN

Internal Control / Segregation of Duties HUD Housing Programs Allowable Costs / Cost Principles § 200.303

Recommendation: See finding 2022-001. The recommendations noted for achieving appropriate oversight in the finance department apply as key individuals with knowledge of the compliance are considered critical for developing an appropriate control environment for internal controls over compliance. Pl...

Recommendation: See finding 2022-001. The recommendations noted for achieving appropriate oversight in the finance department apply as key individuals with knowledge of the compliance are considered critical for developing an appropriate control environment for internal controls over compliance. Planned Corrective Action: We agree with the recommendation. Since year end the Agency has hired a COO, and CFO to fill vacancies within the Agency. Under this new leadership structure, the Agency will continue to work on establishing appropriate controls.

View Audit 1234

Finding 627 (2022-004)

Material Weakness 2022

City of Unalaska, Alaska

AK

Period of Performance Allowable Costs / Cost Principles Material Weakness § 200.512

2022-004: Reporting - Timely Submission of Financial Reports – Material Weakness in Internal control over Financial Reporting and Noncompliance  The City recently hired a Finance Director and is working to fill the Controller position. Being fully staffed will assist in the timely completion of the...

2022-004: Reporting - Timely Submission of Financial Reports – Material Weakness in Internal control over Financial Reporting and Noncompliance  The City recently hired a Finance Director and is working to fill the Controller position. Being fully staffed will assist in the timely completion of the City’s audit.  Anticipated completion: December 2023

View Audit 1217

Finding 406 (2022-003)

Material Weakness 2022

Pioneercare

MN

Reporting Allowable Costs / Cost Principles Material Weakness § 200.303

Federal Agency Name: U.S. Department of Agriculture Department of Health and Human Services Program Name: Community Facilities Loans and Grants Cluster Federal Financial Assistance Listing #10.766 COVID‐19 Provider Relief Fund (PRF) and American Rescue Plan (ARP) Rural Distribution Federal Financial...

Federal Agency Name: U.S. Department of Agriculture Department of Health and Human Services Program Name: Community Facilities Loans and Grants Cluster Federal Financial Assistance Listing #10.766 COVID‐19 Provider Relief Fund (PRF) and American Rescue Plan (ARP) Rural Distribution Federal Financial Assistance Listing #93.498 Finding Summary: Eide Bailly LLP prepared our consolidated schedule of expenditures of federal awards (Schedule) and accompanying notes to the Schedule. Responsible Individuals: Nathan Johnson, CEO Corrective Action Plan: Having auditors assist with preparing the consolidated schedule of expenditures of federal awards (Schedule) is not unusual. We will continue to be aware of the financial reporting requirements relating to PioneerCare’s consolidated schedule of expenditures of federal awards and internal control that impact financial reporting. Anticipated Completion Date: Ongoing

View Audit 857

Finding 376 (2022-002)

Material Weakness 2022

Flagler County, Florida

FL

Questioned Costs Allowable Costs / Cost Principles

The Financial Services Department implemented a three‐step remedy which included working with the implementing department to insert their director as a review and approval step, improving tracking capabilities by amending internal reporting and documenting support, and changing reimbursement request...

The Financial Services Department implemented a three‐step remedy which included working with the implementing department to insert their director as a review and approval step, improving tracking capabilities by amending internal reporting and documenting support, and changing reimbursement request submittals to a monthly schedule. As stated within the “Effect Section” of the finding, these actions have already been implemented. Contact Person – E. John Brower, Financial Services Director Completion Date – Already implemented

View Audit 797 Questioned Costs: $1

Finding 313 (2022-002)

Significant Deficiency 2022

Palmer Senior Citizens Center, Inc.

AK

Questioned Costs Allowable Costs / Cost Principles

Federal Award Finding: 2022-002 Significant Deficiency in Compliance and Internal Controls over Compliance - Allowable Costs/Cost Principles Name and Contact Person: Heather Grato, Controller Corrective Action: Matsu Senior Center will ensure that they implement policies and procedures to address in...

Federal Award Finding: 2022-002 Significant Deficiency in Compliance and Internal Controls over Compliance - Allowable Costs/Cost Principles Name and Contact Person: Heather Grato, Controller Corrective Action: Matsu Senior Center will ensure that they implement policies and procedures to address internal control over record retention to include move of office. The organization has also hired both a new Finance Manager and Accounting Consultant to aid in creating and implementing policies and procedures. Proposed Completion Date: 06/30/2024

View Audit 588 Questioned Costs: $1

Finding 304 (2022-002)

Significant Deficiency 2022

Caminar Latino Inc.

