Corrective Action Plans

Finding 223 (2022-003)

Significant Deficiency 2022

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 1224510 (2021-015)

Material Weakness 2021

Quality Community Health Care, Inc.

PA

Allowable Costs / Cost Principles Internal Control / Segregation of Duties Material Weakness

Criteria Under the Uniform Guidance (2 CFR Part 200, Subpart E), recipients of federal awards must maintain documentation to support costs charged to federal programs, including indirect costs. The documentation should demonstrate that costs are allocable, allowable, and in accordance with the appro...

Criteria Under the Uniform Guidance (2 CFR Part 200, Subpart E), recipients of federal awards must maintain documentation to support costs charged to federal programs, including indirect costs. The documentation should demonstrate that costs are allocable, allowable, and in accordance with the approved indirect cost rate agreement, if applicable. Condition and Context QCHC was unable to provide sufficient records to substantiate costs charged to federal grants. As a result, we were unable to determine the accuracy or allowability of both direct and indirect costs recorded. Furthermore, due to this lack of supporting documentation, we could not verify whether indirect costs were charged, nor could we confirm that any indirect cost calculations were based on an appropriate and complete base of direct costs or were calculated properly in accordance with the approved indirect cost rate agreement. Recommendation We recommend that management implement procedures to ensure that all indirect costs claimed under federal grants are supported by adequate documentation, including detailed allocation methodologies and supporting records, in accordance with federal regulations. Views of Responsible Officials and Planned Corrective Actions QCHC acknowledges the finding and has implemented the following corrective actions: I. QCHC has implemented Section 600- Cost Accounting Policies of the Accounting Manual, which deals with the measurement, assignment and allocation of costs to various cost objectives. 2. QCHC has established Policy 619- Direct and Indirect Costs, which requires that costs benefiting more than one cost objective be consistently treated as indirect costs, and costs necessary for the overall operation of the organization be treated as management and general costs.3. QCHC has implemented the Draw Down Policy & Procedure (Policy #308 DRAWDOWN) which establishes that expenditures of Federal award funds are monitored and allowable in accordance with the terms and conditions of the Federal award and with the federal cost principles in CFR Part 75 Subpart E. 4. QCHC has established Policy 303 - Incurred Cost, which requires that outlays or expenditures represent charges made to the project or program and may be reported on an accrual basis. 5. QCHC has implemented procedures to maintain detailed records of all direct and indirect costs charged to federal grants, including detailed allocation methodologies and supporting records, in accordance with federal regulations.

View Audit 407750

Finding 1224508 (2021-014)

Material Weakness 2021

Quality Community Health Care, Inc.

PA

Allowable Costs / Cost Principles Internal Control / Segregation of Duties

Criteria In accordance with the Uniform Guidance, the costs charged to federal funds must comply with the cost principles of 45 CFR Part 75, Subpart E, and any other requirements or restrictions on the use of federal funding. Condition and Context QCHC was unable to provide the approval of timesheet...

Criteria In accordance with the Uniform Guidance, the costs charged to federal funds must comply with the cost principles of 45 CFR Part 75, Subpart E, and any other requirements or restrictions on the use of federal funding. Condition and Context QCHC was unable to provide the approval of timesheets and the payroll allocation for 60 selections for payroll control testing. Recommendation We recommend that management implement procedures to ensure that timesheets and related approvals are adequately maintained and supported. Views of Responsible Officials and Planned Corrective Actions QCHC acknowledges the finding and has implemented the following corrective actions: 1. QCHC has implemented Policy 911 - Labor Distribution Reporting, which establishes that charges to awards for salaries and wages, whether treated as direct costs or indirect costs, will be based on documented payrolls approved by a responsible supervisory official. 2. QCHC has established that employees are responsible to use the ADP time clock to record their time worked, with supervisors/managers having full access to monitor their department time in/out and leave. 3. QCHC has implemented the Draw Down Policy & Procedure (Policy #308 DRAWDOWN) which establishes that salary and wage charges are supported by a system of internal controls which provides reasonable assurance that they are accurate, allowable, properly allocated and in compliance with the organization's policies and procedures. 4. QCHC has established that employee timesheets are completed electronically and supervisors approve hours worked which are processed by the Accounts Payable Manager, with a salary allocation maintained to track and reconcile the assignment of the Organization's salaries and wages to all grant programs. 5. QCHC has implemented Policy 917 -Timely Submission of Timesheets and Penalties, which establishes that until an accurate and complete timesheet is submitted to the payroll clerk, an employee will not be paid during that pay cycle.

View Audit 407750

Finding 1224506 (2021-013)

Material Weakness 2021

Quality Community Health Care, Inc.

PA

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

Criteria Recipients of federal grants are required by federal regulations (Uniform Guidance, 2 CPR Part 200) to maintain documentation demonstrating that cash receipts correspond to drawdowns based on actual, allowable costs incurred. Drawdowns for Federal awards should be properly supported with re...

