Finding 1170220 (2024-004)

Material Weakness Repeat Finding
Requirement
E
Questioned Costs
-
Year
2024
Accepted
2026-01-21

AI Summary

  • Core Issue: Missing essential components in participant case files jeopardizes program compliance.
  • Impacted Requirements: Grantees must maintain complete case files as per the SSG Fox SPGP Program Guide and ensure data is accurately reflected in the VA tool.
  • Recommended Follow-Up: Implement a checklist for case file documentation and establish a management review process to ensure timely and accurate completion.

Finding Text

2024-004 – Inadequate Case File Documentation Condition: Several instances of essential components required to be included in participant case files were found to be missing. Criteria: Per the SSG Fox SPGP Program Guide, grantees are responsible for maintaining case files for each participant. Additionally, some of this information must also be reflected in the VA data collection tool. Effect: Failure to complete a proper intake and enrollment process will result in participants being unaware of their program rights and responsibilities of receiving critical suicide prevention services, placing them at increased risk. Cause: Homeward Bound Adirondack, Inc. failed to provide proper oversight and sufficient trainings relating to case file documentation. Recommendation: We recommend that Homeward Bound Adirondack, Inc. implement a participant case file checklist to ensure all required documentation is collected and maintained, which includes: (1) program agreements, (2) grievance procedures, (3) religious protections, (4) release(s) of information, (5) service plans, (6) mental health screenings and (7) program exit documents. We also recommend Homeward Bound Adirondack, Inc. establish a review process, including management oversight, to verify that all participant forms are accurately completed and filed timely prior to enrollment. Response: Homeward Bound Adirondack, Inc. agrees with the finding and will implement procedures to address the recommendation in 2025.

Corrective Action Plan

2024-004 – Inadequate Case File Documentation Finding: Our audit procedures disclosed that several instances of essential components required to be included in participant case files were found to be missing. Recommendation: We recommend that Homeward Bound Adirondack, Inc. implement a participant case file checklist to ensure all required documentation is collected and maintained, which includes: (1) program agreements, (2) grievance procedures, (3) religious protections, (4) release(s) of information, (5) service plans, (6) mental health screenings and (7) program exit documents. We also recommend Homeward Bound Adirondack, Inc. establish a review process, including management oversight, to verify that all participant forms are accurately completed and filed timely prior to enrollment. Action Taken: Homeward Bound Adirondacks (HBA) has developed and implemented a formalized Participant Intake Review Process to ensure accuracy, completeness, and compliance with SSG Fox SPGP requirements prior to participant enrollment, Management will conduct monthly audits to ensure all documentation Is complete. New policies/procedures were reviewed at mandatory staff training on 10/29/25

Categories

Internal Control / Segregation of Duties

Other Findings in this Audit

  • 1170217 2024-001
    Material Weakness Repeat
  • 1170218 2024-002
    Material Weakness Repeat
  • 1170219 2024-003
    Material Weakness Repeat
  • 1170221 2024-005
    Material Weakness Repeat

Programs in Audit

ALN Program Name Expenditures
64.055 STAFF SERGEANT PARKER GORDON FOX SUICIDE PREVENTION GRANT PROGRAM $884,513