GA

Allowable Costs / Cost Principles Cash Management Internal Control / Segregation of Duties § 200.303

Condition Upon review of the indirect cost calculations throughout the fiscal year, it was noted that there was no documentation of review and approval of three of the seven calculations tested. The auditors were able to review the drawdown reconciliations performed by the Caminar Latino and determi...

Condition Upon review of the indirect cost calculations throughout the fiscal year, it was noted that there was no documentation of review and approval of three of the seven calculations tested. The auditors were able to review the drawdown reconciliations performed by the Caminar Latino and determine the reports were materially accurate; however, no evidence of a formal supervisory review and approval of the reconciliation was maintained on-file in these three instances. Correction action As of Q4 2022, the Atlanta-based Co-CEO and the Chief of Programs and Administration have instituted a process of review and approval of drawdown reconciliations prior to drawdown to review for accuracy of calculations and to ensure that previous drawdown amounts are accurately recorded. A Finance Manager was hired in April 2023, and the responsibility of ongoing drawdown reconciliation and calculation of invoice amounts has shifted to the Finance Manager position. Monthly invoices and drawdowns are being reviewed and approved by the Co-CEO and Chief of Programs and Administration prior to drawdown. Responsible Person Co-CEO and Chief of Programs and Administration Anticipated completion date Completed - This process is currently in place.

View Audit 574

Finding 289 (2022-001)

Material Weakness 2022

Town of Hempstead Housing Authority

NY

HUD Housing Programs Allowable Costs / Cost Principles Eligibility

Finding 2022-00 I - COCC deficit and the use of LIPH funds in violation of HUD Rule Auditee's Response and Planned Corrective Action The Authority is working to gather the information necessary to complete an analysis of the benefits charged to each AMP and COCC for the above referenced finding. T...

Finding 2022-00 I - COCC deficit and the use of LIPH funds in violation of HUD Rule Auditee's Response and Planned Corrective Action The Authority is working to gather the information necessary to complete an analysis of the benefits charged to each AMP and COCC for the above referenced finding. There is a meeting scheduled for October 16, 2023. HUD has been informed regarding the status of the finding. Planned Implementation Date of Corrective Action: December 2023 Person Responsible for Corrective Action: Ed Cumming, Executive Director

View Audit 514

Finding 223 (2022-003)

Significant Deficiency 2022

Five Towns Community Center INC

NY

Questioned Costs Allowable Costs / Cost Principles

FTCC concurs with this finding and will make every attempt to create time studies to support salary allocations in the future.

View Audit 465 Questioned Costs: $1

Finding 218 (2022-001)

Material Weakness 2022

Valor Christian College

OH

Allowable Costs / Cost Principles Internal Control / Segregation of Duties

Comments on Findings and Recommendations: Valor Christian College concurs with the finding and recommendations in the finding. Actions T...

Comments on Findings and Recommendations: Valor Christian College concurs with the finding and recommendations in the finding. Actions Taken or Planned: The Valor Christian College Finance Department and the Valor Christian College CFO will increase controls over the process to ensure that no recruitment advertising expenses are attributed to CARES ACT funds. The amount of orginally atrributed advertising expenses has been reallocated to allowable items/expenses.

View Audit 443

Finding 180 (2022-002)

Significant Deficiency 2022

Guam Housing and Urban Renewal Authority

GU

Subrecipient Monitoring Special Tests & Provisions Allowable Costs / Cost Principles

Finding #2022-002 Emergency Solutions Grant Program Special Tests and Provisions – Obligation, Expenditure and Payment Requirements Views of Responsible Officials and Planned Corrective Action GHURA agrees with the recommendation to review and process payment requests from subrecipients within the...

Finding #2022-002 Emergency Solutions Grant Program Special Tests and Provisions – Obligation, Expenditure and Payment Requirements Views of Responsible Officials and Planned Corrective Action GHURA agrees with the recommendation to review and process payment requests from subrecipients within the 30-day time frame. Responsible Party: Katherine Taitano, Chief Planner, and Jerricho Garcia, General Accounting Supervisor Anticipated Date of Completion: September 30, 2024

View Audit 281

Finding 1181992 (2021-009)

Material Weakness 2021

Open Door Ministries of High Point, Inc.