Criteria Recipients of federal grants are required by federal regulations (Uniform Guidance, 2 CPR Part 200) to maintain documentation demonstrating that cash receipts correspond to drawdowns based on actual, allowable costs incurred. Drawdowns for Federal awards should be properly supported with relevant forms and reports to substantiate the costs incurred and evidence management review and approval. Condition and Context For the year ended July 31, 2021, QCHC recorded cash receipts related to their federal awards totaling $3,535,567. However, QCHC was unable to provide evidence that these amounts represent drawdowns from the federal grants. The only available documentation substantiates the receipt of cash, without linking it to eligible grant expenditures. Recommendation We recommend that management establish procedures to ensure that documents supporting all drawdown requests are properly retained. Such requests should also be reviewed and approved prior to the request being made, with this approval documented and retained. Views of Responsible Officials and Planned Corrective Actions QCHC acknowledges the finding and has implemented the following corrective actions: l. QCHC has implemented the Draw Down Policy & Procedure (Policy #308 DRAWDOWN) which establishes that drawdown of Federal funds must be made in accordance with the immediate needs of the award terms, to minimize time between request and expenditures, and funds will not be drawn down 5 business days prior to disbursement. 2. QCHC has established procedures requiring the preparation of a justification table of all staff members allocated to the federal grant fund, division of annual salaries by 26 pay periods per year, and preparation of SF-270 (Request for Advance or Reimbursement). 3. QCHC has established that the Chief Financial Officer is responsible for monitoring program cash flow needs and submitting drawdown requests in a timely manner to assure adequate coverage of program needs. 4. QCHC has implemented a review and approval process requiring the Chief Financial Officer and Chief Executive Officer to review, approve and execute the applicable drawdown. 5. QCHC has established that HRSA expenses are tracked in the accounting system by revenue source fund codes by the HRSA budget name, with accounts receivable related to grants recorded when a copy of the HRSA request is received.

View Audit 407750

Finding 1217409 (2021-001)

Material Weakness 2021

Crater Regional Workforce Investment Board

VA

Eligibility Allowable Costs / Cost Principles

The Crater Regional Workforce Development Board obtained a waiver beginning in PY24 to service the WIOA Title 1 Program (instead of using an outside service provider as was the case for PY21) which has led to additional internal controls including but not limited to: 1. Streamlining of enrollment to...

The Crater Regional Workforce Development Board obtained a waiver beginning in PY24 to service the WIOA Title 1 Program (instead of using an outside service provider as was the case for PY21) which has led to additional internal controls including but not limited to: 1. Streamlining of enrollment to a singular assigned staff who has been trained specifically around enrollment/eligibility criteria. 2. Review of every enrollment by CRWDB leadership staff directly after enrollment to identify and correct any missing information. 3. Audit of every file open during the course of a program year at least 2 times during that PY by staff other than the staff who completed the initial enrollment.

View Audit 403603

Finding 1217317 (2021-007)

Material Weakness 2021

Country Doctor Community Health Centers

WA

Allowable Costs / Cost Principles Cash Management Material Weakness § 200.403

2021-007 Cash Management Corrective action planned: Drawdown Support and Timing: Processes have been implemented to ensure all drawdowns are supported by adequately documented, individually identifiable expenditures and are made only after costs have been incurred. Documentation Standards: Standard ...

2021-007 Cash Management Corrective action planned: Drawdown Support and Timing: Processes have been implemented to ensure all drawdowns are supported by adequately documented, individually identifiable expenditures and are made only after costs have been incurred. Documentation Standards: Standard requirements are now in place to maintain complete supporting documentation for each draw, including linkage to underlying expenses. Review and Approval Controls: Formal review procedures have been established, requiring documented evidence of supervisory review and approval prior to submission of draw requests. Anticipated completion date: Completed in 2022 Contact person responsible for corrective action: Angela Treptow, Interim Finance Director

View Audit 403489

Finding 1214952 (2021-004)

Material Weakness 2021

HOUSING AUTHORITY OF THE CITY OF LITTLE ROCK, ARKANSAS

CA

Allowable Costs / Cost Principles Special Tests & Provisions Eligibility

Finding 2021-004 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Housing Voucher Cluster and Public and Indian Housing Program Assistance Listing Numbers: 14.871, 14.879, and 14.850 Material Noncompliance Non Compliance Material to the Financial Statements: Y...

