STDC acknowledges the auditor's finding regarding the inclusion of $12,153 in administrative costs in a supplemental reimbursement request submitted via Form B-13 to the Texas Department of State Health Services (DSHS) under the Ryan White HIV/AIDS Program – Part B. The costs in question lacked contemporaneous supporting documentation at the time of audit review.
While STDC maintains that all costs submitted were incurred in good faith to support the Ryan White program, the lack of appropriate documentation constitutes a lapse in internal controls by the former Finance Director, Julia Gonzalez, over post-award claims processing. STDC has initiated an internal review and will consult with DSHS to determine the appropriate repayment action. Additional controls and protocols are being implemented to ensure that all future reimbursement requests—especially post-period—are fully documented, verified, and approved.
Corrective Action Plan
Finding Number: 2023-02
Planned Completion Date: July 31, 2025
Responsible Official: Director of Finance
Corrective Actions to Be Implemented:
1. Policy and Procedure Development
STDC shall develop a written policy governing post-award and supplemental reimbursement requests, with clear requirements for documentation and approval. The policy will define acceptable forms of documentation, including invoices, time records, internal allocation spreadsheets, and procurement records.
2. Document Verification Protocol
Require pre-submission validation of all reimbursement entries by the Finance Director.
3. Supervisory Review and Sign-Off
Supplemental claims must receive sign-off from both the Finance Director and the Executive Director prior to submission. Claims will include documentation verification and reconciliation to program records.
4. Training
Ensure all finance department staff involved in grant accounting and reporting are trained on documentation requirements under 2 CFR Part 200, and internal review protocols for final and supplemental financial reports.
5. Communication with DSHS
STDC will communicate with DSHS regarding the questioned costs and will take appropriate action based on agency guidance, including cost disallowance and repayment as required.
6. Quarterly Internal Reconciliation
Establish recurring quarterly reviews of actual costs incurred versus amounts reimbursed to identify discrepancies and prevent accumulation of unsupported claims.
Policy Title: Post-Award Reimbursement and Documentation Policy
Effective Date: July 10, 2025, or upon adoption by the STDC Board of Directors
Applies to: Finance Department, Grants Compliance, Department Heads
Purpose
To ensure that all reimbursement requests, including post-award and supplemental claims, are adequately documented, supported, and reviewed in compliance with 2 CFR §200 Subpart E.
Policy Overview
STDC shall not submit for reimbursement any cost for which contemporaneous and auditable documentation is not available. All supplemental reimbursement submissions must undergo a formal review and approval process to ensure the allowability, allocability, and documentation of all requested costs.
Procedures
1. Required Documentation:
Every cost line item included in a supplemental reimbursement must be supported by original documentation including:
o General ledger detail
o Paid invoice or payroll record
o Allocation spreadsheet (if applicable)
o Program approval or correspondence
2. Review Process:
The Department Heads, or their designee, will verify that all documents meet federal allowability and documentation standards prior to submission to the Finance Department.
A Supplemental Reimbursement Review Checklist must be completed and signed before submission of any supplemental requests.
3. Approval Authority:
Final approval must be obtained from the Finance Director and Executive Director.
4. Retention Requirements:
All reimbursement submissions and supporting documentation must be retained according to the STDC Local Record Retention Schedule.
5. Reporting Discrepancies:
Any discrepancy, missing documentation, or unsupported cost identified must be reported to the Finance Director immediately for resolution before claim submission.