NC

Allowable Costs / Cost Principles Material Weakness Period of Performance § 200.302 § 200.303 § 200.430

Department of Housing and Urban Development and Department of Veterans Affairs Federal Program Name: Emergency Solutions Grant Program and VA Homeless Providers Grant and Per Diem Program Assistance Listing Number: 14.231 and 64.024 Recommendation: We recommend the Organization develop a system of i...

Department of Housing and Urban Development and Department of Veterans Affairs Federal Program Name: Emergency Solutions Grant Program and VA Homeless Providers Grant and Per Diem Program Assistance Listing Number: 14.231 and 64.024 Recommendation: We recommend the Organization develop a system of internal controls to ensure that salaries and related payroll expenses are tracked to reasonably reflect the actual time spent working on the programs. In addition we recommend that management retain all documents including evidence of review and approval for all expenditures of federal funds until the latter of the legally required retention period or completion of required audits. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management has implemented internal control procedures to strengthen payroll allocation practices and documentation retention for federally funded expenditures. The Organization has established a process to ensure that salaries and payroll-related costs charged to federal programs are supported by appropriate time tracking and allocation documentation that reasonably reflects actual time worked on each program. Supervisory review and approval requirements have been implemented to validate payroll allocations and supporting documentation. Additionally, the Organization has reinforced documentation retention standards by requiring retention of all federal expenditure support, including invoices, approvals, reconciliations, and evidence of review, in accordance with federal retention requirements and audit availability standards. Name(s) of the contact person(s) responsible for corrective action: Ryan Ross, Executive Director Planned completion date for corrective action plan: March 31, 2026

View Audit 393351

Finding 1179949 (2021-004)

Material Weakness 2021

ADAMS COUNTY PUBLIC HOSPITAL DISTRICT #3 D/B/A OTHELLO COMMUNITY HOSPITAL

WA

Allowable Costs / Cost Principles Cash Management Significant Deficiency

The District hired a new Chief Financial Officer in 2023 and was able to catch the District up on three years of financials statements and all missing audits. The new CFO made the following changes to ensure compliance: 1. Update internal controls and monitoring. The new CFO created a Federal Fundin...

The District hired a new Chief Financial Officer in 2023 and was able to catch the District up on three years of financials statements and all missing audits. The new CFO made the following changes to ensure compliance: 1. Update internal controls and monitoring. The new CFO created a Federal Funding Monitoring and Reporting Policy that specifies that responsibilities over compliance, expenditures, and reporting. 2. Implement Process Improvements. The new CFO and Accounts Payable were able to identify grant fund expenditures and work closely to make sure all future grant expenditures are identified and tracked. 3. Communicate with External Audit Team. The new CFO communicates regularly with the external audit team to ensure they are aware of the grant funds received and the type of audit that is required and coordinate audits with plenty of time to complete the audit before deadlines.

View Audit 392296

Finding 1176727 (2021-001)

Material Weakness 2021

Chuloonawick Native Village

AK

Allowable Costs / Cost Principles Reporting

Chuloonawick Native Village agrees with the finding and will retain documentation supporting its expenditures for subsequent audits and train all new staff correct filing procedures.

View Audit 390654

Finding 1176708 (2021-005)

Material Weakness 2021

Beartooth Billings Clinic

MT

Allowable Costs / Cost Principles Cash Management Reporting

Following the Period 1 submission, the Organization identified that the patient revenue figures used in the lost revenue calculation did not reconcile to the audited financial statements. The lost revenue model was subsequently re performed using audited patient revenue data, and the corrected calcu...

Following the Period 1 submission, the Organization identified that the patient revenue figures used in the lost revenue calculation did not reconcile to the audited financial statements. The lost revenue model was subsequently re performed using audited patient revenue data, and the corrected calculation was incorporated into the Period 4 PRF submission. To prevent recurrence, the Organization has strengthened its internal review protocols for reporting, including mandatory reconciliation of all revenue inputs to audited financial statements and secondary review by the Regional Controller prior to submission. These enhanced controls ensure that future lost revenue calculations are accurate, supportable, and compliant with HRSA reporting requirements.