Finding 2021-004 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Housing Voucher Cluster and Public and Indian Housing Program Assistance Listing Numbers: 14.871, 14.879, and 14.850 Material Noncompliance Non Compliance Material to the Financial Statements: Yes Material Weakness in Internal Control over Compliance Criteria: The Authority must maintain complete and accurate accounts and other records for the program in accordance with HUD compliance requirements. Condition: The Authority did not maintain complete and accurate accounts and other records in accordance with HUD compliance requirements including Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Eligibility, Reporting, and Special Tests and Provisions. Context: The Authority was unable to provide requested documentation at the time of audit to properly test the HUD compliance requirements. Known Questioned Costs: Unknown Cause: There is a material weakness in internal controls over compliance related to the maintenance of tenant files, wait lists, inspection reports and other records. The Authority has not properly considered, designed, implemented, maintained and monitored a system of internal controls that reasonably assures the program is in compliance. Effect: The Housing Voucher Cluster and Public and Indian Housing Program are in material non- compliance with the compliance requirements of the program. Recommendation: We recommend that the Authority implement a process whereby Authority documents are stored and safeguarded to ensure compliance with the Uniform Guidance and the compliance supplement. View of Responsible Officials and Corrective Actions: The Authority experienced significant turnover in employees during the year and as a result certain source documents were misplaced or destroyed. Management agrees with the Auditors' finding and has hired a new Executive Director who will implement the required safeguards and ensure that the Authority follows its internal control over compliance processes and procedures related to the Housing Voucher Cluster and Public and Indian Housing Programs to remedy the aforementioned deficiencies. Byran McClellan, CFO, will be responsible to implement this corrective action by December 31, 2022.

View Audit 401726

Finding 1213652 (2021-002)

Material Weakness 2021

City of Soap Lake

WA

Procurement, Suspension & Debarment Subrecipient Monitoring Allowable Costs / Cost Principles § 200.318

Finding ref number: 2021-002 Finding caption: The City did not have adequate internal controls for ensuring compliance with procurement requirements and charged expenditures that lacked support for the Water and Waste Disposal Systems for Rural Communities program. Name, address, and telephone of Ci...

Finding ref number: 2021-002 Finding caption: The City did not have adequate internal controls for ensuring compliance with procurement requirements and charged expenditures that lacked support for the Water and Waste Disposal Systems for Rural Communities program. Name, address, and telephone of City contact person: Peter Sharp, 239 2nd Ave SE, Soap Lake, WA 98851, 509-246-1211 Corrective action the auditee plans to take in response to the finding: The City acknowledges that due to staff turnover during this period, federal procurement policies, documentation for professional services and other service fees could not be located during the audit. The City will immediately study these issues and implement comprehensive corrective measures: Corrective Actions: Procurement Documentation and Monitoring: 1. Comprehensive Procurement Policy Review and Revision – The City will conduct an immediate review of existing procurement policies against federal requirements (2 CFR Part 200, Subpart D) to identify all gaps. The City will revise and adopt updated procurement policies that conform to the most restrictive requirements and include all required procedures for: • Solicitation and award procedures for public works contracts • Small purchase quotation requirements • Architectural and engineering services procurement procedures • Piggyback purchasing authorization and procedures • Cost and price analysis requirements • Bonding requirements for construction contracts • All other required procurement procedures under federal regulations 2. Standards of Conduct Policy Development – The City will immediately develop and adopt written standards of conduct procedures as required by federal regulations (2 CFR Part 200.112), establishing conflict of interest policies and certification requirements for all City officials and employees involved in federal award transactions. 3. Staff Training and Certification – Implement mandatory training for all procurement personnel and department heads to ensure full understanding and compliance with updated policies. All staff will be required to acknowledge and certify compliance with standards of conduct policies. 4. Establish a system to review and document compliance with procurement policies on all federally-funded transactions, including periodic audits to verify conformance. Financial Controls and Documentation: - Established comprehensive document retention policies requiring all expenditure supporting documentation to be maintained for the required retention period - Implemented approval workflows requiring supervisory review of all federal grant expenditures before payment Federal Grant Management: - Developing formal federal grant administration procedures compliant with 2 CFR Part 200 Uniform Guidance requirements - Established pre-approval processes for all federal program expenditures - Implemented monthly reconciliation procedures for all federal grant activities - Will establish quarterly internal compliance reviews to ensure ongoing adherence to federal requirements Anticipated date to complete the corrective action: Q1 2026

View Audit 400574

Finding 1213600 (2021-002)

Material Weakness 2021

Richmond Housing Authority

CA

Allowable Costs / Cost Principles Procurement, Suspension & Debarment

Finding Reference Number: SA2021-002: Lack of Supporting Documentation for Expenditures Assistance Listing Number: 14.850 Assistance Listing Title: Public and Indian Housing Name of Federal Agency: Department of Housing and Urban Development Contact Person: Antoinette Terrell, Executive Director Cor...

Finding Reference Number: SA2021-002: Lack of Supporting Documentation for Expenditures Assistance Listing Number: 14.850 Assistance Listing Title: Public and Indian Housing Name of Federal Agency: Department of Housing and Urban Development Contact Person: Antoinette Terrell, Executive Director Corrective Action Plan: Staff have implemented procedures requiring that all invoices, contracts, purchase orders, and supporting records be scanned and attached in MUNIS at the time of processing. A new review workflow ensures supervisory approval before expenditures are charged to federal funds. The Authority is conducting retroactive file recovery where possible and implementing staff training on documentation requirements under 2 CFR Part 200. These improvements will ensure expenditures are fully supported, allowable, and readily accessible for audit. Completion Date: May 1, 2023

View Audit 400515

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

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