View Audit 390602

Finding 1176707 (2021-004)

Material Weakness 2021

Beartooth Billings Clinic

MT

Allowable Costs / Cost Principles Cash Management Period of Performance

Capital expenditures charged to the PRF program were allowable; however, at June 30, 2021, HHS had not yet issued clear technical guidance indicating that capital costs must be fully completed or received within the Period of Availability, therefore causing the expenditures to be out of period. Defi...

Capital expenditures charged to the PRF program were allowable; however, at June 30, 2021, HHS had not yet issued clear technical guidance indicating that capital costs must be fully completed or received within the Period of Availability, therefore causing the expenditures to be out of period. Definitive guidance clarifying this requirement was not released until August 2021, after the close of the reporting period. As a result, the Organization applied the best available interpretation at the time of close. To prevent similar issues, the Organization will incorporate ongoing monitoring of updated directives, strengthen pre submission technical reviews, and consult with external advisors to validate compliance with period of availability rules prior to future filings.

View Audit 390602

Finding 1176706 (2021-003)

Material Weakness 2021

Beartooth Billings Clinic

MT

Allowable Costs / Cost Principles Cash Management Reporting

The keying error in the original Period 1 submission was corrected in the Period 4 PRF report, and additional review controls have been implemented to prevent manual data-entry inaccuracies. G&A expenses, initially allocated based on limited guidance, are now supported by a standardized methodology ...

The keying error in the original Period 1 submission was corrected in the Period 4 PRF report, and additional review controls have been implemented to prevent manual data-entry inaccuracies. G&A expenses, initially allocated based on limited guidance, are now supported by a standardized methodology with full underlying documentation in line with PRF reporting requirements.

View Audit 390602

Finding 1171351 (2021-002)

Material Weakness 2021

Ekentucky Advanced Manufacturing Institute INC

KY

Allowable Costs / Cost Principles Reporting Internal Control / Segregation of Duties § 200.512

We concur with the recommendation. The required filings are done in conjunction with the audits of the organization's financial statements. The organization is actively working to get the audits and the required filings current. The organization will submit the infomrntion lo the audit firm for 2022...

We concur with the recommendation. The required filings are done in conjunction with the audits of the organization's financial statements. The organization is actively working to get the audits and the required filings current. The organization will submit the infomrntion lo the audit firm for 2022 by January 3 1, 2026. The information for audits of the subsequent years' financial statements will be submitted within 30 days of the completion of the prior year audit. The organization expects to be current on the audits and filings by December 31, 2027.

View Audit 384645

Finding 1169706 (2021-003)

Material Weakness 2021

Pittsburg County

OK

Allowable Costs / Cost Principles Subrecipient Monitoring Eligibility § 200.303

The BOCC will be more diligent in their overview of grant applications to ensure that all federal grant application requests are not reimbursable through any other federal grant program. All transactions regarding federal grants will be required to be flagged with the grant information and will requ...

The BOCC will be more diligent in their overview of grant applications to ensure that all federal grant application requests are not reimbursable through any other federal grant program. All transactions regarding federal grants will be required to be flagged with the grant information and will require approval by the BOCC before any action can be taken. BOCC will determine the validity of each transaction to ensure compliance with grant requirements.

View Audit 382719

Finding 1169705 (2021-002)

Material Weakness 2021

Pittsburg County

OK

Allowable Costs / Cost Principles Internal Control / Segregation of Duties Period of Performance § 200.303

The BOCC will develop internal control procedures to help ensure that federal grant funding is monitored more closely and that expenditures are verified to be in compliance with grant requirements. Future grant recipients will be required to have BOCC approval before expenditures can be turned in fo...

The BOCC will develop internal control procedures to help ensure that federal grant funding is monitored more closely and that expenditures are verified to be in compliance with grant requirements. Future grant recipients will be required to have BOCC approval before expenditures can be turned in for payment. Grant recipients will also be required to have BOCC approval before depositing grant funds. This should ensure that all transactions are in compliance with grant requirements.

View Audit 382719

Finding 1169704 (2021-001)

Material Weakness 2021

Pittsburg County

OK

Internal Control / Segregation of Duties Subrecipient Monitoring Allowable Costs / Cost Principles

The BOCC will ensure that internal controls are developed and that procedures are adopted and implemented to help ensure compliance with federal grants. Future grant recipients will be required to have BOCC approval before expenditures can be turned in for payment. Grant recipients will also be requ...

The BOCC will ensure that internal controls are developed and that procedures are adopted and implemented to help ensure compliance with federal grants. Future grant recipients will be required to have BOCC approval before expenditures can be turned in for payment. Grant recipients will also be required to have BOCC approval before depositing grant funds. This should ensure that all transactions are in compliance with grant requirements.

View Audit 382719

Finding 1167055 (2021-009)

Material Weakness 2021

STOP INC

VA

Allowable Costs / Cost Principles § 200.303 § 200.331 § 200.403

Finding 2021-008 Noncompliance with Activities Allowed or Unallowed and Allowable Costs/Cost Principles Finding 2021-009 Noncompliance with Eligibility Recommendation: We recommend the Organization strengthen its compliance-related internal controls by: • Requiring standardized documentation to supp...

Finding 2021-008 Noncompliance with Activities Allowed or Unallowed and Allowable Costs/Cost Principles Finding 2021-009 Noncompliance with Eligibility Recommendation: We recommend the Organization strengthen its compliance-related internal controls by: • Requiring standardized documentation to support compliance with each requirement. 37 • Implementing periodic reviews of documentation completeness before charging costs to federal awards. • Providing training to staff responsible for grant management on compliance and record retention requirements. • Retain all documentation related to federal awards in a central location. Management agrees with the finding and the recommendation. During the audit period in the following years until present STOP’s clear policy and practice was to only provide service to individuals and families whose annual income does not exceed the established threshold on the federal poverty guidelines as published annually. While documentation was deficient to demonstrate eligibility for a small number of the total files sampled, the missing documentation is not an indicator that ineligible applicants received services. To address the root causes, the following actions have been implemented: The Organization has implemented Bill.com Accounts Payable workflow and document retention platform as noted above. All STOP staff have/will participate in annual in-service training and will be provided updated eligibility criteria annually. This ensures that all staff have proper information and adheres to the federally published poverty guidelines and that agency practices of only providing services to individuals who meet the established criteria are provided services. Additionally, all files will include an eligibility checklist outlining all documents needed to support eligibility and will also include a compliance reviewer signature. This should ensure that all files are complete and have necessary documentation to support eligibility. Completion Date: December 2025 The individual responsible for ensuring these issues are resolved is Michelle Bryant, Interim CEO. If there are questions regarding these plans, please call Michelle Bryant at 757-858-1360. Michelle Bryant, Interim CEO

View Audit 378149

Finding 1167054 (2021-008)

Material Weakness 2021

STOP INC

VA

Allowable Costs / Cost Principles § 200.303 § 200.331 § 200.403

Finding 2021-008 Noncompliance with Activities Allowed or Unallowed and Allowable Costs/Cost Principles Finding 2021-009 Noncompliance with Eligibility Recommendation: We recommend the Organization strengthen its compliance-related internal controls by: • Requiring standardized documentation to supp...

Finding 2021-008 Noncompliance with Activities Allowed or Unallowed and Allowable Costs/Cost Principles Finding 2021-009 Noncompliance with Eligibility Recommendation: We recommend the Organization strengthen its compliance-related internal controls by: • Requiring standardized documentation to support compliance with each requirement. 37 • Implementing periodic reviews of documentation completeness before charging costs to federal awards. • Providing training to staff responsible for grant management on compliance and record retention requirements. • Retain all documentation related to federal awards in a central location. Management agrees with the finding and the recommendation. During the audit period in the following years until present STOP’s clear policy and practice was to only provide service to individuals and families whose annual income does not exceed the established threshold on the federal poverty guidelines as published annually. While documentation was deficient to demonstrate eligibility for a small number of the total files sampled, the missing documentation is not an indicator that ineligible applicants received services. To address the root causes, the following actions have been implemented: The Organization has implemented Bill.com Accounts Payable workflow and document retention platform as noted above. All STOP staff have/will participate in annual in-service training and will be provided updated eligibility criteria annually. This ensures that all staff have proper information and adheres to the federally published poverty guidelines and that agency practices of only providing services to individuals who meet the established criteria are provided services. Additionally, all files will include an eligibility checklist outlining all documents needed to support eligibility and will also include a compliance reviewer signature. This should ensure that all files are complete and have necessary documentation to support eligibility. Completion Date: December 2025 The individual responsible for ensuring these issues are resolved is Michelle Bryant, Interim CEO. If there are questions regarding these plans, please call Michelle Bryant at 757-858-1360. Michelle Bryant, Interim CEO

View Audit 378149

Finding 1167053 (2021-007)

Material Weakness 2021

STOP INC

VA

Allowable Costs / Cost Principles § 200.303 § 200.331 § 200.403

Finding 2021-006 Noncompliance with Activities Allowed or Unallowed and Allowable Costs/Cost Principles Finding 2021-007 Noncompliance with Eligibility Recommendation: We recommend the Organization strengthen its compliance-related internal controls by: • Requiring standardized documentation to supp...

Finding 2021-006 Noncompliance with Activities Allowed or Unallowed and Allowable Costs/Cost Principles Finding 2021-007 Noncompliance with Eligibility Recommendation: We recommend the Organization strengthen its compliance-related internal controls by: • Requiring standardized documentation to support compliance with each requirement. 36 • Implementing periodic reviews of documentation completeness before charging costs to federal awards. • Providing training to staff responsible for grant management on compliance and record retention requirements. • Retain all documentation related to federal awards in a central location. • Reinforcing the approval process by documenting and communicating approval requirements to all staff involved in initiating and processing transactions, providing mandatory training to employees on expense authorization policies, and establishing monitoring procedures to ensure approvals are consistently documented before transactions are processed. Management agrees with the finding and the recommendation. During the audit period in the following years until present STOP’s clear policy and practice was to only provide service to individuals and families whose annual income does not exceed the established threshold on the federal poverty guidelines as published annually. While documentation was deficient to demonstrate eligibility for a small number of the total files sampled, the missing documentation is not an indicator that ineligible applicants received services. To address the root causes, the following actions have been implemented: The Organization has implemented Bill.com Accounts Payable workflow and document retention platform as noted above. All STOP staff have/will participate in annual in-service training and will be provided updated eligibility criteria annually. This ensures that all staff have proper information and adheres to the federally published poverty guidelines and that agency practices of only providing services to individuals who meet the established criteria are provided services. Additionally, all files will include an eligibility checklist outlining all documents needed to support eligibility and will also include a compliance reviewer signature. This should ensure that all files are complete and have necessary documentation to support eligibility. Completion Date: December 2025

View Audit 378149

Finding 1167052 (2021-006)

Material Weakness 2021

STOP INC

VA

Allowable Costs / Cost Principles § 200.303 § 200.331 § 200.403

Finding 2021-006 Noncompliance with Activities Allowed or Unallowed and Allowable Costs/Cost Principles Finding 2021-007 Noncompliance with Eligibility Recommendation: We recommend the Organization strengthen its compliance-related internal controls by: • Requiring standardized documentation to supp...

Finding 2021-006 Noncompliance with Activities Allowed or Unallowed and Allowable Costs/Cost Principles Finding 2021-007 Noncompliance with Eligibility Recommendation: We recommend the Organization strengthen its compliance-related internal controls by: • Requiring standardized documentation to support compliance with each requirement. 36 • Implementing periodic reviews of documentation completeness before charging costs to federal awards. • Providing training to staff responsible for grant management on compliance and record retention requirements. • Retain all documentation related to federal awards in a central location. • Reinforcing the approval process by documenting and communicating approval requirements to all staff involved in initiating and processing transactions, providing mandatory training to employees on expense authorization policies, and establishing monitoring procedures to ensure approvals are consistently documented before transactions are processed. Management agrees with the finding and the recommendation. During the audit period in the following years until present STOP’s clear policy and practice was to only provide service to individuals and families whose annual income does not exceed the established threshold on the federal poverty guidelines as published annually. While documentation was deficient to demonstrate eligibility for a small number of the total files sampled, the missing documentation is not an indicator that ineligible applicants received services. To address the root causes, the following actions have been implemented: The Organization has implemented Bill.com Accounts Payable workflow and document retention platform as noted above. All STOP staff have/will participate in annual in-service training and will be provided updated eligibility criteria annually. This ensures that all staff have proper information and adheres to the federally published poverty guidelines and that agency practices of only providing services to individuals who meet the established criteria are provided services. Additionally, all files will include an eligibility checklist outlining all documents needed to support eligibility and will also include a compliance reviewer signature. This should ensure that all files are complete and have necessary documentation to support eligibility. Completion Date: December 2025

View Audit 378149

Corrective Action Plans

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